1
00:00:00,000 --> 00:00:09,920
Hello everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Gigena

2
00:00:09,920 --> 00:00:14,480
and I'm Em Gootee. And we are research fellows at Cincinnati Children's Hospital. And along

3
00:00:14,480 --> 00:00:18,920
with Stay Current, we are sharing knowledge to improve child health around the globe.

4
00:00:18,920 --> 00:00:24,580
So today we have another episode of the case-based journal review. So to remind you what this

5
00:00:24,580 --> 00:00:31,880
is, we are working with Dr. Jose Campos. Hi, I'm Jose Campos. I work in Roberto del Río

6
00:00:31,880 --> 00:00:37,120
Hospital in Chile and also leading a group of volunteers called Journal Hive. And we

7
00:00:37,120 --> 00:00:43,320
try to bring you the best of pediatric surgery literature to use. And with Dr. Todd Ponsky,

8
00:00:43,320 --> 00:00:49,760
the pediatric surgeon and the chief innovation officer here at Cincinnati Children's. And

9
00:00:49,760 --> 00:00:57,480
what we do is we go through a case and discuss the latest updates in the literature about

10
00:00:57,480 --> 00:01:03,940
the specific pathology to help treat this patient in a better way. And today I'm super excited

11
00:01:03,940 --> 00:01:07,860
about this podcast. We haven't done one in a while. That's reason number one. But also

12
00:01:07,860 --> 00:01:12,320
I'm super excited about this podcast because Chile is the country with the highest rate

13
00:01:12,320 --> 00:01:18,120
of cholalithiasis. So this is something we can actually say something. So let's start.

14
00:01:18,120 --> 00:01:27,120
We have a 12 year old female with acute gallstone pancreatitis admitted overnight. So for this

15
00:01:27,120 --> 00:01:33,920
patient, do we do an index admission cholecystectomy or a delayed surgery? It really depends on

16
00:01:33,920 --> 00:01:39,560
the patient and the situation. And that was Dr. Todd Ponsky. I typically do it before

17
00:01:39,560 --> 00:01:46,800
they go home and I have not found that it's prohibitively difficult in most cases to do

18
00:01:46,800 --> 00:01:51,440
the operation. I call this a little bit of the history of the cool off period. And in

19
00:01:51,440 --> 00:01:57,280
case you forgot, that was Dr. Jose Campos. We always favor for our index admission surgery,

20
00:01:57,280 --> 00:02:01,600
but they always told me if their symptoms have been going on for too long, just let

21
00:02:01,600 --> 00:02:06,320
the pancreatitis heal for a time at home and then bring the patient back. And that threshold

22
00:02:06,320 --> 00:02:11,920
was around the seven to 10 day mark. And then when I went back to pediatric surgery, that

23
00:02:11,920 --> 00:02:16,160
threshold was around the two to three day mark for them. And it was very difficult for

24
00:02:16,160 --> 00:02:22,040
me to convince them on doing index and admission surgery. Well, maybe this first article of

25
00:02:22,040 --> 00:02:27,720
today can help you to convince them. First article is index admission cholecystectomy

26
00:02:27,720 --> 00:02:34,400
and recurrence of pediatric gallstone pancreatitis, multi-centered cohort analysis. So this is

27
00:02:34,400 --> 00:02:40,760
a paper that came in journal of the American College of Surgeons. It's a multi-center retrospective

28
00:02:40,760 --> 00:02:48,680
review of pediatric patients with gallstones pancreatitis between 2010 and 2017. And their

29
00:02:48,680 --> 00:02:54,760
aim was to compare the recurrence rates of pancreatitis, also compare outcomes and complications

30
00:02:54,760 --> 00:03:02,240
between patients undergoing early cholecystectomy, meaning during the index admission, and those

31
00:03:02,240 --> 00:03:08,440
who underwent delayed surgery, which was those who haven't received surgery at the moment

32
00:03:08,440 --> 00:03:17,480
of the study, or it was done after the stretch. They had 167 underwent an early cholecystectomy

33
00:03:17,480 --> 00:03:24,320
and 79 underwent a delayed cholecystectomy. The general outcome is that patients who underwent

34
00:03:24,320 --> 00:03:34,080
the early cholecystectomy had only 2% of recurrence pancreatitis compared to 22% in patients doing

35
00:03:34,080 --> 00:03:41,200
a delayed surgical approach. Interestingly, if they waited more than six weeks, the recurrence

36
00:03:41,200 --> 00:03:48,040
rate went up to 60%. So 2% of the time in patients, even if they have no stones, they

37
00:03:48,040 --> 00:03:53,400
will get recurrent pancreatitis from their initial insult, whereas 60% if you wait six

38
00:03:53,400 --> 00:03:59,080
weeks, that is so provocative, that is so clear cut, then nobody should be debating

39
00:03:59,080 --> 00:04:02,720
this anymore. That's what I was going to say. Like, first you said, if I have a reliable

40
00:04:02,720 --> 00:04:06,880
patient, but this changes my approach, not even in the reliable patient, we should send

41
00:04:06,880 --> 00:04:11,680
them home without their gallbladder removed. I agree. I think we still need to see on the

42
00:04:11,680 --> 00:04:18,760
skill of the surgeon and still we need to think of the severity of the illness to individualize

43
00:04:18,760 --> 00:04:24,560
this information. But for the vast majority of gallstone pancreatitis, I think this should

44
00:04:24,560 --> 00:04:30,960
be the strategy. Yes. And one thing that is important too is that patients who underwent

45
00:04:30,960 --> 00:04:37,640
the early cholestectomy didn't have more biliary complications. That's a really good

46
00:04:37,640 --> 00:04:43,840
point because the fear of going in early was doing more damage than benefit. And that is

47
00:04:43,840 --> 00:04:51,840
not proven in this article. Yeah. Are we ready for the second question? Yeah. So let's say

48
00:04:51,840 --> 00:04:56,040
pancreatitis is resolved and you're ready to operate on this patient. Can you predict

49
00:04:56,040 --> 00:05:00,880
the risk of cholera choliatesis in this patient? So what do you think about this, Todd? I think

50
00:05:00,880 --> 00:05:07,120
it's a good question. So interestingly, when patients come in with gallstone pancreatitis

51
00:05:07,120 --> 00:05:13,920
and they have all of this pain, most of the time, the symptoms of the pain and the elevated

52
00:05:13,920 --> 00:05:19,320
enzymes are as the stone is passing. So it's interesting that if you wait till the next

53
00:05:19,320 --> 00:05:24,480
day, you find resolution because the stone often has passed. Now there might be other

54
00:05:24,480 --> 00:05:31,640
stones, but oftentimes these will pass overnight. Would you go in a relaxed mode to a lab collate

55
00:05:31,640 --> 00:05:38,320
directly to this patient or would you do something? What would you do? So if your numbers normalize,

56
00:05:38,320 --> 00:05:43,360
I do not do ERCP. I will do an intraoperative clangiogram to make sure there's not another

57
00:05:43,360 --> 00:05:48,880
stone, but I would not do an ERCP if their numbers normalize. And let's hear what Dr.

58
00:05:48,880 --> 00:05:55,280
Jose Campos had to say. So the situation you don't want to be in is you book a case as

59
00:05:55,280 --> 00:06:01,440
a simple lab collate, no intraoperative clangiogram. You didn't think of an MRCP or ERCP or anything

60
00:06:01,440 --> 00:06:07,080
and then boom, you find this stone there. That's what we want to avoid. So how I dealt

61
00:06:07,080 --> 00:06:12,520
with this situation before, if they had no alteration at all, no history of cholangitis

62
00:06:12,520 --> 00:06:18,280
or pancreatitis, I would just do a lab collate and nothing else. But if there was any alteration

63
00:06:18,280 --> 00:06:24,880
whatsoever, I would just do an MRCP and if it's positive, do an ERCP. So that's why I

64
00:06:24,880 --> 00:06:32,940
brought this article. So this article is coming from Western Pediatric Surgery Research Consortium.

65
00:06:32,940 --> 00:06:37,680
It's a retrospective study and they looked at machine learning to predict pediatric choledic

66
00:06:37,680 --> 00:06:44,640
luteitis. And this article was published in 2023 in the Surgery Journal. Their main question

67
00:06:44,640 --> 00:06:49,920
was is it possible to predict the risk of common bile duct stones preoperatively? It's

68
00:06:49,920 --> 00:06:57,520
a multi-center, included 10 different centers between 2016 to 2019. They had nearly 1600

69
00:06:57,520 --> 00:07:05,160
patients. 20% of them had common bile duct stones and they were able to look for nine

70
00:07:05,160 --> 00:07:10,440
most important clinical factors. Their result is yes, we can predict and let's use this

71
00:07:10,440 --> 00:07:11,440
model.

72
00:07:11,440 --> 00:07:16,880
The negative predictive value of this algorithm is 98%. That means that you're going to be

73
00:07:16,880 --> 00:07:23,480
in that nasty situation only 2% of the time if you trust this algorithm. So that's why

74
00:07:23,480 --> 00:07:29,800
I think this is the one to use. And I don't think we can get more precise than this algorithm

75
00:07:29,800 --> 00:07:32,840
in terms of predicting CBD stones preoperatively.

76
00:07:32,840 --> 00:07:38,120
It has a decent amount of patient population too. I think the previous algorithm was around

77
00:07:38,120 --> 00:07:44,400
300 to 400 patients. This one has 1600. It's just so exciting to see we finally trying

78
00:07:44,400 --> 00:07:50,760
to create algorithms and trying to implement in our daily practice to be able to precise

79
00:07:50,760 --> 00:07:51,760
decisions.

80
00:07:51,760 --> 00:07:56,680
But would you trust this algorithm and just don't do an intraoperative conjuct with a

81
00:07:56,680 --> 00:07:58,280
risk of 2%?

82
00:07:58,280 --> 00:08:03,520
I think it's very compelling based on what you guys all just said that there's a huge

83
00:08:03,520 --> 00:08:08,840
patient population that they studied in. They developed an algorithm that has a 98% negative

84
00:08:08,840 --> 00:08:15,760
predictive value. They tested the algorithm afterwards. All of those things coming together,

85
00:08:15,760 --> 00:08:23,680
I could be convinced to change my practice and not do a routine intraoperative clangiogram

86
00:08:23,680 --> 00:08:31,540
if this score showed that there was only a 2% chance I was wrong.

87
00:08:31,540 --> 00:08:36,920
So we determined with this algorithm that there's a high risk of colorectal letiasis.

88
00:08:36,920 --> 00:08:41,680
And what is your approach? I think we talked a little bit about this, but basically is

89
00:08:41,680 --> 00:08:46,880
do you do your CP first or do you approach a laparoscopic convoluted exploration?

90
00:08:46,880 --> 00:08:52,440
So there's a lot of it depends situations here. It depends on your center. It depends

91
00:08:52,440 --> 00:08:56,320
on the capabilities. If it's a combined pediatric adult center.

92
00:08:56,320 --> 00:08:59,000
And again, and that was Todd.

93
00:08:59,000 --> 00:09:03,920
If I have a patient that comes in with an impacted stone and their lipase is elevated

94
00:09:03,920 --> 00:09:08,200
the next day, their lipase goes up even more. They're getting more and more jaundice. They're

95
00:09:08,200 --> 00:09:15,320
getting worse. I would send them for ERCP because I don't know how good I am at retrieving

96
00:09:15,320 --> 00:09:20,840
impacted stones. That is different than if I had an ultrasound reading saying that there

97
00:09:20,840 --> 00:09:25,360
was a stone in the common bile duct because that I would feel confident that I would probably

98
00:09:25,360 --> 00:09:33,440
be able to remove. So in our training, we need to have courses or training on newer

99
00:09:33,440 --> 00:09:40,200
techniques of getting those stones out intraoperatively. And Luke Neff has that new device that I've

100
00:09:40,200 --> 00:09:46,380
never used, but apparently is also good. So I think I would do an intraoperative clangogram,

101
00:09:46,380 --> 00:09:50,960
but I do need to get better at learning all of these new techniques of stone removal.

102
00:09:50,960 --> 00:09:56,160
And we thought of what Todd said here. So we include a session at the next update course

103
00:09:56,160 --> 00:10:02,300
this August, 2024. So if you don't want to miss this, don't forget to subscribe to this

104
00:10:02,300 --> 00:10:04,680
year update course in the link below.

105
00:10:04,680 --> 00:10:07,360
I already said my option.

106
00:10:07,360 --> 00:10:10,080
And again, that was Dr. Jose Campos.

107
00:10:10,080 --> 00:10:16,780
Initially did MRCP and ERCP preoperatively. That was in a hospital where we had those

108
00:10:16,780 --> 00:10:22,120
tools available 24 seven, but then with the cost, with the increased length of stay of

109
00:10:22,120 --> 00:10:28,360
waiting, the alternative of laparoscopic common bile duct exploration is looking more and

110
00:10:28,360 --> 00:10:32,920
more interesting. So I think it's time to maybe, maybe with this article, relearn those

111
00:10:32,920 --> 00:10:35,960
skills and get it to the, to the OR again.

112
00:10:35,960 --> 00:10:41,320
Okay. So let's go to the third article of the day. Finally, you mentioned it, Todd,

113
00:10:41,320 --> 00:10:47,800
because this comes from look next team. So this is a trans-distic laparoscopic common

114
00:10:47,800 --> 00:10:52,920
bile duct exploration for pediatrics patients with colorectal lithiasis. It is a multicenter

115
00:10:52,920 --> 00:10:59,560
retrospective cohort study done between 2018 to 2022. And their aim was to compare the

116
00:10:59,560 --> 00:11:06,600
outcomes between the two different patients. The OR first meaning patients who underwent

117
00:11:06,600 --> 00:11:13,280
laparoscopic colostectomy plus the intraoperative cholangiogram. And according to their results,

118
00:11:13,280 --> 00:11:20,480
they can go for laparoscopic common bile duct exploration. And if that fails, then an ERCP.

119
00:11:20,480 --> 00:11:26,120
And then we compare it to the second group that is first an ERCP and then a laparoscopic

120
00:11:26,120 --> 00:11:34,920
colostectomy. So they have 252 patients, 156, and they went the laparoscopic colostectomy

121
00:11:34,920 --> 00:11:41,400
with the intraoperative cholangiogram first and 96 underwent the ERCP first. And what

122
00:11:41,400 --> 00:11:48,420
they found is that patients who underwent the intraoperative cholangiogram had less

123
00:11:48,420 --> 00:11:55,800
complications and shorter length of stay. And of them, 86% of the patients only needed

124
00:11:55,800 --> 00:11:56,800
that surgery.

125
00:11:56,800 --> 00:12:01,920
I really love this study because you said it requires a lot of skills, but this is not

126
00:12:01,920 --> 00:12:08,320
just a single center, one expert surgeon showing off what they can do. This is four centers.

127
00:12:08,320 --> 00:12:13,760
So the range of surgeons that are doing this, it's quite broad. So this article is trying

128
00:12:13,760 --> 00:12:20,880
to say it's feasible. The other myth that gets debunked was that if you do an ERCP post,

129
00:12:20,880 --> 00:12:26,600
the common bile duct is going to explode. You're going to have a leak, et cetera. No, the 14%

130
00:12:26,600 --> 00:12:30,820
patients that had an ERCP post, they were doing just fine. In this article, they do

131
00:12:30,820 --> 00:12:36,960
a stepwise approach. Of all the patients that had only a flush, a saline flush through the

132
00:12:36,960 --> 00:12:41,280
urethral stent, 84% of them got cleared.

133
00:12:41,280 --> 00:12:45,040
I agree with what you're saying. I'm saying there's two points to be made. One is we should

134
00:12:45,040 --> 00:12:51,480
go try it because most of the time you can clear it. But two is I wish I knew how to

135
00:12:51,480 --> 00:12:56,600
be better at removing the ones that don't flush through. And this is something that

136
00:12:56,600 --> 00:13:01,600
actually would be an effectively taught thing in a lab.

137
00:13:01,600 --> 00:13:08,080
Okay. So patient is booked for surgery tomorrow. Would you use ICG?

138
00:13:08,080 --> 00:13:14,600
So here's an example of where I am old and washed up. The answer to this should be yes.

139
00:13:14,600 --> 00:13:18,360
I just don't have as much experience as my younger colleagues.

140
00:13:18,360 --> 00:13:24,980
So this is published in 2023, October in the signing green fluorescent cholangiography,

141
00:13:24,980 --> 00:13:30,560
the new standard practice to perform laparoscopic cholecystectomy in pediatric patients, a comparative

142
00:13:30,560 --> 00:13:37,880
study with conventional laparoscopic technique. Basically they were trying to answer is ICG

143
00:13:37,880 --> 00:13:46,800
lab collie is better than the standard one. And they had 10 years from 2013 to 2023, they

144
00:13:46,800 --> 00:13:53,720
performed 173 lab collies. They had 83 patients with standard technique and 90 patients with

145
00:13:53,720 --> 00:13:54,720
ICG.

146
00:13:54,720 --> 00:14:00,200
In conclusion, they saw the period complication rate was significantly higher in standard

147
00:14:00,200 --> 00:14:07,040
technique, 12% compared to 0%. Overall length of surgery, length of cystic duct isolation,

148
00:14:07,040 --> 00:14:13,020
clipping and time of gallbladder removal were significantly longer in the standard technique.

149
00:14:13,020 --> 00:14:18,480
And the visualization rate of complete biliary was significantly higher.

150
00:14:18,480 --> 00:14:21,720
And let's hear what Dr. Jose Campos had to say.

151
00:14:21,720 --> 00:14:28,360
I don't like this study a lot to call it the new standard practice. I think it's too much.

152
00:14:28,360 --> 00:14:34,320
There's several key points here. So they're comparing different times and in different

153
00:14:34,320 --> 00:14:40,000
times so many things change. Like you get better with surgery, the instruments get better.

154
00:14:40,000 --> 00:14:46,080
So I don't think they're comparing ICG versus non ICG. Secondly, they put all the complications

155
00:14:46,080 --> 00:14:51,560
in the same bags. They don't even report common bile duct lesion as a separate thing.

156
00:14:51,560 --> 00:14:58,680
And I don't think bleeding, it's attributable to having or not having ICG. And then again,

157
00:14:58,680 --> 00:15:05,240
having a group of patients with zero complication, that again, it's kind of a red flag for me.

158
00:15:05,240 --> 00:15:09,880
I agree with you. I always am skeptical of papers that claim that something is now the

159
00:15:09,880 --> 00:15:14,400
new standard just because it's become their new standard. It doesn't necessarily mean

160
00:15:14,400 --> 00:15:21,160
that it's recommended as the standard of care. So that immediately made me question the paper.

161
00:15:21,160 --> 00:15:26,720
It's a shame because I do think this is a very exciting new technology. But if it's

162
00:15:26,720 --> 00:15:34,800
intravenous, I actually am compelled that you just eliminated the need for instrumentation,

163
00:15:34,800 --> 00:15:36,520
which is a big deal.

164
00:15:36,520 --> 00:15:42,040
That's also an important point, Todd. They're not comparing ICG compared to intraoperative

165
00:15:42,040 --> 00:15:49,800
congenital. They're comparing ICG versus nothing versus just simple visualization. So of course,

166
00:15:49,800 --> 00:15:55,400
your end point is going to be, of course, you see more if you use a technique to visualize

167
00:15:55,400 --> 00:15:56,480
more structures.

168
00:15:56,480 --> 00:16:01,160
I think we should be learning about ICG. I mean, this is provocative for me to say,

169
00:16:01,160 --> 00:16:04,840
Todd, come on, get with it. Like, this is something you should probably learn. I don't

170
00:16:04,840 --> 00:16:09,320
know how to learn it. And I do think it's a good study. I mean, I do think it's good

171
00:16:09,320 --> 00:16:14,040
that this study was published because it opened up our eyes that we should be paying attention

172
00:16:14,040 --> 00:16:19,440
to ICG. There's almost no downside to it. It's just a matter of is it really as much

173
00:16:19,440 --> 00:16:23,720
of the holy grail that this article says it is.

174
00:16:23,720 --> 00:16:32,320
Great. So now it's time to summarize. So first, we talked about index admission, cholecystectomy

175
00:16:32,320 --> 00:16:39,720
versus delayed surgery. And we find out that waiting for six weeks to do a cholecystectomy

176
00:16:39,720 --> 00:16:48,000
after an acute gallstone pancreatitis can lead to a 60% recurrence instead of a 2% recurrence.

177
00:16:48,000 --> 00:16:53,800
Then we talk about the algorithms to predict cholericolithiasis. And we find out there's

178
00:16:53,800 --> 00:17:01,000
a new algorithm that can predict cholericolithiasis with a great success rate. So we probably want

179
00:17:01,000 --> 00:17:08,520
to use that in our patients before doing a lab cholecystectomy. Then we talk about cholericolithiasis

180
00:17:08,520 --> 00:17:16,240
and how to approach them with an interpretive clangiogram and if needed, a laparoscopic

181
00:17:16,240 --> 00:17:22,720
common by-lag exploration or an ERCP. And what we find out is that if we have the resources,

182
00:17:22,720 --> 00:17:28,760
we can go for an ERCP first, but we need to learn more on how to do a laparoscopic common

183
00:17:28,760 --> 00:17:34,760
by-lag exploration because that can help our patients to reduce their length of stay in

184
00:17:34,760 --> 00:17:41,400
the hospital and to avoid a second surgery. Last but not least, we talk about ICG and

185
00:17:41,400 --> 00:17:49,320
how that helps us to visualize more the ability to retreat but doesn't necessarily change

186
00:17:49,320 --> 00:17:54,360
the outcomes in our patients.

187
00:17:54,360 --> 00:17:58,880
Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media

188
00:17:58,880 --> 00:18:05,280
channels and download the Stay Current MD app for tons of content in pediatric surgery.

189
00:18:05,280 --> 00:18:10,960
GlobalCast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child

190
00:18:10,960 --> 00:18:11,960
health around the globe.