Hello everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Gigena
and I'm Em Gootee. And we are research fellows at Cincinnati Children's Hospital. And along
with Stay Current, we are sharing knowledge to improve child health around the globe.
So today we have another episode of the case-based journal review. So to remind you what this
is, we are working with Dr. Jose Campos. Hi, I'm Jose Campos. I work in Roberto del Río
Hospital in Chile and also leading a group of volunteers called Journal Hive. And we
try to bring you the best of pediatric surgery literature to use. And with Dr. Todd Ponsky,
the pediatric surgeon and the chief innovation officer here at Cincinnati Children's. And
what we do is we go through a case and discuss the latest updates in the literature about
the specific pathology to help treat this patient in a better way. And today I'm super excited
about this podcast. We haven't done one in a while. That's reason number one. But also
I'm super excited about this podcast because Chile is the country with the highest rate
of cholalithiasis. So this is something we can actually say something. So let's start.
We have a 12 year old female with acute gallstone pancreatitis admitted overnight. So for this
patient, do we do an index admission cholecystectomy or a delayed surgery? It really depends on
the patient and the situation. And that was Dr. Todd Ponsky. I typically do it before
they go home and I have not found that it's prohibitively difficult in most cases to do
the operation. I call this a little bit of the history of the cool off period. And in
case you forgot, that was Dr. Jose Campos. We always favor for our index admission surgery,
but they always told me if their symptoms have been going on for too long, just let
the pancreatitis heal for a time at home and then bring the patient back. And that threshold
was around the seven to 10 day mark. And then when I went back to pediatric surgery, that
threshold was around the two to three day mark for them. And it was very difficult for
me to convince them on doing index and admission surgery. Well, maybe this first article of
today can help you to convince them. First article is index admission cholecystectomy
and recurrence of pediatric gallstone pancreatitis, multi-centered cohort analysis. So this is
a paper that came in journal of the American College of Surgeons. It's a multi-center retrospective
review of pediatric patients with gallstones pancreatitis between 2010 and 2017. And their
aim was to compare the recurrence rates of pancreatitis, also compare outcomes and complications
between patients undergoing early cholecystectomy, meaning during the index admission, and those
who underwent delayed surgery, which was those who haven't received surgery at the moment
of the study, or it was done after the stretch. They had 167 underwent an early cholecystectomy
and 79 underwent a delayed cholecystectomy. The general outcome is that patients who underwent
the early cholecystectomy had only 2% of recurrence pancreatitis compared to 22% in patients doing
a delayed surgical approach. Interestingly, if they waited more than six weeks, the recurrence
rate went up to 60%. So 2% of the time in patients, even if they have no stones, they
will get recurrent pancreatitis from their initial insult, whereas 60% if you wait six
weeks, that is so provocative, that is so clear cut, then nobody should be debating
this anymore. That's what I was going to say. Like, first you said, if I have a reliable
patient, but this changes my approach, not even in the reliable patient, we should send
them home without their gallbladder removed. I agree. I think we still need to see on the
skill of the surgeon and still we need to think of the severity of the illness to individualize
this information. But for the vast majority of gallstone pancreatitis, I think this should
be the strategy. Yes. And one thing that is important too is that patients who underwent
the early cholestectomy didn't have more biliary complications. That's a really good
point because the fear of going in early was doing more damage than benefit. And that is
not proven in this article. Yeah. Are we ready for the second question? Yeah. So let's say
pancreatitis is resolved and you're ready to operate on this patient. Can you predict
the risk of cholera choliatesis in this patient? So what do you think about this, Todd? I think
it's a good question. So interestingly, when patients come in with gallstone pancreatitis
and they have all of this pain, most of the time, the symptoms of the pain and the elevated
enzymes are as the stone is passing. So it's interesting that if you wait till the next
day, you find resolution because the stone often has passed. Now there might be other
stones, but oftentimes these will pass overnight. Would you go in a relaxed mode to a lab collate
directly to this patient or would you do something? What would you do? So if your numbers normalize,
I do not do ERCP. I will do an intraoperative clangiogram to make sure there's not another
stone, but I would not do an ERCP if their numbers normalize. And let's hear what Dr.
Jose Campos had to say. So the situation you don't want to be in is you book a case as
a simple lab collate, no intraoperative clangiogram. You didn't think of an MRCP or ERCP or anything
and then boom, you find this stone there. That's what we want to avoid. So how I dealt
with this situation before, if they had no alteration at all, no history of cholangitis
or pancreatitis, I would just do a lab collate and nothing else. But if there was any alteration
whatsoever, I would just do an MRCP and if it's positive, do an ERCP. So that's why I
brought this article. So this article is coming from Western Pediatric Surgery Research Consortium.
It's a retrospective study and they looked at machine learning to predict pediatric choledic
luteitis. And this article was published in 2023 in the Surgery Journal. Their main question
was is it possible to predict the risk of common bile duct stones preoperatively? It's
a multi-center, included 10 different centers between 2016 to 2019. They had nearly 1600
patients. 20% of them had common bile duct stones and they were able to look for nine
most important clinical factors. Their result is yes, we can predict and let's use this
model.
The negative predictive value of this algorithm is 98%. That means that you're going to be
in that nasty situation only 2% of the time if you trust this algorithm. So that's why
I think this is the one to use. And I don't think we can get more precise than this algorithm
in terms of predicting CBD stones preoperatively.
It has a decent amount of patient population too. I think the previous algorithm was around
300 to 400 patients. This one has 1600. It's just so exciting to see we finally trying
to create algorithms and trying to implement in our daily practice to be able to precise
decisions.
But would you trust this algorithm and just don't do an intraoperative conjuct with a
risk of 2%?
I think it's very compelling based on what you guys all just said that there's a huge
patient population that they studied in. They developed an algorithm that has a 98% negative
predictive value. They tested the algorithm afterwards. All of those things coming together,
I could be convinced to change my practice and not do a routine intraoperative clangiogram
if this score showed that there was only a 2% chance I was wrong.
So we determined with this algorithm that there's a high risk of colorectal letiasis.
And what is your approach? I think we talked a little bit about this, but basically is
do you do your CP first or do you approach a laparoscopic convoluted exploration?
So there's a lot of it depends situations here. It depends on your center. It depends
on the capabilities. If it's a combined pediatric adult center.
And again, and that was Todd.
If I have a patient that comes in with an impacted stone and their lipase is elevated
the next day, their lipase goes up even more. They're getting more and more jaundice. They're
getting worse. I would send them for ERCP because I don't know how good I am at retrieving
impacted stones. That is different than if I had an ultrasound reading saying that there
was a stone in the common bile duct because that I would feel confident that I would probably
be able to remove. So in our training, we need to have courses or training on newer
techniques of getting those stones out intraoperatively. And Luke Neff has that new device that I've
never used, but apparently is also good. So I think I would do an intraoperative clangogram,
but I do need to get better at learning all of these new techniques of stone removal.
And we thought of what Todd said here. So we include a session at the next update course
this August, 2024. So if you don't want to miss this, don't forget to subscribe to this
year update course in the link below.
I already said my option.
And again, that was Dr. Jose Campos.
Initially did MRCP and ERCP preoperatively. That was in a hospital where we had those
tools available 24 seven, but then with the cost, with the increased length of stay of
waiting, the alternative of laparoscopic common bile duct exploration is looking more and
more interesting. So I think it's time to maybe, maybe with this article, relearn those
skills and get it to the, to the OR again.
Okay. So let's go to the third article of the day. Finally, you mentioned it, Todd,
because this comes from look next team. So this is a trans-distic laparoscopic common
bile duct exploration for pediatrics patients with colorectal lithiasis. It is a multicenter
retrospective cohort study done between 2018 to 2022. And their aim was to compare the
outcomes between the two different patients. The OR first meaning patients who underwent
laparoscopic colostectomy plus the intraoperative cholangiogram. And according to their results,
they can go for laparoscopic common bile duct exploration. And if that fails, then an ERCP.
And then we compare it to the second group that is first an ERCP and then a laparoscopic
colostectomy. So they have 252 patients, 156, and they went the laparoscopic colostectomy
with the intraoperative cholangiogram first and 96 underwent the ERCP first. And what
they found is that patients who underwent the intraoperative cholangiogram had less
complications and shorter length of stay. And of them, 86% of the patients only needed
that surgery.
I really love this study because you said it requires a lot of skills, but this is not
just a single center, one expert surgeon showing off what they can do. This is four centers.
So the range of surgeons that are doing this, it's quite broad. So this article is trying
to say it's feasible. The other myth that gets debunked was that if you do an ERCP post,
the common bile duct is going to explode. You're going to have a leak, et cetera. No, the 14%
patients that had an ERCP post, they were doing just fine. In this article, they do
a stepwise approach. Of all the patients that had only a flush, a saline flush through the
urethral stent, 84% of them got cleared.
I agree with what you're saying. I'm saying there's two points to be made. One is we should
go try it because most of the time you can clear it. But two is I wish I knew how to
be better at removing the ones that don't flush through. And this is something that
actually would be an effectively taught thing in a lab.
Okay. So patient is booked for surgery tomorrow. Would you use ICG?
So here's an example of where I am old and washed up. The answer to this should be yes.
I just don't have as much experience as my younger colleagues.
So this is published in 2023, October in the signing green fluorescent cholangiography,
the new standard practice to perform laparoscopic cholecystectomy in pediatric patients, a comparative
study with conventional laparoscopic technique. Basically they were trying to answer is ICG
lab collie is better than the standard one. And they had 10 years from 2013 to 2023, they
performed 173 lab collies. They had 83 patients with standard technique and 90 patients with
ICG.
In conclusion, they saw the period complication rate was significantly higher in standard
technique, 12% compared to 0%. Overall length of surgery, length of cystic duct isolation,
clipping and time of gallbladder removal were significantly longer in the standard technique.
And the visualization rate of complete biliary was significantly higher.
And let's hear what Dr. Jose Campos had to say.
I don't like this study a lot to call it the new standard practice. I think it's too much.
There's several key points here. So they're comparing different times and in different
times so many things change. Like you get better with surgery, the instruments get better.
So I don't think they're comparing ICG versus non ICG. Secondly, they put all the complications
in the same bags. They don't even report common bile duct lesion as a separate thing.
And I don't think bleeding, it's attributable to having or not having ICG. And then again,
having a group of patients with zero complication, that again, it's kind of a red flag for me.
I agree with you. I always am skeptical of papers that claim that something is now the
new standard just because it's become their new standard. It doesn't necessarily mean
that it's recommended as the standard of care. So that immediately made me question the paper.
It's a shame because I do think this is a very exciting new technology. But if it's
intravenous, I actually am compelled that you just eliminated the need for instrumentation,
which is a big deal.
That's also an important point, Todd. They're not comparing ICG compared to intraoperative
congenital. They're comparing ICG versus nothing versus just simple visualization. So of course,
your end point is going to be, of course, you see more if you use a technique to visualize
more structures.
I think we should be learning about ICG. I mean, this is provocative for me to say,
Todd, come on, get with it. Like, this is something you should probably learn. I don't
know how to learn it. And I do think it's a good study. I mean, I do think it's good
that this study was published because it opened up our eyes that we should be paying attention
to ICG. There's almost no downside to it. It's just a matter of is it really as much
of the holy grail that this article says it is.
Great. So now it's time to summarize. So first, we talked about index admission, cholecystectomy
versus delayed surgery. And we find out that waiting for six weeks to do a cholecystectomy
after an acute gallstone pancreatitis can lead to a 60% recurrence instead of a 2% recurrence.
Then we talk about the algorithms to predict cholericolithiasis. And we find out there's
a new algorithm that can predict cholericolithiasis with a great success rate. So we probably want
to use that in our patients before doing a lab cholecystectomy. Then we talk about cholericolithiasis
and how to approach them with an interpretive clangiogram and if needed, a laparoscopic
common by-lag exploration or an ERCP. And what we find out is that if we have the resources,
we can go for an ERCP first, but we need to learn more on how to do a laparoscopic common
by-lag exploration because that can help our patients to reduce their length of stay in
the hospital and to avoid a second surgery. Last but not least, we talk about ICG and
how that helps us to visualize more the ability to retreat but doesn't necessarily change
the outcomes in our patients.
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