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GlobalCastMD, along with Cincinnati Children's
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Hospital, sharing knowledge to improve child
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health around the globe. Hello, pediatric surgery
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family. I'm Emgoti from Cincinnati Children's
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Hospital Medical Center. In this video series,
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we'll be recapping the sessions and sharing the
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key highlights from our 12th annual update course
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in pediatric surgery, which was held in August
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2024. This year, we introduced a new approach
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to classify practice -changing ideas at our update
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course. Presentations now fall into three categories.
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Green Circle for established practice, Blue Square
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for promising newer practice, and Black Diamond
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for early adopter practice only. In this video,
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Drs. David Vitale, Luke Neff, and Jeff Ponsky
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will talk about how to prevent gallstone pancreatitis
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in pediatric biliary stone cases. This session
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is classified as a green circle for established
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practice. This is a 16 -year -old male. This
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is actually a patient of mine from about four
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months ago. This patient currently undergoing
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treatment for acute lymphoblastic leukemia, or
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ALL, presents with right upper quadrant pain.
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He's neutropenic, has markedly elevated liver
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function tests, and ultrasound findings are consistent
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with acute cholecystitis and cholecystitis. So
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now we have a little bit more of a different
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situation with a neutropenic thrombocytopenic
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patient. What are we going to do? According to
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our live and virtual audience poll, over 50 %
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opted to start antibiotics and address the elevated
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liver function tests. And that's the exact approach
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Dr. Neff took. And he spontaneously passed the
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stone. LFTs came back down. We were able to get
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him, his counts recovered, and get him to elective
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cholecystectomy. I want to bring up one other
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scenario, too, for the audience, which is gallstone
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pancreatitis, which I think is a little bit different
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Load full transcript
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than our conventional show up with a stone in
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the duct. Gallstone pancreatitis is inflammation
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of the pancreas triggered by a gallstone obstructing
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the bile duct, which can also impede pancreatic
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drainage. This blockage prevents pancreatic enzymes
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from reaching the small intestine, leading them
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to accumulate and damage the pancreas. So the
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question is... How would you manage this patient?
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In my experience, some surgeon will go in and
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say, hey, we're going to do the cholecystectomy
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within a few days. Some will say, hey, we're
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going to wait for a week. From an ERCP standpoint,
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unless there's a persistent biliary obstruction
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or cholangitis, we're not jumping in to go do
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this case right away. So I just want to hear
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from folks about gallstone pancreatitis. When
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things are improving, we don't need to see biochemical
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normalization. But when the symptoms are improving,
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we go right to cholecystectomy with intraoperative
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cholangiogram. and coordinate with you just in
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case there might be a need for an ERCP. There's
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been some studies done to show if you wait one
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day when the patient comes in with acute biliary
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pancreatitis, if the amylase lipase go up, then
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you do the ERCP because you have it impacted.
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But most of the time, it will go right down.
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And if it starts going down, they pass the stone
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and you can go to cholecystectomy. This is just
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from my standpoint. Most stones can be cleared.
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Some stones pass spontaneously, right? We have
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to use good judgment with that. In local resources,
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you have to factor in what you have available
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to you. In summary, in neutropenic and thrombocytopenic
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patients with cholecystitis and cholecystitis,
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initial conservative management with antibiotics
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can be effective, particularly when spontaneous
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stone passage occurs. For gallstone pancreatitis,
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early ERCP is typically reserved for cases with
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persistent biliary obstruction or cholangitis.
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as many patients improve without intervention.
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The timing of cholecystectomy should be based
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on clinical improvement rather than complete
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biochemical normalization with intraoperative
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cholangiogram and ERCP coordinated as needed.
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Thank you for watching this video.