1 00:00:00,000 --> 00:00:05,840 Hello, everyone. 2 00:00:05,840 --> 00:00:09,560 Welcome back to another episode of the Stay Current podcast. 3 00:00:09,560 --> 00:00:15,360 I'm Cecilia Gigena, a research fellow at Cincinnati Children's Hospital, and along with Stay Current, 4 00:00:15,360 --> 00:00:20,400 we are sharing knowledge to improve child health around the globe. 5 00:00:20,400 --> 00:00:25,120 Today we are talking about treatment for common bile duct pathology. 6 00:00:25,120 --> 00:00:30,120 And for that, we have Dr. David Vitale, a pediatric gastroenterologist, 7 00:00:30,120 --> 00:00:35,880 director of the Interventional Endoscopy Center here at Cincinnati Children's Hospital, 8 00:00:35,880 --> 00:00:43,520 and Dr. Luke Neff, a pediatric surgeon at Atrium Health at Wake Forest Baptist. 9 00:00:43,520 --> 00:00:50,000 As we know, chelatorcholothiasis is the presence of at least one gallstone in the common bile duct. 10 00:00:50,000 --> 00:00:55,600 The stone may be made up of biopigments or calcium and cholesterol salts. 11 00:00:55,600 --> 00:00:58,320 We know that there are metabolic risk factors. 12 00:00:58,320 --> 00:01:03,480 Hemolysis, such as sickle cell, congenital and biliary anomalies, like colorectal cysts. 13 00:01:03,480 --> 00:01:08,960 It's more common in older children, children with higher BMI, and patients of Hispanic ethnicity. 14 00:01:08,960 --> 00:01:15,280 So risk factors include metabolic diseases, hemolysis, and biliary anomalies. 15 00:01:15,280 --> 00:01:18,120 Now, let's start with a case. 16 00:01:18,120 --> 00:01:22,480 So this is the case of a 14-year-old who came in presenting with right upper quadrant pain, 17 00:01:22,480 --> 00:01:25,480 and her initial exam and evaluation was relatively unremarkable, 18 00:01:25,480 --> 00:01:28,120 other than some right upper quadrant tenderness. 19 00:01:28,120 --> 00:01:37,000 She had elevated AST and ALT with total bilirubin of 1.8 and direct bilirubin of 1.3. 20 00:01:37,000 --> 00:01:42,120 She had an abdominal ultrasound done, and the common bile duct was about 5 millimeters. 21 00:01:42,120 --> 00:01:46,760 She did have gallbladder stones on the imaging, but they could not see the distal common bile duct. 22 00:01:46,760 --> 00:01:50,360 BMI was in the 98th percentile. 23 00:01:50,360 --> 00:01:52,800 So what do we do next? 24 00:01:52,800 --> 00:01:58,440 This slide is actually taken from ASGE, which is the Adult Endoscopy Society for GI. 25 00:01:58,440 --> 00:02:04,600 So patients with a high probability would have things like common bile duct seen on ultrasound, 26 00:02:04,600 --> 00:02:07,680 ascending cholangitis, or quite high bilirubin. 27 00:02:07,680 --> 00:02:11,480 And recommendation in those patients really is to go straight to ERCP. 28 00:02:11,480 --> 00:02:17,520 Patients with intermediate risk include those who have abnormal liver biochemical tests 29 00:02:17,520 --> 00:02:20,320 or dilated common bile ducts. 30 00:02:20,320 --> 00:02:23,000 We can do an endoscopic ultrasound to look for a stone. 31 00:02:23,000 --> 00:02:28,640 We can do an MRCP, a laparoscopic clangiogram, or an intraoperative ultrasound. 32 00:02:28,640 --> 00:02:32,880 This intermediate category is where our patient falls. 33 00:02:32,880 --> 00:02:36,320 And then patients that have no predictors present, obviously, 34 00:02:36,320 --> 00:02:38,840 would just go on to potentially call a cystectomy. 35 00:02:38,840 --> 00:02:39,920 What about in children? 36 00:02:39,920 --> 00:02:44,640 So there's a few publications related to this, and they found that direct bilirubin 37 00:02:44,640 --> 00:02:50,480 or conjugated bilirubin more than two was the most predictive factor. 38 00:02:50,480 --> 00:02:55,760 And secondarily, a common bile duct diameter greater than six millimeters, 39 00:02:55,760 --> 00:02:59,280 although they didn't find a statistical difference, 40 00:02:59,280 --> 00:03:03,600 was most sensitive for predicting common bile duct stones. 41 00:03:03,600 --> 00:03:08,320 And there is a pediatric duct score, and this was published in the Journal of American College 42 00:03:08,320 --> 00:03:11,440 of Surgeons with 10 centers that participated. 43 00:03:11,440 --> 00:03:14,800 And they found that patients with ducts greater than six millimeters, 44 00:03:14,800 --> 00:03:19,200 common bile duct stones on ultrasound, or a total bilirubin greater than 1.8 45 00:03:19,200 --> 00:03:21,040 were the most predictive risk factors. 46 00:03:21,040 --> 00:03:26,520 So if patients had three risk factors, it was very high predictability. 47 00:03:26,520 --> 00:03:30,000 If they have two, it was high predictability. 48 00:03:30,000 --> 00:03:34,480 And if they only have one, they fall in this intermediate category. 49 00:03:34,480 --> 00:03:38,240 So how do we continue treating this patient? 50 00:03:38,240 --> 00:03:41,440 We did an MRCP that showed stone in the common bile ducts. 51 00:03:41,440 --> 00:03:45,360 The patient had an ERCP that was done in a subsequent lab collie. 52 00:03:45,360 --> 00:03:49,360 There's some pretty good pediatric literature out there in a small sample pot size 53 00:03:49,360 --> 00:03:54,400 that show that doing same anesthesia laparoscopic colostectomy with ERCP 54 00:03:54,400 --> 00:03:57,760 and stone disease led to less anesthesia time and lower length of stay. 55 00:03:58,560 --> 00:04:03,840 And what about ERCP versus laparoscopic common bile duct exploration? 56 00:04:03,840 --> 00:04:06,240 There's a lot of retrospective data that's out there. 57 00:04:06,240 --> 00:04:09,200 I looked through a lot of the studies and the data is really conflicted. 58 00:04:09,200 --> 00:04:13,920 I really think, again, it gets back to institution-dependent expertise 59 00:04:13,920 --> 00:04:18,800 and it's probably provider-dependent and the institution's experience with this. 60 00:04:18,800 --> 00:04:24,560 There are a few randomized trials from 2013, but they show no significant difference 61 00:04:24,560 --> 00:04:30,880 in morbidity, mortality, retained stones, or failure rates between the two groups. 62 00:04:30,880 --> 00:04:33,360 But what about real-world experience? 63 00:04:33,360 --> 00:04:38,400 What are the considerations we have to know when approaching one of these patients? 64 00:04:39,040 --> 00:04:42,160 Stones above the cystic duct obviously pose a big problem 65 00:04:42,160 --> 00:04:46,960 and even with attempted laparoscopic removal, these stones can float up there 66 00:04:46,960 --> 00:04:50,720 and make a pretty straightforward ERCP, a much more difficult one. 67 00:04:50,720 --> 00:04:54,320 So when there's one stone and it's pretty easy to flush out, 68 00:04:54,320 --> 00:04:57,040 doing this laparoscopically is not that big of a deal 69 00:04:57,040 --> 00:05:00,240 as if there's four or five stones there or a larger stone. 70 00:05:00,240 --> 00:05:05,520 I think local expertise and availability is probably the most important thing in this decision tree. 71 00:05:07,440 --> 00:05:12,720 Now that we covered this view from a gastroenterologist's point of view with Dr. Vitale, 72 00:05:13,280 --> 00:05:17,360 let's move to the surgical side with Dr. Luke Neff. 73 00:05:17,360 --> 00:05:23,520 We know the dominant paradigm across the country is an MRCP, very often followed by an ERCP, 74 00:05:23,520 --> 00:05:27,200 but surgeons should be comfortable dealing with issues in the chondrodoc. 75 00:05:27,200 --> 00:05:29,520 Resource utilization is a real thing. 76 00:05:29,520 --> 00:05:32,160 And then length of stay in the hospital is an important issue. 77 00:05:32,160 --> 00:05:37,920 So to avoid this longer length of stay and reduced resource utilization, 78 00:05:37,920 --> 00:05:41,760 Dr. Neff is proposing a different approach for those centers that 79 00:05:41,760 --> 00:05:44,880 doesn't have a pediatric endoscopist available. 80 00:05:45,440 --> 00:05:48,720 The paradigm we are presenting is a surgery-first presentation. 81 00:05:48,720 --> 00:05:52,240 Go to the operating room. You are comfortable doing IOC. 82 00:05:52,880 --> 00:05:57,600 In case you were wondering, IOC means intraoperative cholangiogram. 83 00:05:57,600 --> 00:06:01,600 And there's essentially kind of three different things that can come out of that, right? 84 00:06:01,600 --> 00:06:04,640 You shoot it and it's negative. That's great. You send them home. 85 00:06:04,640 --> 00:06:10,560 So if you have a negative IOC, you can finish your laparoscopic cholestectomy and send them home. 86 00:06:10,560 --> 00:06:14,160 The other two scenarios are if you have a positive IOC. 87 00:06:14,160 --> 00:06:18,480 So if it is positive, but you don't feel comfortable with a common bile duct exploration, 88 00:06:18,480 --> 00:06:22,720 they can get what they would have had in the first place, an ERCP. 89 00:06:22,720 --> 00:06:26,320 And then obviously something that would be an ideal scenario. 90 00:06:26,320 --> 00:06:29,040 They go to the operating room, they get their common duct exploration out, 91 00:06:29,040 --> 00:06:34,720 and you're able to avoid all these other things, particularly a second genital anesthetic. 92 00:06:34,720 --> 00:06:42,320 So in a superficial way, how can we approach to laparoscopically remove common bile duct stones? 93 00:06:42,320 --> 00:06:44,880 So our mantra is all stones go forward. 94 00:06:44,880 --> 00:06:49,680 And so we use balloons to dilate up the sphincter and then flush them, integrating them. 95 00:06:49,680 --> 00:06:59,280 Great. So perform an IOC and first try to flush the stone forward to the duodenum using wire or catheters. 96 00:06:59,280 --> 00:07:04,160 Second, we'll try to dilate the ampulla with balloons and then flush the stones. 97 00:07:04,800 --> 00:07:05,440 What's next? 98 00:07:06,480 --> 00:07:11,040 There's more exotic things like the spyglass, lipotripsy as well for these big stones. 99 00:07:11,040 --> 00:07:14,720 And again, this is probably more on the adult side. I've not seen any massive, massive stones 100 00:07:14,720 --> 00:07:19,600 in children. You can place it in your stents laparoscopically, transistically, and then colloidal 101 00:07:19,600 --> 00:07:24,000 got to me, which is something that I think would be mentioned only to be condemned. 102 00:07:24,000 --> 00:07:29,920 And when do you say, okay, I couldn't do it laparoscopically, let's do an ERCP. 103 00:07:29,920 --> 00:07:35,040 If you're having to open up the common bile to extract the stone and you had ERCP capability, 104 00:07:35,040 --> 00:07:38,560 I think that that's probably in most cases, not the right thing to do. 105 00:07:39,200 --> 00:07:43,280 Now let's go into deeper detail. What kind of equipment 106 00:07:43,280 --> 00:07:47,920 are you using to do all this? We've created a cart. Actually, 107 00:07:47,920 --> 00:07:51,680 we want to keep this as cheap as possible. Five or six French, your readable stent, 108 00:07:51,680 --> 00:07:58,240 $7, 035, gladwire. That's 50 bucks. And that gets you started. That can do a lot for you, 109 00:07:58,240 --> 00:08:00,800 actually. So you can not only shoot your initial gram. 110 00:08:00,800 --> 00:08:06,720 In case you were wondering, shooting grams is the cool way of saying, doing an IOC. 111 00:08:06,720 --> 00:08:11,120 You can traverse the dock to just use the simplest, cheapest stuff you've got. 112 00:08:11,120 --> 00:08:14,880 And it's actually really effective. If you want to see the full list of the 113 00:08:14,880 --> 00:08:19,840 equipment they use, go to the description to find the link with all the necessary things 114 00:08:19,840 --> 00:08:23,920 that you need to fill your common bile back exploration cart. 115 00:08:23,920 --> 00:08:27,840 And everything we do is over a guide wire so that it makes that next step. If you, 116 00:08:27,840 --> 00:08:32,240 that step up approach that I talked about, your kit is already designed to help you take the next 117 00:08:32,240 --> 00:08:37,120 step. Especially if you're using balloons at some point to dilate the ampullin and flush through. 118 00:08:37,120 --> 00:08:42,400 And in patients that you couldn't address them surgically and they need to go to an ERCP, 119 00:08:42,400 --> 00:08:46,400 do you do something to the cystic duct? I put an endo loop on there, just a little 120 00:08:46,400 --> 00:08:50,640 belt and suspenders. I mean, maybe I've already put a clip and I'll try to get an endo loop 121 00:08:50,640 --> 00:08:54,880 more proximal to that. And, you know, with our cholangiogram, we have an idea of how much 122 00:08:54,880 --> 00:08:59,840 cystic duct we have. So I like that little extra bit of security. Don't typically leave a drain. 123 00:08:59,840 --> 00:09:05,360 So ERCP and laparoscopic common bile that exploration in hands of an expert have similar 124 00:09:05,360 --> 00:09:10,000 outcomes, but you have to be aware of the resources in place have to make the better 125 00:09:10,000 --> 00:09:15,840 choice for the patients. For example, most freestanding children's hospitals do not have 126 00:09:15,840 --> 00:09:20,400 ERCP capabilities, which is something that Cincinnati Children's counts with. 127 00:09:21,280 --> 00:09:24,960 I will completely agree with that. You're the unicorn, right? Not everybody has a unicorn. 128 00:09:26,720 --> 00:09:30,720 Okay. So now that we discussed the pros and cons of the different approaches, 129 00:09:30,720 --> 00:09:37,120 let's talk about how is that Dr. Neff does the common bile duct exploration. 130 00:09:37,120 --> 00:09:41,360 We just use a 12 gauge angiocath, which may be hard to find in a pediatric hospital, 131 00:09:41,360 --> 00:09:45,360 but you can order them. We don't use existing ports because we want our angle of entry into 132 00:09:45,360 --> 00:09:52,000 the cystic ductotomy to be as flat as possible. Great. Making new incision to pass the instruments 133 00:09:52,000 --> 00:09:56,720 at a better angle through the cystic duct. And what type of catheter do you use? 134 00:09:56,720 --> 00:10:02,080 This is just a little six French urethral stent that we cut down. We make it a lot smaller or 135 00:10:02,080 --> 00:10:06,880 shorter for better flow. And we put a, we put the glide wire in there. We almost use like a 136 00:10:06,880 --> 00:10:11,680 cylinder technique to get it into the duct so that we can navigate all those valves. 137 00:10:12,480 --> 00:10:18,560 So six French urethral catheter, pass it through the cystic duct. And then? 138 00:10:18,560 --> 00:10:22,960 The one thing we would do next is we would get using the guide wire to help us direct in, 139 00:10:22,960 --> 00:10:29,120 we would get that catheter actually parked into the common duct and get it right at the point 140 00:10:29,120 --> 00:10:32,640 of obstruction and really push hard. And if it doesn't work? 141 00:10:32,640 --> 00:10:37,040 And then you can even push that catheter over the wire to kind of ream out the sphincter a little 142 00:10:37,040 --> 00:10:42,960 bit. And then through that 12 French angiocath over the wire, we pass a angioplasty balloon. And 143 00:10:42,960 --> 00:10:48,720 I typically will use either a six millimeter or eight millimeter, but definitely not more than that. 144 00:10:48,720 --> 00:10:55,680 Perfect. So pass the wire up to the dune denum and then grab an angioplasty balloon of six to eight 145 00:10:55,680 --> 00:11:01,920 millimeters and dilate. But do you dilate in the duct, the sphincter or both? 146 00:11:01,920 --> 00:11:06,320 So what we do is we blow up the balloon in the duct and we actually pull back on it and give a 147 00:11:06,320 --> 00:11:10,800 little tactile feedback to know exactly where that sphincter is. And then we partially deflate 148 00:11:10,800 --> 00:11:16,480 and we straddle the ampule. And then we go to full profile under fluoro, seeing the balloon come up 149 00:11:16,480 --> 00:11:21,920 to its full diameter. And then we hold that for about five minutes. And Dr. Vitale had some advice 150 00:11:21,920 --> 00:11:27,360 for us too. I think your point there, never use a balloon that's larger than the dilated common 151 00:11:27,360 --> 00:11:32,240 bile duct, which is really important because we know that there is some URSP literature out there 152 00:11:32,240 --> 00:11:38,320 with people looking at doing dilations of the ampule without doing sphincterotomy. And there's 153 00:11:38,320 --> 00:11:44,080 definitely a higher rate of pancreatitis in those patients. Perfect. So six to eight millimeters 154 00:11:44,080 --> 00:11:50,400 balloons that are smaller than the dilated common bile duct. Watch for possible pancreatitis post 155 00:11:50,400 --> 00:11:56,560 procedure. And what do we do with the stones after dilating the sphincter? We keep our guide wire 156 00:11:56,560 --> 00:12:01,360 access in the duodenum and then I'll actually pull back and I generally actually will straddle the 157 00:12:01,360 --> 00:12:06,080 cystic duct common duct, but I won't fully inflate. I'll inflate a little bit because I want to create 158 00:12:06,080 --> 00:12:12,320 a seal on that distal common duct so that everything I flush through the guide wire lumen gets 159 00:12:12,320 --> 00:12:18,640 pressurized downstream. And what happens if it fails? And you know, at that point, if we're not 160 00:12:18,640 --> 00:12:24,480 getting the job done, then we quit, you know, and we'll throw our endolupal on and call GI. Dr. 161 00:12:24,480 --> 00:12:30,080 Vitale also recommended that if we start seeing the pancreatic duct in the floral, we should stop, 162 00:12:30,080 --> 00:12:37,280 since that has a higher risk for pancreatitis. Stone disease is not going anywhere. If anything, 163 00:12:37,280 --> 00:12:41,440 prevalence is increasing. So it's just nice to have some tools in your toolkit. Even if you don't go 164 00:12:41,440 --> 00:12:47,120 to the point of balloons, knowing that thinking about how to navigate across the ampoule with 165 00:12:47,120 --> 00:12:51,680 wire and using your little catheter to wring it out and get some really good flushes right at the 166 00:12:51,680 --> 00:12:57,760 point of obstruction. I think those things are just helpful. Awesome. And is there any advice on how 167 00:12:57,760 --> 00:13:03,120 to get comfortable and learn the skills among surgeons? I think number one is getting familiar 168 00:13:03,120 --> 00:13:07,680 with the kit and if you put together a cart or have something like that where somebody can purchase 169 00:13:07,680 --> 00:13:12,560 those items, just plan around and getting familiar with it. So first step, getting to know the 170 00:13:12,560 --> 00:13:19,440 equipment we are going to need to work with. Have a plan. Have the equipment at your disposal and 171 00:13:19,440 --> 00:13:24,800 just start shooting grams, maybe even on elective cases, just to get a feel for it. And truly, 172 00:13:24,800 --> 00:13:31,360 the position of that 12 gauge angiocath is really important. Your ability to manipulate the catheter 173 00:13:31,360 --> 00:13:37,600 and the wire in the duct is all about your initial setup and how flat your angle of entry is into the 174 00:13:37,600 --> 00:13:43,760 cystic duct. What's the learning curve on this? So that's a very person specific question, but I 175 00:13:43,760 --> 00:13:52,400 would say around five to ten. Awesome. So now it's time to summarize. Risk factors for common 176 00:13:52,400 --> 00:13:59,360 bile duct stones include metabolic diseases, hemolysis, and biliary anomalies. Within the 177 00:13:59,360 --> 00:14:08,320 diagnostic tools, we have endoscopic ultrasound, MRCP, or laparoscopic cholangiogram. ERCP and 178 00:14:08,320 --> 00:14:14,800 laparoscopic common bile duct exploration are both useful in the treatment of this pathology, 179 00:14:14,800 --> 00:14:20,320 with few differences in outcomes, though ERCP may represent longer length of stay 180 00:14:20,880 --> 00:14:27,200 and two procedures with anesthesia in the majority of the establishments. Important 181 00:14:27,200 --> 00:14:34,240 tools for laparoscopic common bile duct exploration include urethral stents, glide wire, 182 00:14:34,240 --> 00:14:41,440 and balloons for dilating the sphincter and flushing stones. It is very important to be familiarized 183 00:14:41,440 --> 00:14:48,640 with this equipment prior to using it in a patient. Proper setup and angle of entry are crucial for 184 00:14:48,640 --> 00:14:55,360 successful catheter and wire navigation during procedures. A statewide approach for treating 185 00:14:55,360 --> 00:15:03,600 common bile duct stones is key, knowing that if we fail, patients can always have an ERCP post-op. 186 00:15:06,480 --> 00:15:12,880 And that was Galerical Atheism with Dr. Vitale and Neff. I hope you enjoy it. Don't forget to subscribe 187 00:15:12,880 --> 00:15:17,760 to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay 188 00:15:17,760 --> 00:15:24,000 Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati 189 00:15:24,000 --> 00:15:29,440 Children's Hospital, sharing knowledge to improve child health around the globe.