Choledocholithiasis with Drs. David Vitale & Lucas Neff

Hello, everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Gigena, a research fellow at Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe. Today we are talking about treatment for common bile duct pathology.

And for that, we have Dr. David Vitale, a pediatric gastroenterologist, director of the Interventional Endoscopy Center here at Cincinnati Children's Hospital, and Dr. Luke Neff, a pediatric surgeon at Atrium Health at Wake Forest Baptist. As we know, chelatorcholothiasis is the presence of at least one gallstone in the common bile duct.

The stone may be made up of biopigments or calcium and cholesterol salts. We know that there are metabolic risk factors. Hemolysis, such as sickle cell, congenital and biliary anomalies, like colorectal cysts. It's more common in older children, children with higher BMI, and patients of Hispanic ethnicity. So risk factors include metabolic diseases, hemolysis, and biliary anomalies. Now, let's start with a case.

So this is the case of a 14-year-old who came in presenting with right upper quadrant pain, and her initial exam and evaluation was relatively unremarkable, other than some right upper quadrant tenderness. She had elevated AST and ALT with total bilirubin of 1.8 and direct bilirubin of 1.3. She had an abdominal ultrasound done, and the common bile duct was about 5 millimeters. She did have gallbladder stones on the imaging, but they could not see the distal common bile duct.

BMI was in the 98th percentile. So what do we do next? This slide is actually taken from ASGE, which is the Adult Endoscopy Society for GI. So patients with a high probability would have things like common bile duct seen on ultrasound, ascending cholangitis, or quite high bilirubin. And recommendation in those patients really is to go straight to ERCP. Patients with intermediate risk include those who have abnormal liver biochemical tests or dilated common bile ducts.

We can do an endoscopic ultrasound to look for a stone. We can do an MRCP, a laparoscopic clangiogram, or an intraoperative ultrasound. This intermediate category is where our patient falls. And then patients that have no predictors present, obviously, would just go on to potentially call a cystectomy. What about in children? So there's a few publications related to this, and they found that direct bilirubin or conjugated bilirubin more than two was the most predictive factor.

And secondarily, a common bile duct diameter greater than six millimeters, although they didn't find a statistical difference, was most sensitive for predicting common bile duct stones. And there is a pediatric duct score, and this was published in the Journal of American College of Surgeons with 10 centers that participated.

And they found that patients with ducts greater than six millimeters, common bile duct stones on ultrasound, or a total bilirubin greater than 1.8 were the most predictive risk factors. So if patients had three risk factors, it was very high predictability. If they have two, it was high predictability. And if they only have one, they fall in this intermediate category. So how do we continue treating this patient?

We did an MRCP that showed stone in the common bile ducts. The patient had an ERCP that was done in a subsequent lab collie. There's some pretty good pediatric literature out there in a small sample pot size that show that doing same anesthesia laparoscopic colostectomy with ERCP and stone disease led to less anesthesia time and lower length of stay. And what about ERCP versus laparoscopic common bile duct exploration? There's a lot of retrospective data that's out there.

I looked through a lot of the studies and the data is really conflicted. I really think, again, it gets back to institution-dependent expertise and it's probably provider-dependent and the institution's experience with this. There are a few randomized trials from 2013, but they show no significant difference in morbidity, mortality, retained stones, or failure rates between the two groups. But what about real-world experience?

What are the considerations we have to know when approaching one of these patients? Stones above the cystic duct obviously pose a big problem and even with attempted laparoscopic removal, these stones can float up there and make a pretty straightforward ERCP, a much more difficult one. So when there's one stone and it's pretty easy to flush out, doing this laparoscopically is not that big of a deal as if there's four or five stones there or a larger stone.

I think local expertise and availability is probably the most important thing in this decision tree. Now that we covered this view from a gastroenterologist's point of view with Dr. Vitale,

let's move to the surgical side with Dr. Luke Neff. We know the dominant paradigm across the country is an MRCP, very often followed by an ERCP, but surgeons should be comfortable dealing with issues in the chondrodoc. Resource utilization is a real thing. And then length of stay in the hospital is an important issue.

So to avoid this longer length of stay and reduced resource utilization, Dr. Neff is proposing a different approach for those centers that doesn't have a pediatric endoscopist available. The paradigm we are presenting is a surgery-first presentation. Go to the operating room. You are comfortable doing IOC. In case you were wondering, IOC means intraoperative cholangiogram. And there's essentially kind of three different things that can come out of that, right?

You shoot it and it's negative. That's great. You send them home. So if you have a negative IOC, you can finish your laparoscopic cholestectomy and send them home. The other two scenarios are if you have a positive IOC. So if it is positive, but you don't feel comfortable with a common bile duct exploration, they can get what they would have had in the first place, an ERCP. And then obviously something that would be an ideal scenario.

They go to the operating room, they get their common duct exploration out, and you're able to avoid all these other things, particularly a second genital anesthetic. So in a superficial way, how can we approach to laparoscopically remove common bile duct stones? So our mantra is all stones go forward.

And so we use balloons to dilate up the sphincter and then flush them, integrating them. Great. So perform an IOC and first try to flush the stone forward to the duodenum using wire or catheters. Second, we'll try to dilate the ampulla with balloons and then flush the stones. What's next? There's more exotic things like the spyglass, lipotripsy as well for these big stones. And again, this is probably more on the adult side. I've not seen any massive, massive stones

in children. You can place it in your stents laparoscopically, transistically, and then colloidal got to me, which is something that I think would be mentioned only to be condemned. And when do you say, okay, I couldn't do it laparoscopically, let's do an ERCP. If you're having to open up the common bile to extract the stone and you had ERCP capability, I think that that's probably in most cases, not the right thing to do. Now let's go into deeper detail. What kind of equipment

are you using to do all this? We've created a cart. Actually, we want to keep this as cheap as possible. Five or six French, your readable stent, $7, 035, gladwire. That's 50 bucks. And that gets you started. That can do a lot for you, actually. So you can not only shoot your initial gram. In case you were wondering, shooting grams is the cool way of saying, doing an IOC. You can traverse the dock to just use the simplest, cheapest stuff you've got.

And it's actually really effective. If you want to see the full list of the equipment they use, go to the description to find the link with all the necessary things that you need to fill your common bile back exploration cart. And everything we do is over a guide wire so that it makes that next step. If you, that step up approach that I talked about, your kit is already designed to help you take the next

step. Especially if you're using balloons at some point to dilate the ampullin and flush through. And in patients that you couldn't address them surgically and they need to go to an ERCP, do you do something to the cystic duct? I put an endo loop on there, just a little belt and suspenders. I mean, maybe I've already put a clip and I'll try to get an endo loop more proximal to that. And, you know, with our cholangiogram, we have an idea of how much

cystic duct we have. So I like that little extra bit of security. Don't typically leave a drain. So ERCP and laparoscopic common bile that exploration in hands of an expert have similar outcomes, but you have to be aware of the resources in place have to make the better choice for the patients. For example, most freestanding children's hospitals do not have ERCP capabilities, which is something that Cincinnati Children's counts with.

I will completely agree with that. You're the unicorn, right? Not everybody has a unicorn. Okay. So now that we discussed the pros and cons of the different approaches,

let's talk about how is that Dr. Neff does the common bile duct exploration. We just use a 12 gauge angiocath, which may be hard to find in a pediatric hospital, but you can order them. We don't use existing ports because we want our angle of entry into the cystic ductotomy to be as flat as possible. Great. Making new incision to pass the instruments at a better angle through the cystic duct. And what type of catheter do you use?

This is just a little six French urethral stent that we cut down. We make it a lot smaller or shorter for better flow. And we put a, we put the glide wire in there. We almost use like a cylinder technique to get it into the duct so that we can navigate all those valves. So six French urethral catheter, pass it through the cystic duct. And then?

The one thing we would do next is we would get using the guide wire to help us direct in, we would get that catheter actually parked into the common duct and get it right at the point of obstruction and really push hard. And if it doesn't work? And then you can even push that catheter over the wire to kind of ream out the sphincter a little

bit. And then through that 12 French angiocath over the wire, we pass a angioplasty balloon. And I typically will use either a six millimeter or eight millimeter, but definitely not more than that. Perfect. So pass the wire up to the dune denum and then grab an angioplasty balloon of six to eight millimeters and dilate. But do you dilate in the duct, the sphincter or both? So what we do is we blow up the balloon in the duct and we actually pull back on it and give a

little tactile feedback to know exactly where that sphincter is. And then we partially deflate and we straddle the ampule. And then we go to full profile under fluoro, seeing the balloon come up to its full diameter. And then we hold that for about five minutes. And Dr. Vitale had some advice for us too. I think your point there, never use a balloon that's larger than the dilated common bile duct, which is really important because we know that there is some URSP literature out there

with people looking at doing dilations of the ampule without doing sphincterotomy. And there's definitely a higher rate of pancreatitis in those patients. Perfect. So six to eight millimeters balloons that are smaller than the dilated common bile duct. Watch for possible pancreatitis post procedure. And what do we do with the stones after dilating the sphincter? We keep our guide wire access in the duodenum and then I'll actually pull back and I generally actually will straddle the

cystic duct common duct, but I won't fully inflate. I'll inflate a little bit because I want to create a seal on that distal common duct so that everything I flush through the guide wire lumen gets pressurized downstream. And what happens if it fails? And you know, at that point, if we're not getting the job done, then we quit, you know, and we'll throw our endolupal on and call GI. Dr. Vitale also recommended that if we start seeing the pancreatic duct in the floral, we should stop,

since that has a higher risk for pancreatitis. Stone disease is not going anywhere. If anything,

prevalence is increasing. So it's just nice to have some tools in your toolkit. Even if you don't go to the point of balloons, knowing that thinking about how to navigate across the ampoule with wire and using your little catheter to wring it out and get some really good flushes right at the point of obstruction. I think those things are just helpful. Awesome. And is there any advice on how

to get comfortable and learn the skills among surgeons? I think number one is getting familiar with the kit and if you put together a cart or have something like that where somebody can purchase those items, just plan around and getting familiar with it. So first step, getting to know the equipment we are going to need to work with. Have a plan. Have the equipment at your disposal and just start shooting grams, maybe even on elective cases, just to get a feel for it. And truly,

the position of that 12 gauge angiocath is really important. Your ability to manipulate the catheter and the wire in the duct is all about your initial setup and how flat your angle of entry is into the cystic duct. What's the learning curve on this? So that's a very person specific question, but I would say around five to ten. Awesome. So now it's time to summarize. Risk factors for common

bile duct stones include metabolic diseases, hemolysis, and biliary anomalies. Within the diagnostic tools, we have endoscopic ultrasound, MRCP, or laparoscopic cholangiogram. ERCP and laparoscopic common bile duct exploration are both useful in the treatment of this pathology, with few differences in outcomes, though ERCP may represent longer length of stay

and two procedures with anesthesia in the majority of the establishments. Important tools for laparoscopic common bile duct exploration include urethral stents, glide wire, and balloons for dilating the sphincter and flushing stones. It is very important to be familiarized with this equipment prior to using it in a patient. Proper setup and angle of entry are crucial for

successful catheter and wire navigation during procedures. A statewide approach for treating common bile duct stones is key, knowing that if we fail, patients can always have an ERCP post-op. And that was Galerical Atheism with Dr. Vitale and Neff. I hope you enjoy it. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay

Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.