رونوشت 🔗
WEBVTT
00:00:02.030 --> 00:00:04.669
GlobalCastMD, along with Cincinnati Children's
00:00:04.669 --> 00:00:06.830
Hospital, sharing knowledge to improve child
00:00:06.830 --> 00:00:09.730
health around the globe. Hello, pediatric surgery
00:00:09.730 --> 00:00:12.449
family. I'm Emgoti from Cincinnati Children's
00:00:12.449 --> 00:00:14.789
Hospital Medical Center. In this video series,
00:00:15.169 --> 00:00:17.589
we'll be recapping the sessions and sharing the
00:00:17.589 --> 00:00:20.449
key highlights from our 12th annual update course
00:00:20.449 --> 00:00:22.969
in pediatric surgery, which was held in August
00:00:22.969 --> 00:00:25.829
2024. This year, we introduced a new approach
00:00:25.829 --> 00:00:28.710
to classify practice -changing ideas at our update
00:00:28.710 --> 00:00:31.929
course. Presentations now fall into three categories.
00:00:32.310 --> 00:00:35.149
Green Circle for established practice, Blue Square
00:00:35.149 --> 00:00:38.109
for promising newer practice, and Black Diamond
00:00:38.109 --> 00:00:41.170
for early adopter practice only. In this video,
00:00:41.310 --> 00:00:44.630
Drs. David Vitale, Luke Neff, and Jeff Ponsky
00:00:44.630 --> 00:00:47.329
will talk about how to prevent gallstone pancreatitis
00:00:47.329 --> 00:00:50.310
in pediatric biliary stone cases. This session
00:00:50.310 --> 00:00:52.509
is classified as a green circle for established
00:00:52.509 --> 00:00:54.750
practice. This is a 16 -year -old male. This
00:00:54.750 --> 00:00:56.109
is actually a patient of mine from about four
00:00:56.109 --> 00:00:57.969
months ago. This patient currently undergoing
00:00:57.969 --> 00:01:00.969
treatment for acute lymphoblastic leukemia, or
00:01:00.969 --> 00:01:03.810
ALL, presents with right upper quadrant pain.
00:01:04.049 --> 00:01:06.769
He's neutropenic, has markedly elevated liver
00:01:06.769 --> 00:01:09.530
function tests, and ultrasound findings are consistent
00:01:09.530 --> 00:01:13.469
with acute cholecystitis and cholecystitis. So
00:01:13.469 --> 00:01:15.230
now we have a little bit more of a different
00:01:15.230 --> 00:01:18.329
situation with a neutropenic thrombocytopenic
00:01:18.329 --> 00:01:20.870
patient. What are we going to do? According to
00:01:20.870 --> 00:01:23.510
our live and virtual audience poll, over 50 %
00:01:23.510 --> 00:01:26.230
opted to start antibiotics and address the elevated
00:01:26.230 --> 00:01:29.909
liver function tests. And that's the exact approach
00:01:29.909 --> 00:01:32.849
Dr. Neff took. And he spontaneously passed the
00:01:32.849 --> 00:01:35.810
stone. LFTs came back down. We were able to get
00:01:35.810 --> 00:01:38.950
him, his counts recovered, and get him to elective
00:01:38.950 --> 00:01:41.870
cholecystectomy. I want to bring up one other
00:01:41.870 --> 00:01:44.310
scenario, too, for the audience, which is gallstone
00:01:44.310 --> 00:01:46.750
pancreatitis, which I think is a little bit different
00:01:46.750 -->
Load full transcript
00:01:48.909
than our conventional show up with a stone in
00:01:48.909 --> 00:01:51.150
the duct. Gallstone pancreatitis is inflammation
00:01:51.150 --> 00:01:54.409
of the pancreas triggered by a gallstone obstructing
00:01:54.409 --> 00:01:56.670
the bile duct, which can also impede pancreatic
00:01:56.670 --> 00:01:59.390
drainage. This blockage prevents pancreatic enzymes
00:01:59.390 --> 00:02:01.930
from reaching the small intestine, leading them
00:02:01.930 --> 00:02:04.430
to accumulate and damage the pancreas. So the
00:02:04.430 --> 00:02:06.709
question is... How would you manage this patient?
00:02:06.890 --> 00:02:08.909
In my experience, some surgeon will go in and
00:02:08.909 --> 00:02:10.509
say, hey, we're going to do the cholecystectomy
00:02:10.509 --> 00:02:12.610
within a few days. Some will say, hey, we're
00:02:12.610 --> 00:02:14.909
going to wait for a week. From an ERCP standpoint,
00:02:15.129 --> 00:02:17.289
unless there's a persistent biliary obstruction
00:02:17.289 --> 00:02:19.810
or cholangitis, we're not jumping in to go do
00:02:19.810 --> 00:02:22.409
this case right away. So I just want to hear
00:02:22.409 --> 00:02:24.750
from folks about gallstone pancreatitis. When
00:02:24.750 --> 00:02:27.610
things are improving, we don't need to see biochemical
00:02:27.610 --> 00:02:30.430
normalization. But when the symptoms are improving,
00:02:30.710 --> 00:02:33.689
we go right to cholecystectomy with intraoperative
00:02:33.689 --> 00:02:36.759
cholangiogram. and coordinate with you just in
00:02:36.759 --> 00:02:39.139
case there might be a need for an ERCP. There's
00:02:39.139 --> 00:02:42.020
been some studies done to show if you wait one
00:02:42.020 --> 00:02:44.599
day when the patient comes in with acute biliary
00:02:44.599 --> 00:02:49.520
pancreatitis, if the amylase lipase go up, then
00:02:49.520 --> 00:02:52.659
you do the ERCP because you have it impacted.
00:02:53.039 --> 00:02:55.199
But most of the time, it will go right down.
00:02:55.400 --> 00:02:57.659
And if it starts going down, they pass the stone
00:02:57.659 --> 00:03:00.379
and you can go to cholecystectomy. This is just
00:03:00.379 --> 00:03:02.900
from my standpoint. Most stones can be cleared.
00:03:03.039 --> 00:03:05.560
Some stones pass spontaneously, right? We have
00:03:05.560 --> 00:03:07.719
to use good judgment with that. In local resources,
00:03:07.740 --> 00:03:10.139
you have to factor in what you have available
00:03:10.139 --> 00:03:13.520
to you. In summary, in neutropenic and thrombocytopenic
00:03:13.520 --> 00:03:15.680
patients with cholecystitis and cholecystitis,
00:03:16.080 --> 00:03:18.300
initial conservative management with antibiotics
00:03:18.300 --> 00:03:20.979
can be effective, particularly when spontaneous
00:03:20.979 --> 00:03:24.240
stone passage occurs. For gallstone pancreatitis,
00:03:24.500 --> 00:03:27.439
early ERCP is typically reserved for cases with
00:03:27.439 --> 00:03:30.039
persistent biliary obstruction or cholangitis.
00:03:30.639 --> 00:03:32.520
as many patients improve without intervention.
00:03:32.939 --> 00:03:35.400
The timing of cholecystectomy should be based
00:03:35.400 --> 00:03:37.719
on clinical improvement rather than complete
00:03:37.719 --> 00:03:40.340
biochemical normalization with intraoperative
00:03:40.340 --> 00:03:43.240
cholangiogram and ERCP coordinated as needed.
00:03:43.479 --> 00:03:44.919
Thank you for watching this video.