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SCORE School Benign Biliary, Part 1 of 2
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SCORE School Benign Biliary, Part 1 of 2
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Language: EN.
Segment:0 .
ALFRED CHAHINE: OK, everyone. It's 8 o'clock, so we'll go ahead and get started. Good evening, everyone, and welcome to SCORE School. My name is Alfred Chahine. I'm one of the assistant editors of SCORE. And I want to welcome you into tonight's edition. Before we start, a few housekeeping issues. We would like the session to be as interactive as possible, so we encourage you to use the chat box to ask questions and make comments.
ALFRED CHAHINE: And everyone has been muted to avoid unnecessary feedback noise. We will be discussing six modules today, and we'll take questions and comments after each one. The first one is Cholecystitis, authored by Drs. [INAUDIBLE] and [INAUDIBLE]. The second one is Benign Biliary Obstruction by Drs. [? Randall ?] and [? Funk. ?] The third one is Cholecystostomy by Drs.
ALFRED CHAHINE: Stankowski, Drengler, and Greenberg. The fourth one is Common Bile Duct Exploration and Choledochoscopy by Drs. Newton and [? Li. ?] The next one is Cholecystectomy With or Without Cholangiograms by Drs. [INAUDIBLE] and [INAUDIBLE]. And we might not have time to get to the advanced module, The Ultrasound of the Biliary Tree my Drs.
ALFRED CHAHINE: [INAUDIBLE] and [INAUDIBLE]. We are using a QR system to track attendance for residency programs that subscribe to SCORE. So you will see a QR score, a QR code for this week displayed after the modules are presented and during the discussion. You only need to submit the form once even though it'll be displayed a few times during the presentation. And finally, all these sessions will be recorded for later viewing on the website, the SCORE website.
ALFRED CHAHINE: We're very pleased by the number of residents viewing those sessions each week. Tonight's presenter is Dr. Steven Schwaitzberg. Dr. Schwaitzberg is chairman of the Department of Surgery at the University at Buffalo School of Medicine and Biomedical Sciences and professor of surgery and bioinformatics there. He's a graduate of Johns Hopkins University and received his MD from Baylor College of Medicine and an MA from Harvard.
ALFRED CHAHINE: He completed his surgical residency at the Baylor Affiliated Hospitals, a fellowship in infectious diseases at the Methodist Hospital, and in pediatric trauma at the Pediatric Trauma institute in Boston. Prior to coming to Buffalo, he was professor of surgery at Harvard Medical School, where he held a variety of leadership roles. He also served with the 365th Evacuation Hospital in the US Military Medical Complex in Oman.
ALFRED CHAHINE: He is an internationally recognized physician investigator. He has made important contributions in both the preclinical and clinical areas in the development of surgical robots. He's currently the principal investigator on two grants looking at outcomes in biliary tract surgery and a national perspective clinical trial of natural orifice surgery versus conventional laparoscopic cholecystectomy.
ALFRED CHAHINE: He has authored over 200 peer-reviewed manuscript articles, chapters, and so on. He holds three US patents and has received numerous awards, including the American College of Surgeons Health Policy Scholar Award, Computerworld/National Smithsonian Honors 21st Century Laureate Achievement Award, and many awards for teaching excellence. He's On the Board of Governors of the American College of Surgeons and is past president of SAGES and chairman of the FLS Committee.
ALFRED CHAHINE: So please join me in welcoming Dr. Schwaitzberg. Thank you for doing this, Dr. Schwaitzberg, and please take it away.
STEVEN SCHWAITZBERG: Thank you so much. It's a real honor to be here for SCORE School. One of the things about speaking is, tell them what you're going to say, say it, and then tell them what you said. So we'll use that. This is the order of events tonight. I don't know that we're going to get all the way through. We'll have somewhere between 30 and 50 on the line. I welcome everybody to use the chat.
STEVEN SCHWAITZBERG: If any of my own residents are on the line, they know that it's always totally interactive. So we'll see how far we get. This is one of the great general surgery topics. And for those of you who are going to go on to do some form of general surgery, this really needs to be your area of expertise. Next slide.
STEVEN SCHWAITZBERG: So in our first module, which is Cholecystitis, the five topics that are in the SCORE curriculum are chronic cholecystitis, acute cholecystitis, acute acalculous cholecystitis, biliary colic, and then I've added one more, which is hydrops. Because I think this is a good way to organize it.
STEVEN SCHWAITZBERG: And if you have a system of organization in your head, then when you do your consults and you communicate with your senior residents and your attendings, you want to have a framework to communicate all these findings in, which is critically important. So if you're wondering why I'm saying "next slide," is that the way we're set up is the SCORE group are actually moving my slides forward. So this, for me, it's like doing this from like the old Kodachrome slides.
STEVEN SCHWAITZBERG: So next slide.
ALFRED CHAHINE: It's like robotic surgery, Dr. Schwaitzberg.
STEVEN SCHWAITZBERG: It's exactly like that. So let's start with biliary colic. So next slide. So what is biliary colic? Patients present with abdominal pain. Generally, the blockages are intermittent, there's no fever, the labs are normal. There's no persistent tenderness. And many of these patients come in either because they've called their primary care doctor or they show up to the emergency room.
STEVEN SCHWAITZBERG: And this is a very, very common cause of ER consults. So many patients use their emergency room as their primary care doctor's office. They come in after work. They complain of right lower quadrant pain. And then a lot of this is, what is the disposition for these patients? Often by the time you get downstairs, if you've been operating that night, the ER has often given their version of the GI cocktail.
STEVEN SCHWAITZBERG: They can't help themselves. They give pain medicine to everybody. And most of these patients can go home. The question really is, how much of a workup do you need to do? And the answer to that is often it depends on what time of day. In a world where we are living in a volume-based health care, not a value-based health care, the answers could change. So if you are responsible, for instance, for every dime that you spend in the workup of a patient, and they told you at 2 o'clock in the morning there's no ultrasound tech, the idea that you would use a CAT scan as the rich man's ultrasound is kind of disappointing.
STEVEN SCHWAITZBERG: But as you have all learned, people are doing CAT scans for biliary colic left and right because ultrasound techs are hard to find. And they'll often use a CT scan to make a diagnosis of stones and reinforce the fact that there's no free air in this and that. In a higher functioning system, particularly where there's good coordination between the ER, maybe the surgeon's office, some of these patients can be seen the next day.
STEVEN SCHWAITZBERG: I like to take a call on Mondays because I have clinic on Tuesdays, and in a perfect world, I can send some of these people home, get their ultrasound in the morning, and see them in clinic if they have no fever, normal labs, they're no longer tender, and can be seen in the office. Here's the deal with biliary colic, though-- once patients have symptoms, they will continue to have intermittent symptoms on some cadence every week, every month, every six months, until you take out their gallbladder.
STEVEN SCHWAITZBERG: It is absolutely true that many patients go to their grave with their gallstones. And the presence of gallstones, in and of itself, is not an indication for surgery. But once people have symptoms, they can do all the dietary change they want, they can eat roots and berries if they want, you're going to get the gallbladder. Because nobody can go on a diet restricted enough to ultimately keep them out of the operating room.
STEVEN SCHWAITZBERG: It just doesn't work. One of the interesting things if you stay and practice long enough, and I've been in practice over 30 years, is patients that you schedule for elective laparoscopic cholecystectomy occasionally will progress to acute cholecystitis in the interim. And you might come in on Monday, find out that one of your partners took out your pre-op patient's gallbladder because they progressed from biliary colic to acute cholecystitis.
STEVEN SCHWAITZBERG: Next slide. So next on the list up from colic is hydrops of the gallbladder. Next slide. What is hydrops? hydrops is cystic duct obstruction resulting in dilation of the gallbladder.
STEVEN SCHWAITZBERG: And this is a trap. The trap is no fever, no white count, normal labs-- next slide, and advance one more slide-- but they're tender. That is the trap. Even if they have no fever, no white count, normal labs, but they are tender, you need to entertain a diagnosis of hydrops until proven otherwise, and the single best test for that is a HIDA scan.
STEVEN SCHWAITZBERG: So a question for you all, when you aspirate the gallbladder on the picture, if anybody is brave enough to answer the question in the chat, why is the fluid clear when you aspirate a patient with hydrops? And I'll give you all a moment to assess the level of your bravery and answer, why is the fluid clear when they have hydrops?
ALFRED CHAHINE: Let's hear it, guys.
STEVEN SCHWAITZBERG: Don't be shy. Ashley Rosenberg, it's mucus instead of bile being secreted. That's close. Sarah, serous accumulation. No, the mucus answer is right. Anybody else? Only Ashley and Sarah. Brandon, bile distills from stasis.
STEVEN SCHWAITZBERG: Getting closer. Mucoid or watery content that's a residual, from Rox9007. What a great name. So the answer is, there was bile in the gallbladder at one point, but the cystic duct is obstructed and the bile is resorbed across the mucous membrane, across the membrane of the mucosa. And what remains is the mucus and serous fluid.
STEVEN SCHWAITZBERG: And so if you were to drop a stone into the cystic duct at time zero, It would all be green bile. But as time goes by, the bile is resorbed. And this is why the fluid is clear. It presents with inflammation. It can be a hard gallbladder to take out. But the trap, particularly for junior residents, is the ER doc calls you, listen, I've got a patient that's got tenderness, no fever, no white count, they've got some gallstones.
STEVEN SCHWAITZBERG: I'm going to send him home, right? The answer is no. The magic word is tenderness because over time left untreated, they will often get infected, and they will be just as bad as any missed acute cholecystitis. So hydrops is a trap. Be prepared, be vigilant. Semper vigilans. Next slide.
STEVEN SCHWAITZBERG: So now let's talk about acute calculus cholecystitis. Next slide. All right, so same mechanism as hydrops, cystic duct obstruction. However, there is generally a component of infection. Therefore, there is fever, white count, abnormal LFTs are common, but not required for the diagnosis. These patients should be tender because they have peritoneal irritation.
STEVEN SCHWAITZBERG: And then the question is, what tests do you need? Would you simply take a patient with right upper quadrant pain for a laparoscopic cholecystectomy? Generally not. Generally, there's some form of imaging. And the best test as ultrasound. But occasionally in the middle of the night, particularly if the patient has fever or a white count, it's not uncommon to see somebody with a CT.
STEVEN SCHWAITZBERG: Now, here's the trap. Ultrasound is the most common test, but ultrasound, in my experience in 30 years, is really only good for one thing-- the presence of gallstones. If your ultrasound tells you that there is a gallstone in the gallbladder, and the same is true for the common bile duct, if there's a gallstone in the gallbladder, you can take that to the bank.
STEVEN SCHWAITZBERG: The false positive rate is pretty darn low. So my next question for the group is, who knows what the false negative rate of a gallbladder ultrasound performed for the detection of gallstones or cholecystitis? Any takers on the chat, what is the false negative rate?
STEVEN SCHWAITZBERG: Irene goes, 20%. Robert goes, 5%. Rox9007, less than 5%. Any other takers? Becca, 7.5%. Jay, 2%, 15%. James Knight, 15% to 20%. James Knight, the second. So the answer is about 5%.
STEVEN SCHWAITZBERG: And you could argue that a better ultra stenographer can move those numbers in one direction or another, but that means one out of every 20 patients who presents with signs and symptoms of cholecystitis will have a false ultrasound. If your clinical suspicion is high enough, then you can go ahead and move to HIDA scan, and your HIDA scan is likely to be positive.
STEVEN SCHWAITZBERG: And so I have had occasional patients that I've operated on for biliary dyskinesia that had a negative ultrasound. They went on to HIDA scan with a gallbladder ejection fraction, and you, go, huh. They missed a stone. So you'll see that periodically, but your test is you need directional. A high positive predictive value, a 5% error rate.
STEVEN SCHWAITZBERG: And doing a CT after an ultrasound does not improve it. Because there's probably a lack of calcium. If you have a positive ultrasound, white count, tenderness, abnormal LFTs, plus or minus in amylase, to be certain they don't have pancreatitis as well, do you need to do a CT? Absolute waste of money. You do not need a CT to take somebody to the operating room. An ultrasound and a clinical index of suspicion is more than sufficient.
STEVEN SCHWAITZBERG: The treatment for acute calculus cholecystitis is threefold. There's medical therapy, there's surgical therapy, and there's decompressive therapy. And I'm not going to go into great detail for the Tokyo Guidelines, TG13 and TG18, but they do have a series of workflows that sort of outline if your patient has this profile or that profile, consider early laparoscopic cholecystectomy.
STEVEN SCHWAITZBERG: For me, this is sort of trying to cookbook common sense. If your patient is healthy and they have acute cholecystitis, and they do not have a specific contraindication for surgery, they can go for early laparoscopic cholecystectomy. And if you ask me my choice, would I rather operate on acute cholecystitis, all things being equal, or somebody who's had 10 episodes of acute cholecystitis or biliary colic, I'll take the acute patient every single time.
STEVEN SCHWAITZBERG: Now, it gets messier when you start talking about days of presentation. The magic number that people kick around is around 72 hours. And if you want to write a paper, you can go into your institution and look at the results for acute cholecystitis both before and after 72 hours, and write a paper that it increases the conversion rate or it's doable, you can do these gallbladders later, it is just harder and bloodier.
STEVEN SCHWAITZBERG: So your goal would be to do the gallbladder at the next point of election. If you have to do it at 2 o'clock in the morning, that's a bad idea. Doing it the next day is a great idea if you can manage it. And depending on your circumstance, if you have an acute care service, you don't, you have overtime the next day, you really want to try to get these patients done within 72 hours.
STEVEN SCHWAITZBERG: It's a little bloodier because of the inflammation, but the dissection is actually reasonably easy. If they have a big stone at the neck of the gallbladder, it's really not too difficult. The rest of the porta is OK. There are patients, however, that you can choose medical therapy. There is a reason why they can't be operated on, maybe they're four or five days out, you don't want to dive in there.
STEVEN SCHWAITZBERG: And so you can put them on antibiotics aimed at the microbiology. If you heard I did an infectious disease fellowship, really true. It was an amazing thing for somebody in surgery. You can put them on medical therapy. So my question for the group tonight is, what are the bacteria that you need to direct your medical therapy towards?
STEVEN SCHWAITZBERG: What are the bacteria that you want to treat for routine acute cholecystitis with no evidence of air in the gallbladder? What are the likely bacteria? Rox9007, E. coli Klebsiella. That's a good start. What else? Brandon, as an Enterobacter. James Knight, through an aenerobe.
STEVEN SCHWAITZBERG: OK, James, no style points for you. Aenerobes are not a prominent feature of acute cholecystitis in the absence of air in the gallbladder. So E. coli Klebsiella is good. Enterobacter, a good comment from Joe. Joe, are you actually coming to UB sometime in the near future? You can just add that to the chat. Ashley, Enterococcus, yes.
STEVEN SCHWAITZBERG: So this actually helps define-- yep. Yeah, near future is like now. See, I've already promoted you. I couldn't understand if you were the fellow or the intern. Sorry about that, Joe. I look forward to meeting you and talking to you. Oh, now he's laughing at me.
STEVEN SCHWAITZBERG: Definitely not the fellow. But the microbiology of all surgical infections helps us define what the appropriate antibiotic's for. So in the absence of air, some of those super high power antibiotics, piperacillin and things like that are designed to be shotgun for, say, for instance, perforated diverticulitis, which is you need to treat the anaerobes, you have much simpler, much simpler choices.
STEVEN SCHWAITZBERG: So what would be a good regimen for our Enterococci, E. coli, Klebsiella, Enterobacter presumptive infection? What are the right antibiotics for this? So let's see what we can do. Who's brave? Zosyn, overkill. We don't need the anaerobic coverage, Sarah.
STEVEN SCHWAITZBERG: Unasyn, from TD. Great choice. Unasyn's a good one. Ceftriaxone, too much anaerobic coverage. First generation cephalosporin plus a fluoroquinolone, not bad. Meropenem, overkill.
STEVEN SCHWAITZBERG: Sarah's got bazookas and grenades tonight. So the classic therapy is amp and gent. Because combined with aminoglycoside, your ampicillin gets all of your Enterobacter, your E. coli, your Klebsiella. And so you don't really need a Cipro or Flagyl that you might use for diverticulitis. That would be inappropriate therapy for acute cholecystitis.
STEVEN SCHWAITZBERG: So Unasyn's not a bad drug. You can switch them to oral therapy if you want to send them out. But there's some good oral therapies that can follow from the Unasyn. And you can go from there. But all of your antibiotic therapy should be geared at the microbiology of the infection. Third on the list is decompression-- surgical decompression, percutaneous decompression for acute cholecystitis.
STEVEN SCHWAITZBERG: And that's reserved for patients who you would consider to be poor surgical risk. There might be a patient, and they come in with a positive review of systems and 30 meds, and they're in a nursing home, and all the bad things. They might be better served with a tube cholecystostomy that we'll talk about in a minute. But I want to make you aware of the current literature. The mortality rate for using a C-tube in places you could have used at an operation is actually higher.
STEVEN SCHWAITZBERG: And it is higher. So I don't think that C-tube for convenience because your attending doesn't want to get out of bed is the right way to teach you. Going back to Brandon's chat question, he hasn't seen much gent used. A single dose of gent you know, give them a shot of 100, is not associated with very much toxicity.
STEVEN SCHWAITZBERG: It's just that because we have higher grade things like Unasyn, you don't see amp and gent anymore. But if you had to use amp and gent, a short course of aminoglycoside really is a great choice, particularly in patients who have normal kidneys, Brandon. So decompression, percutaneously, we'll get to that in a moment. Next slide.
STEVEN SCHWAITZBERG: Let's talk about acalculous cholecystitis. Next slide. So this is really an ischemic disease. So the patients that you see this are often patients who've had some episode of global ischemia, not that uncommon after a coronary bypass, for other severe multisystem organ failure scenarios.
STEVEN SCHWAITZBERG: Yes, it can become secondarily infected. It is very, very rare for a patient to come in off the street with acute acalculous cholecystitis. Most often these patients will be diagnosed by CT. Because you have a patient in the unit, you're working a fever or tenderness or elevated white count, they're more likely to get a CT before a HIDA scan. There will be some inflammation around the gallbladder.
STEVEN SCHWAITZBERG: If you're unsure, you can follow it up with a HIDA scan. That can be problematic because the patients won't have eaten. Because these people are sick, decompression is appealing, it's very appealing. However, it may fail. Next slide. So this is a shot from a laparoscopic cholecystectomy that I did a few years ago.
STEVEN SCHWAITZBERG: Next slide should have an arrow. You can see at the arrow that there was a C-tube in there and the patient continued to progress. Because the C-tube doesn't truly treat the ischemia. So a C-tube is probably the right way to go. It may fail and you may have to bite the bullet and do the case. Next slide.
STEVEN SCHWAITZBERG: So let's talk about chronic cholecystitis. Next slide. So this is the bane of your existence. Chronic cholecystitis is the absolute bane of the gallbladder surgeon. Patients often have repeated attacks. Occasionally, the stones may fall into a new configuration, and they'll get acute chronic cholecystitis.
STEVEN SCHWAITZBERG: The chronic inflammation causes shortening of the structures. It makes the tissue woody. Occasionally, if you're unsure, you can do a HIDA scan with gallbladder ejection fraction, the same way you would for biliary dyskinesia. But when somebody says to me, oh, I'm going to do a gallbladder for real live chronic cholecystitis, the real deal, I just go, Danger, Will Robinson. This is the place where common bile duct injuries occur most frequently.
STEVEN SCHWAITZBERG: I've been blessed to not have personally experienced a bile duct injury. I've done more than 2,500, probably almost 3,000 gall bladders. I live in fear of chronic cholecystitis. Next slide. Chronic cholecystitis more typically looks like this. It doesn't look so horrible.
STEVEN SCHWAITZBERG: The gallbladder loses its robin egg blue appearance. And there are other traps for this. Next slide. Oh, go back one. I'm sorry, Madison. This patient had gallbladder cancer. So always be aware that the situation can be more complicated than you think. Go ahead to the QR code.
STEVEN SCHWAITZBERG: So we'll have a moment. We can talk about these. Does anybody have any questions about general treatments? So when you talk to your attending, you really want to earn your style points for, I have a patient in the ER. No fever, no white count, but he is tender. I think he might have hydrops. I'm going to work him up with a HIDA scan.
STEVEN SCHWAITZBERG: That would earn a gold star, for me anyway. All right, next slide. All right, so let's talk about this cholecystostomy decompression business. There is sort of a stylized diagram of this. We put this in patients considered too sick to remove the gallbladder.
STEVEN SCHWAITZBERG: I have a variety of partners. They have different thresholds for using tubes. I do not like to put in tube cholecystostomies unless the patients really need it and they deserve it. There are a few contraindications. It's not fair to ask the interventional radiologist to put something in the liver and the peritoneum if they have a PT that's off the charts, if the liver's full of tumor, then that can be a tough stick for the interventional radiologist, if there's just no window, which doesn't happen very often, but that can happen.
STEVEN SCHWAITZBERG: But one of the things that people don't talk about very much is if the gallbladder is packed with stones, you may not have a place for the tube to go in, and you may be stuck putting this in. Ideally, if you're going to put this in percutaneously, you want to go trans-hepatically. And that's so that you can have a seal. You don't want to have a gallbladder where you just pulled out the tube and you're draining bile in the abdomen.
STEVEN SCHWAITZBERG: If you're going to do it open, you want to put a purse string in the fundus. There's a couple videos on YouTube that show it nicely. You can do it laparoscopically. You can do it open. You can put in a bigger tube. If you decide that you don't have the skills to do it laparoscopically, you could use the on table ultrasound right before you operate to visualize the gallbladder and make your incision right over on top of the gallbladder so you can make it nice and small, put a little purse string in there, and deal with it later.
STEVEN SCHWAITZBERG: I want to make you aware of the literature suggesting that under certain circumstances, cholecystostomy is associated with a higher mortality from the biliary tract disease independent of the factors that made them appealing to have the tube in to begin with. This is the direct effect of that form of treatment. Next slide. If you do it open, you put in a purse string.
STEVEN SCHWAITZBERG: You can put in the Malecot catheter, as shown here. You can put in a Pezzer catheter. But you want to make a purse string so that you can pull it out after the track has matured. Next slide. The next challenge is managing these patients. How do you manage them? You put it to drainage initially.
STEVEN SCHWAITZBERG: I do a tube study about a week later to see if the cystic duct is open. If the cystic duct is patent, then I'll clamp it and ask the patient to report symptoms and notify the patient that if they develop symptoms after they've been clamped, they can unclamp it. The biggest headache about these tubes is dislodgement. I saw a patient in clinic that had a tube that was on our service, transferred from the VA.
STEVEN SCHWAITZBERG: And he showed up in clinic, he had no tube. I said, what happened to your tube? He said it fell out. They took it out in the ER. So dislodgement is a real headache for these patients. That's the real deal. Pay attention to how these tubes are secured. It'll save you a lot of aggravation. I generally don't pull them out before four weeks.
STEVEN SCHWAITZBERG: And my question for you is, you have a patient you've treated with a tube cholecystostomy. You pull the tube at four weeks after verifying that the cystic duct is patent. They walk out of your clinic. They get to the parking lot, and they are doubled over with pain. What's the diagnosis?
STEVEN SCHWAITZBERG: So any brave souls? You pull the tube. They're in the parking lot. They are doubled over with pain. What's the diagnosis? Becca, right on, bile leak. Bile is incredibly irritating. It is a chemical peritonitis. It occurs that quickly.
STEVEN SCHWAITZBERG: It generally means they did not go through the liver. Natasha, bile peritonitis, even better. It did not go through the liver. It leaked right out of the gallbladder into the abdomen. And the only thing you can do is take them right to the ER. It is incredibly painful, incredibly painful. Next slide. End of that short section when I get to the cholecystectomy. any questions?
STEVEN SCHWAITZBERG: All right, let's move on. All right, now let's get to what it's all about. I have been doing laparoscopic cholecystectomies since 1991. Some of you people are going, oh, crap, I wasn't even born then. That's frightening for me, too. Unfortunately, all of my pictures before 1996 were actually photographs, and so I don't have my most original lap cholies.
STEVEN SCHWAITZBERG: But what I'm showing you is a body of work from the early days of laparoscopic cholecystectomy to a robotic cholecystectomy, yes, that I do occasionally. And I have been committed to the critical view of safety for at least 25 years. This is how you generate a series of more than a thousand without a bile duct injury.
STEVEN SCHWAITZBERG: So your commitment to the critical view of safety is really what's going to keep you out of court, your patients out of danger. Bile duct injury is incredibly morbid. It will be a topic for SCORE School next week, so I'm not going to talk about the implications of bile duct injury. I am talking about the medical/legal implications of bile duct injury at the virtual stages in August.
STEVEN SCHWAITZBERG: If you want to hear the talk about the medical/legal, that's for another time. It's on the SAGES schedule in their bile safety program. But this is a lifelong commitment to safety. I do it every time. Can you achieve the critical view of safety in everybody? Not quite. Sometimes I'll take the artery if I can clearly see a clamp under the gallbladder.
STEVEN SCHWAITZBERG: I'll take it off the gallbladder and pull it down. But this is my lifelong commitment to my patients. Next slide. So before we even operate, cholecystectomy starts way before the operating room. And you should ask yourself why are you doing this operation on this patient. And the way I want you to think about it is if this patient dies on the operating table, can you look their family in the eye and go, this patient needed an operation?
STEVEN SCHWAITZBERG: If you can't do that, and you're operating on a truly asymptomatic patient who just happens to have a positive ultrasound because they were looking at their kidney, if you can't truly justify what happens if they die on the operating table, don't do it just because you need some money or you have a hole in your schedule. Does this patient have any unusual risks that you need to think about and put into your brain before you operate?
STEVEN SCHWAITZBERG: Preload your frontal cortex. Have they had a lot of abdominal surgery? Have they had a previous gastric bypass? Do they have any number of diseases that can make this hard? Do they have situs inversus? So yes, I've done two lap cholies in patients with situs inversus.
STEVEN SCHWAITZBERG: It's a real trip to do. And are there predictable hazards that you can think about and plan for as you do the operation? Next slide. One of the things that I do for every patient is I give them a personalized consent about their surgery. This is a clip from a video.
STEVEN SCHWAITZBERG: I use an iPad and I work with a small company, that we record the video for each and every patient. I've been either showing my patients videos or now recording videos for 25 years. Adding it to my education lexicon so that if I were to be sued, and the patient said, you didn't tell me anything, that is just not true and I can prove it. A lot of people say, well, it's my practice to tell them this, or it's my practice to tell them that.
STEVEN SCHWAITZBERG: That's not good enough. Every patient gets a URL. They can go watch the consent again. And if somebody wants to know what I did in my consent session, they can actually watch it. I've got partners who say, well, that takes too long. Well, I assure you that whatever time you spend in a consent-based malpractice suit will be a hundred times more than a few extra minutes I spend teaching every single patient about their surgery.
STEVEN SCHWAITZBERG: If you look on the stomach, you can see I'm talking about the critical view of safety and a few other things for the patient. Consent is an opportunity to build a therapeutic relationship with your patients. Next slide.
ALFRED CHAHINE: Dr. Schwaitzberg, Rox has a question about whether you do that only for a cholecystectomy or for all--
STEVEN SCHWAITZBERG: No, I do it for everything, Rox. Natasha has been in my clinic. I do happen to do endocrine surgery as well and hernias. I do it for everybody. But I started showing the videos for cholecystectomy and hernia, and now I video the consent session for everybody, unless the system happens to be down, and then I don't feel good about it. I do what I do, but I can't record it occasionally. So I spend a lot of time on consent.
STEVEN SCHWAITZBERG: I think it's because I believe-- and you go, well, where did this all come from? I spent five years as the chair of the IRB. And if anybody has done a protocol, IRBs are all about consent. The truth of the matter is, the surgeon's the most conflicted person in the room and stands the most to gain by talking a patient into surgery. I don't have anything to hide.
STEVEN SCHWAITZBERG: I'm more than happy to show the world what I said to the patient. That's a personal choice. The culture of safety. Live in a culture of safety, recognize danger. So if anybody says, well, he probably just does easy gallbladders, I have one of the largest series in the United States of doing laproscopic cholecystectomy, when I was at Tufts, in cirrhotics because we had a liver transplant service.
STEVEN SCHWAITZBERG: That's an operation that really gets your attention. Next slide. This is not the case you want to do a year or two after you graduate. Just because you're thrilled that somebody sent you a gallbladder, I implore you, don't do a cirrhotic by yourself. Your conversion rate will be high. Your return to OR rate will be high.
STEVEN SCHWAITZBERG: And it is an unnecessary-- there's no case, there is no payment that is worth this level of aggravation. Next slide. This is an opportunity to exercise its wisdom and judgment. This is where you call a senior partner for help. I'm not saying you can't book the case, just don't do it by yourself.
STEVEN SCHWAITZBERG: Next slide. So I'm committed to the critical view of safety. This is from the SAGES Safe Choly program. The critical view of safety has three components. If you graduate from your residency and you can't recite this chapter and verse, then your program failed you. The hepatocystic triangle is cleared to the fat and fibrous tissue.
STEVEN SCHWAITZBERG: The common bile duct and the hepatic duct do not need to be exposed. The lower one third of the gallbladder is separated from the liver to expose the cystic plate. The liver bed and two and only two structures can be seen entering the gallbladder. So that's almost true, but occasionally the cystic artery divides into anterior and posterior. So it's true-ish.
STEVEN SCHWAITZBERG: And so there's always an exception to the rule. The SAGES Safe Coley program was the brainchild of Michael Brunt, who was SAGE's president a little bit after me. And he and I had been in conversations where I reviewed 53,000 lap cholies and discovered that the injury rate among surgeons who were less than seven years from their residency is three times higher than that of their more senior surgeons.
STEVEN SCHWAITZBERG: So have a method. A safe coley, critical view of safety, for one thing. Next slide. This is my lifelong consistency. So the reason why I go back to this because I wanted to show you, yes, I actually do lift up the cystic plate in each and every case. Next slide. So here's my question for you-- all right, campers, is this the critical view of safety?
STEVEN SCHWAITZBERG: Yes or no.
ALFRED CHAHINE: Let's hear it, folks.
STEVEN SCHWAITZBERG: All right. No, no, no, no. You are all correct. Next slide. I am an obsessive dissector, and this is the same patient. If you look at where those arrows are, you would have been right on top of the common bile duct and you would have cut the right hepatic artery in half. And you can see the right hepatic artery is traveling right under the gallbladder and the cystic artery comes off more anteriorly Dissect, dissect, dissect.
STEVEN SCHWAITZBERG: Use the easy cases to serve as your dissection teacher for the hard cases. Next slide. Recognize danger. Chronic cholecystitis, as seen in this picture, if you look at the blue arrows on the left side, that's 1 centimeter measured. I had already taken the artery, as I said I do sometimes.
STEVEN SCHWAITZBERG: In fact, the curved line is the common bile duct. The trap here is excessive tension on the short cystic duct pulling the common bile duct into the clips. So you can see in that picture of afterwards, you can see that the common bile duct is intact, and that I took it very close to the bile duct with complete visualization the whole time. Next slide.
STEVEN SCHWAITZBERG: If you fail to do this, this is how you can get a non-tract transectional injury. You can see there are clips where the arrows are often associated with a bile leak because you don't have a good purchase. So one of the things that you should do before you take the cystic duct is to take all the tension off. Take all the tension of the cystic duct so you can let that common bile duct retract and make sure that you're putting it around the cystic duct and not onto the common bile duct because you've pulled it up into the wound.
STEVEN SCHWAITZBERG: Avoid the risk of a transectional injury. Next slide. OK, a big, fat cystic duct. Tell me what your favorite ways of dealing with this big, fat cystic duct is. Let's get some more brave people. I don't bite too much.
STEVEN SCHWAITZBERG: Brandon goes, endoloop. What else? Hem-o-Lock clips. Maybe. Come on, there's too many silent people on there. Be brave.
STEVEN SCHWAITZBERG: Feedback is a gift. Make the call. It's scary to think about, but stapler. Thanks you, Katie. Yes, scary to think about it. I do get scared if I feel inclined to use a stapler that I'm making a mistake.
STEVEN SCHWAITZBERG: I agree with that completely. Anybody else? All right, so let's see what our choices are. Next slide. So you got choices. You could clip it with the regular clip and pray. I don't think that's a very good strategy because you look at it carefully, and when you go to these M&Ms and you hear about these cystic duct leaks and they said, oh, yeah, the duct was really big, but I thought it was OK, that's just defending stupidity.
STEVEN SCHWAITZBERG: You can get a bigger clip. If you're one of those folks that uses a 5 millimeter clip applier, then a bigger clip is not a bad idea. There are some pretty big clips. One thing about the 5 millimeter clip appliers, I don't love them because I've done a lot of clip studies, and the variability of holding power is pretty great in a 5 millimeter clip applier. Yes, you can use a stapler.
STEVEN SCHWAITZBERG: Yes, you can hand tie. Yes, you can use an endoloop. Next slide. This is a really good time for a cholangiogram, just to be safe, to take down that fear factor from when you want to use a stapler. Next slide. So, yeah, you can do a free tie of the cystic duct.
STEVEN SCHWAITZBERG: And so here's an example. We're doing an extracorporeal tie of the cystic duct. You're going, why did you do that? Didn't you have a stapler? I was in a really cost-economic mood. And a 3-0 silk is, or maybe that was a 2-0 silk, a 2-0 silk is like under a dollar. And so we solved the problem for under a dollar.
STEVEN SCHWAITZBERG: If you use a stapler, and I just spent a dollar, any takers on how much a 30 millimeter, 3 centimeter linear cutter, pick your favorite brand, costs to take this duct? And I say common-- from Alfred, the 5-millimeter stapling devices. Yeah, that's done by the guy from Colorado, Steve Rothenberg. That's his group.
ALFRED CHAHINE: That's right, yeah.
STEVEN SCHWAITZBERG: I'm a failed pediatric surgeon wannabe. I know all those guys. Yeah, a lot of money. $750, probably a little high. $300 to $500 is probably a good guess. So in a world where somebody might hold you accountable for the cost of your operation, a buck looks pretty good. This is a standard extracorporeal technique.
STEVEN SCHWAITZBERG: It's right out of the FLS playbook. And everybody who's going to do a gallbladder should be able to do an extracorporeal tie or an endoloop because these are FLS skills, an endoloop is about $40, and that you have the skill to do it. And, in fact, if you haven't done an extracorporeal tie in a while, use this as an opportunity to practice.
STEVEN SCHWAITZBERG: Next slide. Another choices is endoloop. You're saying, wait, what's that other tie? Did you not have faith in your extracorporeal tie? No, we were just creating teaching slides, so we did both. But the trap is avoid the temptation to pull the cystic duct out too far unless you know you really have a lot.
STEVEN SCHWAITZBERG: Because, again, you don't want to create that partial thickness injury. It is a very secure way to do it. It's about $40 compared to a stapler. And it is cheaper than getting out a second clip applier, no matter what. Next slide. At the end of the case, if you look in the upper right-hand corner, you'll see this round thing.
STEVEN SCHWAITZBERG: That is a flexible ovarian retractor. I use it and lift it up. Ashley asks, did you clip above the cut and then place the endoloop? Yes, on the keeper side, I just threw a clip on. I didn't care that much, but you could tie both sides or do endoloops. But if you have the clip applier, it's usually good enough.
STEVEN SCHWAITZBERG: Or then when I go to retract it, I grab that part with my retractor. Good question, Ashley. But at the end of every case, I elevate the liver. Sometimes you have to pull down the colon. And I look and make sure that my clips are hemostatic and in place. Next slide. Cholangiography, important skill for all surgeons.
STEVEN SCHWAITZBERG: This is a Reda catheter going in. Next slide. Here's the cholangiogram. Oop, do we have too many? So you got spared the question. But the first cholangiogram is unacceptable. If you can't demonstrate the upper ductal system, you cannot leave the operating room without an upper cholangiogram.
STEVEN SCHWAITZBERG: You might as well just get out your checkbook if there's an injury. So there's a number of things that you can do to get this cholangiogram to come up. So anybody have some ideas about how you can get that second cholangiogram-- this is the same patient, you can see that-- how do we get a better cholangiogram? And the short answer is not scored harder.
STEVEN SCHWAITZBERG: Ashley goes, glucagon. That actually won't help you. That will hurt you because it will reduce the pressure on the other end. Good thought, though. Any other takers? Morphine. Some people have tried morphine to try to increase the pressure at the sphincter of Oddi.
STEVEN SCHWAITZBERG: Any other takers? Because none of these are the correct answer yet. None of these were the answer for this cholangiogram yet. So the cheapest solution--
ALFRED CHAHINE: There you go.
STEVEN SCHWAITZBERG: There you go, Katie. Well, Katie has been with me. We did a case where we put the patient in Trendelenburg recently. So, yes, you stand the patient on their head and let gravity help you. Good call, Rox9007. So, yes, let gravity be your friend and stand the patient on their head. We were actually doing an ERCP with a gastroenterologist, and they couldn't get the cholangiogram, so we said, stand the patient on their head.
STEVEN SCHWAITZBERG: And it was like, wow. He actually came to the EOR. We were doing a transgastric ERCP, and they actually walked out of the operating room with a tip. So this is incredibly important. Next slide. I used an Olsen clamp. There's a variety of different methods.
STEVEN SCHWAITZBERG: I happen to like the Olsen clamp. If you use the Olsen clamp, turn it upside down. It works better. Next slide. Again, that's a bad cholangiogram. Next slide. A good cholangiogram. I must've put two slides in.
STEVEN SCHWAITZBERG: Next, keep going. How often do you do cholangiograms in your practice? Well, the short answer is not as often as I should, and that's for a couple of reasons. One, I have the skill, so I don't need to practice. But the reason why I'm sort of embarrassed that you asked this question-- because I've got my residents keeping me honest-- I should do it more often, if for nothing else to make sure that everybody in my program can do a cholangiogram.
STEVEN SCHWAITZBERG: And I'm going to comment on that in a second, but I do it selectively. If you get good at it, it adds about 10 or 15 minutes to the case. But there are days where I feel like I should just do a cholangiogram for the experience with my team. You need to learn how to read the cholangiogram, for sure. So that's the other part of the equation, Ashley, is if you don't do cholangiograms, you can't learn to read the cholangiograms.
STEVEN SCHWAITZBERG: And there you can see, this is a real patient, an extra little duct traveling around, and there it is, the hepatocystic duct. Next slide. One of the things that puts cholangiography in jeopardy is indocyanine green. And I think ICG is great. I have no conflicts to report about anything related to ICG.
STEVEN SCHWAITZBERG: And despite the fact of having done more than 2,000 with a bile duct injury, I use it every single case. Because why wouldn't you want more information? A vial of ICG is about $120. You could split into 10 doses, you could do this for $10 or $20 a case. And that also has impacted the rate of cholangiography. I use it to see the common bile duct. I often have the ICG running when I put my clips on so I can see the bile duct.
STEVEN SCHWAITZBERG: There's some new technologies that will be looking through tissue, but as you can see, the artery is right next door, and maybe we'll have a new critical view of safety one day, two and only two structures, and one of them doesn't light up. And if I ever am in a mood to waste a little extra ICG, sometimes I'll just flash the artery just for fun just to demonstrate that you can use it to find the artery as well. 25 milligrams in powder diluted in 10 CCs, give a half a CC.
STEVEN SCHWAITZBERG: I started off by giving 2, then 1, now a half. A half is plenty. Next slide. So we're going to play a video. I've sped this up, and we'll see if this works. I'm always leery about using videos in someone else's system. Give it a moment. I'll click.
STEVEN SCHWAITZBERG: There we go. Let's see what happens. Give it a moment. And so this is running a little bit more quickly. And I just want to make a few comments. This is not going to be the world's hardest gallbladder. As you can see, this is a highly edited video. I use these scallop graspers.
STEVEN SCHWAITZBERG: I use [INAUDIBLE] to strip down the peritoneum. Pull, pull, pull. Notice I don't use any cautery in here. I use very little cautery during this whole thing. I use a lot of spreading. I use a lot of lifting of the peritoneum, of creating pockets. You see that little bit of bleeding?
STEVEN SCHWAITZBERG: I don't care about it. It's all going to stop. Here's a peanut. And for the love of God, please don't spin your peanuts while you're using it. Eventually you'll just pick up some little vessel and twist it right off and cause more bleeding than it's worth. The key to making the surgery safer, I think, is the posterior dissection.
STEVEN SCHWAITZBERG: So I open it up anteriorly, I open it up posteriorly. Here we are using a hook. Hook is your finest right angle. Use all your basic fuse principles of dissection, current density to make these devices work for you. I open it way up because I'm going to do a good cystic plate dissection every time, so I do this early. This is not me operating. But it's what we do every time.
STEVEN SCHWAITZBERG: You can see, we're starting to get the structures. Just sweeping things down, not so hard that you rip things off. Now we're opening up the plate on the other side. One of the things I would suggest that all of you consider doing is record your surgeries. Record your laparoscopic surgeries and go back and look at them.
STEVEN SCHWAITZBERG: There is the window being formed. Continue to dissect. A lot of people would just take the structures here, but I'm too obsessive to do it at this point. I'm going to drag the fat down. But by recording your surgeries, you can learn to become a better surgeon. I have spent a lot of time in video. I was a video editor for surgical endoscopy for 15 years.
STEVEN SCHWAITZBERG: I've literally reviewed every video that came to SAGES for the journal. And I learned so much surgery by watching other people operate and by watching myself operate. It's horrifying. I go, I can't possibly be that clumsy. Here's the dissection of the artery. Don't be afraid of it.
STEVEN SCHWAITZBERG: I use a right angle. I love my right angles. 5 mm and 10 mm right angles. I'm not afraid to dissect. This is the way you build fine motor skills. I'm going to open up a little bit of the plate in the back. You got to take the stuff anyway. And I'm always looking for a posterior cystic artery.
STEVEN SCHWAITZBERG: The only patient that I have ever taken back to the operating room was a patient with a sickle cell disease. I was actually in Saudi Arabia, of all places. And here's the ICG. You can see it nicely. We gave it a pre-op. Notice the artery is not lighting up. I'm going to use the peanut.
STEVEN SCHWAITZBERG: I'm going to find the common bile duct. There it is down there. So now I know the common bile duct's pretty far away. And then I'm going to clip the artery, two below and one above. Usually I put the bottom one on first. Clip then divide. Seems like common sense.
STEVEN SCHWAITZBERG: I like sharp scissors. I don't like reusable scissors. I got burned. You can see the artery pulsing. I got burned by a pair of scissors that wasn't very sharp. I'm going to relax. You see, I'm going to relax a little bit on the cystic duct. Relax, relax, relax.
STEVEN SCHWAITZBERG: There it goes. And the scissoring of the bad scissors knocked the clips off, and I had to go chase a bunch of bleeding. I was able to control it laparoscopically. This is an edited video. I went back and saw where the common bile duct was. Leave a nice cup on your clips so you're not cutting flush. These are the little details or the difference between a leak or not.
STEVEN SCHWAITZBERG: And you're off and running. Sometimes I leave the ICG on while I'm doing the dissection. It's kind of pretty. I play around with the [? gain ?] and this and that. Madison, why don't we go to the next slide. I already showed you that I lift the liver up. I put it in an Endo Bag and take it out. Next slide.
STEVEN SCHWAITZBERG: To drain or not to drain, that is the question. And when I was a resident-- I'll answer your question in a second, Robert-- when I was a resident, we used Penrose drains on everybody. And now it's pretty uncommon for me to drain. But when I drain somebody, I have a reason. So if my reason is it looks a little bloody, I just want to get the blood out, then I leave that drain in for a day or two and pull it out.
STEVEN SCHWAITZBERG: If I'm worried about a bile leak or the clips are not very secure, it was the best I can do, then I'll leave it on much longer. So Robert asked about the spatula. So I did my first thousand lap cholies with a spatula. And then I went to and was operating in Brazil and they didn't have a spatula, and somebody handed me a hook. And I like the hook for doing the dissection around the bile duct.
STEVEN SCHWAITZBERG: And then sometimes I'll switch to a spatula to take the gallbladder out. This is really all about understanding current density. So sometimes I'll use the back of the hook the way I would use the spatula. But if you really want to use high current density with a high level of precision, pointing the point of the spatula right at your target tissue is great. But I did a thousand with a spatula.
STEVEN SCHWAITZBERG: It's great for taking out the gallbladder. And you can also use the spatula to kind of push a little. Or you can use the flat side of the hook. So there's nothing wrong with the spatula. It's all about your personal technique. Thanks on the video. Next slide. What happens after surgery? Leaks.
STEVEN SCHWAITZBERG: Duct of Luschkas can be found in 10% of patients. It was described in 1863. A lot of what are called Luschka leaks are probably hepatocystic duct leaks, which is not quite the same thing. And, of course, there's the vaunted cystic duct stump leak. In my series, I reported on 1,500 lap cholies in my own series. The leak rate was about a half a percent.
STEVEN SCHWAITZBERG: And getting back to that question of the Hem-o-lok clips, I personally don't love it. It's used a lot in robotics. But when I wanted to go find the data to support my personal bias, the Hem-o-lok clips performed fine. But if you ever read the literature on doing renal transplantation, there is a black box warning because they often cut flesh with these clips and they're at risk for falling off.
STEVEN SCHWAITZBERG: Any clip you cut flush is at risk for falling off. Hem-o-lok clips can be useful in some circumstances. Next slide. If you have a leak-- here's a 60-year-old man-- what's your test? My test? ERCP every time.
STEVEN SCHWAITZBERG: But when a patient comes back with an elevated bilirubin or some pain-- because I am so obsessive about the critical view of safety and not creating a non-transectional injury, I'm usually pretty cool about it because I know I have not cut the bile duct in half. I just know I haven't for sure because I've dissected it out completely. ERCP is both therapeutic and diagnostic.
STEVEN SCHWAITZBERG: Some people use a HIDA scan to good effect, but my go-to test is an ERCP. And then I want to know if there's a collection. Next slide. Here's an ERCP, another one showing a bile duct leak in a patient who had a pretty fat cystic duct. Next slide. And here's something that I've done occasionally.
STEVEN SCHWAITZBERG: There was a fellow in Rhode Island named Joe Amaral. He used to use a HIDA scan, and he said if he got an early leak, he went back and reoperated on them. And I go, wow, that's ballsy. And I had an occasion to consult on a patient who had been operated on by a surgeon who went on vacation. And the medical student came up to me and said truthfully he thought the surgeon had clipped a piece of fat and not the cystic duct.
STEVEN SCHWAITZBERG: And I go, huh, the cystic duct's going to be wide open. It was about five or six or seven days out, I went back and reoperated on the patient. You can see the clip. None of them were actually on the cystic duct. I found the cystic duct, shot a cholangiogram and closed the thing laparoscopically. Next slide. So that's an option.
STEVEN SCHWAITZBERG: If you do have a bile leak, please, please, please, drain both sides. There is a certain amount of morbidity and mortality associated with these minor ductal leaks. You want to drain the collection to avoid a septic event. Next slide. This is going to bring us to the end of the hour. I apologize for being four minutes over. There are so many things that we can talk about for cholecystectomy and biliary obstructions.
STEVEN SCHWAITZBERG: It's a great topic. And I will be thrilled to entertain any questions that you might have.
ALFRED CHAHINE: Dr. Schweitzer--
STEVEN SCHWAITZBERG: Any questions?
ALFRED CHAHINE: --we only have a few more slides to go if you want to finish the rest, but it's up to you.
STEVEN SCHWAITZBERG: OK, well, let's go one more module then. I'll be quick. We'll talk about benign biliary obstruction. The trap here is ignoring the possibility that they have hepatitis. I can't tell you the number of times you get a consult from a medical service, and the SGOT and the SGPT, otherwise known as the AST and the ALT, is like 700 and the alk phos is like 100.
STEVEN SCHWAITZBERG: So like the patient has hepatitis. So nothing more fun for a surgery resident than to tell the medical resident their patient has hepatitis. Not every painless jaundice is a malignancy. Some strictures occur slowly. There can be choledochoceles, benign strictures. Lemmel syndrome. I had never heard of Lemmel syndrome.
STEVEN SCHWAITZBERG: I looked it up. I found it in the SCORE curriculum. It is an obstruction from a duodenal diverticulum, just to show you that I really did come prepared to give this lecture. There are patients who have primary choledocholithiasis. This has been more commonly seen in East Asia, occasionally associated with liver fluke disease. When I was at Tufts, the hospital was literally in Chinatown, and I did a number of partial hepatectomies for what was then termed at that time oriental cholangiohepatitis.
STEVEN SCHWAITZBERG: And it was more common in the left lobe for some reason, so we would do left lateral segmentectomies and sew to the biliary tree directly. It was kind of cool. Mirizzi syndrome, where a stone in the cystic duct occludes the common bile duct. Those can be very difficult cases, a lot of inflammation. Really think hard about shooting a cholangiogram. And these are really important.
STEVEN SCHWAITZBERG: Some of the patients with benign biliary obstruction, including the malignancies, will have an elevated PT. And some of these are associated with gallstone pancreatitis. One of the things to keep in mind is most patients who get diagnosed with gallstone pancreatitis don't actually have pancreatitis. What they really have is a one-time amylase leak. And the half life of amylase is about 24 hours.
STEVEN SCHWAITZBERG: So you'll find that their amylase of 1,000 is 500 the next day, 250 the day after, and 125. Those patients don't have pancreatitis. They can be operated on during that same admission. Next slide. The real danger that I want to sort of finish up this section with is missing cholangitis. And you never want to miss a patient with cholangitis.
STEVEN SCHWAITZBERG: It'll break your heart because these patients get really sick. This is a clinical diagnosis. Everybody knows what Charcot's triad is. Somebody named Reynolds said, I want something named after me. So he came up with adding mental status and hypotension. Now it's Reynolds pentad. There's a Tokyo classification for this. But the truth of the matter is, is that sick people are sicker than patients who are not so sick.
STEVEN SCHWAITZBERG: This does not require creating scores for this. You should be able to figure out in your surgical residency who is sick. And the basic pathophysiology of this is gram negative infection under pressure. The other clearest example of gram negative infection under pressure is a gram negative urinary tract infection behind a kidney stone. Gram negative infection under pressure causes phenomenal sepsis, endotoxic shock, and time matters.
STEVEN SCHWAITZBERG: Next slide. Decompression is mandatory. And this can be a massive problem. I'm sure anybody who's been a resident for more than a month, Joe, has run into the problem of, you think you have a problem, that has a patient with cholangitis, it's Saturday and you can't get an ERCP. That's a nightmare.
STEVEN SCHWAITZBERG: It's a nightmare for the resident. It's a nightmare for the surgeon. ERCP isn't always possible. If it happens in a gastric bypass patient, it may not even be doable. Your go-to procedure is PTC, and then you find you can't get an IR on the weekend. And now it's all about you. Next slide.
STEVEN SCHWAITZBERG: Oops, that's the end. Go back one. Actually, go forward, go forward. There we go. You got to learn how to do a common bile duct exploration. And this is a classic board question. As an associate examiner of the boards, it is pretty common to get a common bile duct, how do you do it?
STEVEN SCHWAITZBERG: Even if you've never done one, you should know the steps. This is a view through choledochoscopy. Know how, call for help, and if you can't do the first two, this is an indication for an immediate transfer, even if it's 2 o'clock in the morning. The clock is ticking. You want to avoid gram negative endotoxic toxic shock. And nobody will fault you. If you are covering an ER all by yourself, you've got a job in the community, there's nobody to help you, get that patient out of your hospital, even if it's the middle of the night.
STEVEN SCHWAITZBERG: Your patient will thank you. And even the person receiving the transfer will thank you because earlier intervention is less work for everybody and produces a better clinical result. And that should be my last slide. Next slide. Thank you.
ALFRED CHAHINE: Thank you so much.
STEVEN SCHWAITZBERG: Thank you, everybody. Thank you to the board for the privilege of doing SCORE School. If you have any questions, I'm findable on the internet. It's schwaitz@buffalo.edu. Be safe, be committed to your patients. Take a little bit of-- oh, hi, Mary-- take a little bit of extra time developing the critical view of safety.
STEVEN SCHWAITZBERG: Every minute you spend is an investment for both you and your patient. Because invariably, somebody's going to come back with abdominal pain, somebody's going to come back with a bile leak and their bilirubin will be 3, and you'll go, I had the critical view of safety. This is either a retained stone or a bile leak. I can deal with these things and all will be well in the world. Thank you so much.
STEVEN SCHWAITZBERG: And that's it.
ALFRED CHAHINE: Thank you, Dr. Schwaitzberg. And thank you, everybody. We're going to stop the recording right now. Have a good night. See you next week.
STEVEN SCHWAITZBERG: Take care, everybody. Thank you.
Segment:0 .
ALFRED CHAHINE: OK, everyone. It's 8 o'clock, so we'll go ahead and get started. Good evening, everyone, and welcome to SCORE School. My name is Alfred Chahine. I'm one of the assistant editors of SCORE. And I want to welcome you into tonight's edition. Before we start, a few housekeeping issues. We would like the session to be as interactive as possible, so we encourage you to use the chat box to ask questions and make comments.
ALFRED CHAHINE: And everyone has been muted to avoid unnecessary feedback noise. We will be discussing six modules today, and we'll take questions and comments after each one. The first one is Cholecystitis, authored by Drs. [INAUDIBLE] and [INAUDIBLE]. The second one is Benign Biliary Obstruction by Drs. [? Randall ?] and [? Funk. ?] The third one is Cholecystostomy by Drs.
ALFRED CHAHINE: Stankowski, Drengler, and Greenberg. The fourth one is Common Bile Duct Exploration and Choledochoscopy by Drs. Newton and [? Li. ?] The next one is Cholecystectomy With or Without Cholangiograms by Drs. [INAUDIBLE] and [INAUDIBLE]. And we might not have time to get to the advanced module, The Ultrasound of the Biliary Tree my Drs.
ALFRED CHAHINE: [INAUDIBLE] and [INAUDIBLE]. We are using a QR system to track attendance for residency programs that subscribe to SCORE. So you will see a QR score, a QR code for this week displayed after the modules are presented and during the discussion. You only need to submit the form once even though it'll be displayed a few times during the presentation. And finally, all these sessions will be recorded for later viewing on the website, the SCORE website.
ALFRED CHAHINE: We're very pleased by the number of residents viewing those sessions each week. Tonight's presenter is Dr. Steven Schwaitzberg. Dr. Schwaitzberg is chairman of the Department of Surgery at the University at Buffalo School of Medicine and Biomedical Sciences and professor of surgery and bioinformatics there. He's a graduate of Johns Hopkins University and received his MD from Baylor College of Medicine and an MA from Harvard.
ALFRED CHAHINE: He completed his surgical residency at the Baylor Affiliated Hospitals, a fellowship in infectious diseases at the Methodist Hospital, and in pediatric trauma at the Pediatric Trauma institute in Boston. Prior to coming to Buffalo, he was professor of surgery at Harvard Medical School, where he held a variety of leadership roles. He also served with the 365th Evacuation Hospital in the US Military Medical Complex in Oman.
ALFRED CHAHINE: He is an internationally recognized physician investigator. He has made important contributions in both the preclinical and clinical areas in the development of surgical robots. He's currently the principal investigator on two grants looking at outcomes in biliary tract surgery and a national perspective clinical trial of natural orifice surgery versus conventional laparoscopic cholecystectomy.
ALFRED CHAHINE: He has authored over 200 peer-reviewed manuscript articles, chapters, and so on. He holds three US patents and has received numerous awards, including the American College of Surgeons Health Policy Scholar Award, Computerworld/National Smithsonian Honors 21st Century Laureate Achievement Award, and many awards for teaching excellence. He's On the Board of Governors of the American College of Surgeons and is past president of SAGES and chairman of the FLS Committee.
ALFRED CHAHINE: So please join me in welcoming Dr. Schwaitzberg. Thank you for doing this, Dr. Schwaitzberg, and please take it away.
STEVEN SCHWAITZBERG: Thank you so much. It's a real honor to be here for SCORE School. One of the things about speaking is, tell them what you're going to say, say it, and then tell them what you said. So we'll use that. This is the order of events tonight. I don't know that we're going to get all the way through. We'll have somewhere between 30 and 50 on the line. I welcome everybody to use the chat.
STEVEN SCHWAITZBERG: If any of my own residents are on the line, they know that it's always totally interactive. So we'll see how far we get. This is one of the great general surgery topics. And for those of you who are going to go on to do some form of general surgery, this really needs to be your area of expertise. Next slide.
STEVEN SCHWAITZBERG: So in our first module, which is Cholecystitis, the five topics that are in the SCORE curriculum are chronic cholecystitis, acute cholecystitis, acute acalculous cholecystitis, biliary colic, and then I've added one more, which is hydrops. Because I think this is a good way to organize it.
STEVEN SCHWAITZBERG: And if you have a system of organization in your head, then when you do your consults and you communicate with your senior residents and your attendings, you want to have a framework to communicate all these findings in, which is critically important. So if you're wondering why I'm saying "next slide," is that the way we're set up is the SCORE group are actually moving my slides forward. So this, for me, it's like doing this from like the old Kodachrome slides.
STEVEN SCHWAITZBERG: So next slide.
ALFRED CHAHINE: It's like robotic surgery, Dr. Schwaitzberg.
STEVEN SCHWAITZBERG: It's exactly like that. So let's start with biliary colic. So next slide. So what is biliary colic? Patients present with abdominal pain. Generally, the blockages are intermittent, there's no fever, the labs are normal. There's no persistent tenderness. And many of these patients come in either because they've called their primary care doctor or they show up to the emergency room.
STEVEN SCHWAITZBERG: And this is a very, very common cause of ER consults. So many patients use their emergency room as their primary care doctor's office. They come in after work. They complain of right lower quadrant pain. And then a lot of this is, what is the disposition for these patients? Often by the time you get downstairs, if you've been operating that night, the ER has often given their version of the GI cocktail.
STEVEN SCHWAITZBERG: They can't help themselves. They give pain medicine to everybody. And most of these patients can go home. The question really is, how much of a workup do you need to do? And the answer to that is often it depends on what time of day. In a world where we are living in a volume-based health care, not a value-based health care, the answers could change. So if you are responsible, for instance, for every dime that you spend in the workup of a patient, and they told you at 2 o'clock in the morning there's no ultrasound tech, the idea that you would use a CAT scan as the rich man's ultrasound is kind of disappointing.
STEVEN SCHWAITZBERG: But as you have all learned, people are doing CAT scans for biliary colic left and right because ultrasound techs are hard to find. And they'll often use a CT scan to make a diagnosis of stones and reinforce the fact that there's no free air in this and that. In a higher functioning system, particularly where there's good coordination between the ER, maybe the surgeon's office, some of these patients can be seen the next day.
STEVEN SCHWAITZBERG: I like to take a call on Mondays because I have clinic on Tuesdays, and in a perfect world, I can send some of these people home, get their ultrasound in the morning, and see them in clinic if they have no fever, normal labs, they're no longer tender, and can be seen in the office. Here's the deal with biliary colic, though-- once patients have symptoms, they will continue to have intermittent symptoms on some cadence every week, every month, every six months, until you take out their gallbladder.
STEVEN SCHWAITZBERG: It is absolutely true that many patients go to their grave with their gallstones. And the presence of gallstones, in and of itself, is not an indication for surgery. But once people have symptoms, they can do all the dietary change they want, they can eat roots and berries if they want, you're going to get the gallbladder. Because nobody can go on a diet restricted enough to ultimately keep them out of the operating room.
STEVEN SCHWAITZBERG: It just doesn't work. One of the interesting things if you stay and practice long enough, and I've been in practice over 30 years, is patients that you schedule for elective laparoscopic cholecystectomy occasionally will progress to acute cholecystitis in the interim. And you might come in on Monday, find out that one of your partners took out your pre-op patient's gallbladder because they progressed from biliary colic to acute cholecystitis.
STEVEN SCHWAITZBERG: Next slide. So next on the list up from colic is hydrops of the gallbladder. Next slide. What is hydrops? hydrops is cystic duct obstruction resulting in dilation of the gallbladder.
STEVEN SCHWAITZBERG: And this is a trap. The trap is no fever, no white count, normal labs-- next slide, and advance one more slide-- but they're tender. That is the trap. Even if they have no fever, no white count, normal labs, but they are tender, you need to entertain a diagnosis of hydrops until proven otherwise, and the single best test for that is a HIDA scan.
STEVEN SCHWAITZBERG: So a question for you all, when you aspirate the gallbladder on the picture, if anybody is brave enough to answer the question in the chat, why is the fluid clear when you aspirate a patient with hydrops? And I'll give you all a moment to assess the level of your bravery and answer, why is the fluid clear when they have hydrops?
ALFRED CHAHINE: Let's hear it, guys.
STEVEN SCHWAITZBERG: Don't be shy. Ashley Rosenberg, it's mucus instead of bile being secreted. That's close. Sarah, serous accumulation. No, the mucus answer is right. Anybody else? Only Ashley and Sarah. Brandon, bile distills from stasis.
STEVEN SCHWAITZBERG: Getting closer. Mucoid or watery content that's a residual, from Rox9007. What a great name. So the answer is, there was bile in the gallbladder at one point, but the cystic duct is obstructed and the bile is resorbed across the mucous membrane, across the membrane of the mucosa. And what remains is the mucus and serous fluid.
STEVEN SCHWAITZBERG: And so if you were to drop a stone into the cystic duct at time zero, It would all be green bile. But as time goes by, the bile is resorbed. And this is why the fluid is clear. It presents with inflammation. It can be a hard gallbladder to take out. But the trap, particularly for junior residents, is the ER doc calls you, listen, I've got a patient that's got tenderness, no fever, no white count, they've got some gallstones.
STEVEN SCHWAITZBERG: I'm going to send him home, right? The answer is no. The magic word is tenderness because over time left untreated, they will often get infected, and they will be just as bad as any missed acute cholecystitis. So hydrops is a trap. Be prepared, be vigilant. Semper vigilans. Next slide.
STEVEN SCHWAITZBERG: So now let's talk about acute calculus cholecystitis. Next slide. All right, so same mechanism as hydrops, cystic duct obstruction. However, there is generally a component of infection. Therefore, there is fever, white count, abnormal LFTs are common, but not required for the diagnosis. These patients should be tender because they have peritoneal irritation.
STEVEN SCHWAITZBERG: And then the question is, what tests do you need? Would you simply take a patient with right upper quadrant pain for a laparoscopic cholecystectomy? Generally not. Generally, there's some form of imaging. And the best test as ultrasound. But occasionally in the middle of the night, particularly if the patient has fever or a white count, it's not uncommon to see somebody with a CT.
STEVEN SCHWAITZBERG: Now, here's the trap. Ultrasound is the most common test, but ultrasound, in my experience in 30 years, is really only good for one thing-- the presence of gallstones. If your ultrasound tells you that there is a gallstone in the gallbladder, and the same is true for the common bile duct, if there's a gallstone in the gallbladder, you can take that to the bank.
STEVEN SCHWAITZBERG: The false positive rate is pretty darn low. So my next question for the group is, who knows what the false negative rate of a gallbladder ultrasound performed for the detection of gallstones or cholecystitis? Any takers on the chat, what is the false negative rate?
STEVEN SCHWAITZBERG: Irene goes, 20%. Robert goes, 5%. Rox9007, less than 5%. Any other takers? Becca, 7.5%. Jay, 2%, 15%. James Knight, 15% to 20%. James Knight, the second. So the answer is about 5%.
STEVEN SCHWAITZBERG: And you could argue that a better ultra stenographer can move those numbers in one direction or another, but that means one out of every 20 patients who presents with signs and symptoms of cholecystitis will have a false ultrasound. If your clinical suspicion is high enough, then you can go ahead and move to HIDA scan, and your HIDA scan is likely to be positive.
STEVEN SCHWAITZBERG: And so I have had occasional patients that I've operated on for biliary dyskinesia that had a negative ultrasound. They went on to HIDA scan with a gallbladder ejection fraction, and you, go, huh. They missed a stone. So you'll see that periodically, but your test is you need directional. A high positive predictive value, a 5% error rate.
STEVEN SCHWAITZBERG: And doing a CT after an ultrasound does not improve it. Because there's probably a lack of calcium. If you have a positive ultrasound, white count, tenderness, abnormal LFTs, plus or minus in amylase, to be certain they don't have pancreatitis as well, do you need to do a CT? Absolute waste of money. You do not need a CT to take somebody to the operating room. An ultrasound and a clinical index of suspicion is more than sufficient.
STEVEN SCHWAITZBERG: The treatment for acute calculus cholecystitis is threefold. There's medical therapy, there's surgical therapy, and there's decompressive therapy. And I'm not going to go into great detail for the Tokyo Guidelines, TG13 and TG18, but they do have a series of workflows that sort of outline if your patient has this profile or that profile, consider early laparoscopic cholecystectomy.
STEVEN SCHWAITZBERG: For me, this is sort of trying to cookbook common sense. If your patient is healthy and they have acute cholecystitis, and they do not have a specific contraindication for surgery, they can go for early laparoscopic cholecystectomy. And if you ask me my choice, would I rather operate on acute cholecystitis, all things being equal, or somebody who's had 10 episodes of acute cholecystitis or biliary colic, I'll take the acute patient every single time.
STEVEN SCHWAITZBERG: Now, it gets messier when you start talking about days of presentation. The magic number that people kick around is around 72 hours. And if you want to write a paper, you can go into your institution and look at the results for acute cholecystitis both before and after 72 hours, and write a paper that it increases the conversion rate or it's doable, you can do these gallbladders later, it is just harder and bloodier.
STEVEN SCHWAITZBERG: So your goal would be to do the gallbladder at the next point of election. If you have to do it at 2 o'clock in the morning, that's a bad idea. Doing it the next day is a great idea if you can manage it. And depending on your circumstance, if you have an acute care service, you don't, you have overtime the next day, you really want to try to get these patients done within 72 hours.
STEVEN SCHWAITZBERG: It's a little bloodier because of the inflammation, but the dissection is actually reasonably easy. If they have a big stone at the neck of the gallbladder, it's really not too difficult. The rest of the porta is OK. There are patients, however, that you can choose medical therapy. There is a reason why they can't be operated on, maybe they're four or five days out, you don't want to dive in there.
STEVEN SCHWAITZBERG: And so you can put them on antibiotics aimed at the microbiology. If you heard I did an infectious disease fellowship, really true. It was an amazing thing for somebody in surgery. You can put them on medical therapy. So my question for the group tonight is, what are the bacteria that you need to direct your medical therapy towards?
STEVEN SCHWAITZBERG: What are the bacteria that you want to treat for routine acute cholecystitis with no evidence of air in the gallbladder? What are the likely bacteria? Rox9007, E. coli Klebsiella. That's a good start. What else? Brandon, as an Enterobacter. James Knight, through an aenerobe.
STEVEN SCHWAITZBERG: OK, James, no style points for you. Aenerobes are not a prominent feature of acute cholecystitis in the absence of air in the gallbladder. So E. coli Klebsiella is good. Enterobacter, a good comment from Joe. Joe, are you actually coming to UB sometime in the near future? You can just add that to the chat. Ashley, Enterococcus, yes.
STEVEN SCHWAITZBERG: So this actually helps define-- yep. Yeah, near future is like now. See, I've already promoted you. I couldn't understand if you were the fellow or the intern. Sorry about that, Joe. I look forward to meeting you and talking to you. Oh, now he's laughing at me.
STEVEN SCHWAITZBERG: Definitely not the fellow. But the microbiology of all surgical infections helps us define what the appropriate antibiotic's for. So in the absence of air, some of those super high power antibiotics, piperacillin and things like that are designed to be shotgun for, say, for instance, perforated diverticulitis, which is you need to treat the anaerobes, you have much simpler, much simpler choices.
STEVEN SCHWAITZBERG: So what would be a good regimen for our Enterococci, E. coli, Klebsiella, Enterobacter presumptive infection? What are the right antibiotics for this? So let's see what we can do. Who's brave? Zosyn, overkill. We don't need the anaerobic coverage, Sarah.
STEVEN SCHWAITZBERG: Unasyn, from TD. Great choice. Unasyn's a good one. Ceftriaxone, too much anaerobic coverage. First generation cephalosporin plus a fluoroquinolone, not bad. Meropenem, overkill.
STEVEN SCHWAITZBERG: Sarah's got bazookas and grenades tonight. So the classic therapy is amp and gent. Because combined with aminoglycoside, your ampicillin gets all of your Enterobacter, your E. coli, your Klebsiella. And so you don't really need a Cipro or Flagyl that you might use for diverticulitis. That would be inappropriate therapy for acute cholecystitis.
STEVEN SCHWAITZBERG: So Unasyn's not a bad drug. You can switch them to oral therapy if you want to send them out. But there's some good oral therapies that can follow from the Unasyn. And you can go from there. But all of your antibiotic therapy should be geared at the microbiology of the infection. Third on the list is decompression-- surgical decompression, percutaneous decompression for acute cholecystitis.
STEVEN SCHWAITZBERG: And that's reserved for patients who you would consider to be poor surgical risk. There might be a patient, and they come in with a positive review of systems and 30 meds, and they're in a nursing home, and all the bad things. They might be better served with a tube cholecystostomy that we'll talk about in a minute. But I want to make you aware of the current literature. The mortality rate for using a C-tube in places you could have used at an operation is actually higher.
STEVEN SCHWAITZBERG: And it is higher. So I don't think that C-tube for convenience because your attending doesn't want to get out of bed is the right way to teach you. Going back to Brandon's chat question, he hasn't seen much gent used. A single dose of gent you know, give them a shot of 100, is not associated with very much toxicity.
STEVEN SCHWAITZBERG: It's just that because we have higher grade things like Unasyn, you don't see amp and gent anymore. But if you had to use amp and gent, a short course of aminoglycoside really is a great choice, particularly in patients who have normal kidneys, Brandon. So decompression, percutaneously, we'll get to that in a moment. Next slide.
STEVEN SCHWAITZBERG: Let's talk about acalculous cholecystitis. Next slide. So this is really an ischemic disease. So the patients that you see this are often patients who've had some episode of global ischemia, not that uncommon after a coronary bypass, for other severe multisystem organ failure scenarios.
STEVEN SCHWAITZBERG: Yes, it can become secondarily infected. It is very, very rare for a patient to come in off the street with acute acalculous cholecystitis. Most often these patients will be diagnosed by CT. Because you have a patient in the unit, you're working a fever or tenderness or elevated white count, they're more likely to get a CT before a HIDA scan. There will be some inflammation around the gallbladder.
STEVEN SCHWAITZBERG: If you're unsure, you can follow it up with a HIDA scan. That can be problematic because the patients won't have eaten. Because these people are sick, decompression is appealing, it's very appealing. However, it may fail. Next slide. So this is a shot from a laparoscopic cholecystectomy that I did a few years ago.
STEVEN SCHWAITZBERG: Next slide should have an arrow. You can see at the arrow that there was a C-tube in there and the patient continued to progress. Because the C-tube doesn't truly treat the ischemia. So a C-tube is probably the right way to go. It may fail and you may have to bite the bullet and do the case. Next slide.
STEVEN SCHWAITZBERG: So let's talk about chronic cholecystitis. Next slide. So this is the bane of your existence. Chronic cholecystitis is the absolute bane of the gallbladder surgeon. Patients often have repeated attacks. Occasionally, the stones may fall into a new configuration, and they'll get acute chronic cholecystitis.
STEVEN SCHWAITZBERG: The chronic inflammation causes shortening of the structures. It makes the tissue woody. Occasionally, if you're unsure, you can do a HIDA scan with gallbladder ejection fraction, the same way you would for biliary dyskinesia. But when somebody says to me, oh, I'm going to do a gallbladder for real live chronic cholecystitis, the real deal, I just go, Danger, Will Robinson. This is the place where common bile duct injuries occur most frequently.
STEVEN SCHWAITZBERG: I've been blessed to not have personally experienced a bile duct injury. I've done more than 2,500, probably almost 3,000 gall bladders. I live in fear of chronic cholecystitis. Next slide. Chronic cholecystitis more typically looks like this. It doesn't look so horrible.
STEVEN SCHWAITZBERG: The gallbladder loses its robin egg blue appearance. And there are other traps for this. Next slide. Oh, go back one. I'm sorry, Madison. This patient had gallbladder cancer. So always be aware that the situation can be more complicated than you think. Go ahead to the QR code.
STEVEN SCHWAITZBERG: So we'll have a moment. We can talk about these. Does anybody have any questions about general treatments? So when you talk to your attending, you really want to earn your style points for, I have a patient in the ER. No fever, no white count, but he is tender. I think he might have hydrops. I'm going to work him up with a HIDA scan.
STEVEN SCHWAITZBERG: That would earn a gold star, for me anyway. All right, next slide. All right, so let's talk about this cholecystostomy decompression business. There is sort of a stylized diagram of this. We put this in patients considered too sick to remove the gallbladder.
STEVEN SCHWAITZBERG: I have a variety of partners. They have different thresholds for using tubes. I do not like to put in tube cholecystostomies unless the patients really need it and they deserve it. There are a few contraindications. It's not fair to ask the interventional radiologist to put something in the liver and the peritoneum if they have a PT that's off the charts, if the liver's full of tumor, then that can be a tough stick for the interventional radiologist, if there's just no window, which doesn't happen very often, but that can happen.
STEVEN SCHWAITZBERG: But one of the things that people don't talk about very much is if the gallbladder is packed with stones, you may not have a place for the tube to go in, and you may be stuck putting this in. Ideally, if you're going to put this in percutaneously, you want to go trans-hepatically. And that's so that you can have a seal. You don't want to have a gallbladder where you just pulled out the tube and you're draining bile in the abdomen.
STEVEN SCHWAITZBERG: If you're going to do it open, you want to put a purse string in the fundus. There's a couple videos on YouTube that show it nicely. You can do it laparoscopically. You can do it open. You can put in a bigger tube. If you decide that you don't have the skills to do it laparoscopically, you could use the on table ultrasound right before you operate to visualize the gallbladder and make your incision right over on top of the gallbladder so you can make it nice and small, put a little purse string in there, and deal with it later.
STEVEN SCHWAITZBERG: I want to make you aware of the literature suggesting that under certain circumstances, cholecystostomy is associated with a higher mortality from the biliary tract disease independent of the factors that made them appealing to have the tube in to begin with. This is the direct effect of that form of treatment. Next slide. If you do it open, you put in a purse string.
STEVEN SCHWAITZBERG: You can put in the Malecot catheter, as shown here. You can put in a Pezzer catheter. But you want to make a purse string so that you can pull it out after the track has matured. Next slide. The next challenge is managing these patients. How do you manage them? You put it to drainage initially.
STEVEN SCHWAITZBERG: I do a tube study about a week later to see if the cystic duct is open. If the cystic duct is patent, then I'll clamp it and ask the patient to report symptoms and notify the patient that if they develop symptoms after they've been clamped, they can unclamp it. The biggest headache about these tubes is dislodgement. I saw a patient in clinic that had a tube that was on our service, transferred from the VA.
STEVEN SCHWAITZBERG: And he showed up in clinic, he had no tube. I said, what happened to your tube? He said it fell out. They took it out in the ER. So dislodgement is a real headache for these patients. That's the real deal. Pay attention to how these tubes are secured. It'll save you a lot of aggravation. I generally don't pull them out before four weeks.
STEVEN SCHWAITZBERG: And my question for you is, you have a patient you've treated with a tube cholecystostomy. You pull the tube at four weeks after verifying that the cystic duct is patent. They walk out of your clinic. They get to the parking lot, and they are doubled over with pain. What's the diagnosis?
STEVEN SCHWAITZBERG: So any brave souls? You pull the tube. They're in the parking lot. They are doubled over with pain. What's the diagnosis? Becca, right on, bile leak. Bile is incredibly irritating. It is a chemical peritonitis. It occurs that quickly.
STEVEN SCHWAITZBERG: It generally means they did not go through the liver. Natasha, bile peritonitis, even better. It did not go through the liver. It leaked right out of the gallbladder into the abdomen. And the only thing you can do is take them right to the ER. It is incredibly painful, incredibly painful. Next slide. End of that short section when I get to the cholecystectomy. any questions?
STEVEN SCHWAITZBERG: All right, let's move on. All right, now let's get to what it's all about. I have been doing laparoscopic cholecystectomies since 1991. Some of you people are going, oh, crap, I wasn't even born then. That's frightening for me, too. Unfortunately, all of my pictures before 1996 were actually photographs, and so I don't have my most original lap cholies.
STEVEN SCHWAITZBERG: But what I'm showing you is a body of work from the early days of laparoscopic cholecystectomy to a robotic cholecystectomy, yes, that I do occasionally. And I have been committed to the critical view of safety for at least 25 years. This is how you generate a series of more than a thousand without a bile duct injury.
STEVEN SCHWAITZBERG: So your commitment to the critical view of safety is really what's going to keep you out of court, your patients out of danger. Bile duct injury is incredibly morbid. It will be a topic for SCORE School next week, so I'm not going to talk about the implications of bile duct injury. I am talking about the medical/legal implications of bile duct injury at the virtual stages in August.
STEVEN SCHWAITZBERG: If you want to hear the talk about the medical/legal, that's for another time. It's on the SAGES schedule in their bile safety program. But this is a lifelong commitment to safety. I do it every time. Can you achieve the critical view of safety in everybody? Not quite. Sometimes I'll take the artery if I can clearly see a clamp under the gallbladder.
STEVEN SCHWAITZBERG: I'll take it off the gallbladder and pull it down. But this is my lifelong commitment to my patients. Next slide. So before we even operate, cholecystectomy starts way before the operating room. And you should ask yourself why are you doing this operation on this patient. And the way I want you to think about it is if this patient dies on the operating table, can you look their family in the eye and go, this patient needed an operation?
STEVEN SCHWAITZBERG: If you can't do that, and you're operating on a truly asymptomatic patient who just happens to have a positive ultrasound because they were looking at their kidney, if you can't truly justify what happens if they die on the operating table, don't do it just because you need some money or you have a hole in your schedule. Does this patient have any unusual risks that you need to think about and put into your brain before you operate?
STEVEN SCHWAITZBERG: Preload your frontal cortex. Have they had a lot of abdominal surgery? Have they had a previous gastric bypass? Do they have any number of diseases that can make this hard? Do they have situs inversus? So yes, I've done two lap cholies in patients with situs inversus.
STEVEN SCHWAITZBERG: It's a real trip to do. And are there predictable hazards that you can think about and plan for as you do the operation? Next slide. One of the things that I do for every patient is I give them a personalized consent about their surgery. This is a clip from a video.
STEVEN SCHWAITZBERG: I use an iPad and I work with a small company, that we record the video for each and every patient. I've been either showing my patients videos or now recording videos for 25 years. Adding it to my education lexicon so that if I were to be sued, and the patient said, you didn't tell me anything, that is just not true and I can prove it. A lot of people say, well, it's my practice to tell them this, or it's my practice to tell them that.
STEVEN SCHWAITZBERG: That's not good enough. Every patient gets a URL. They can go watch the consent again. And if somebody wants to know what I did in my consent session, they can actually watch it. I've got partners who say, well, that takes too long. Well, I assure you that whatever time you spend in a consent-based malpractice suit will be a hundred times more than a few extra minutes I spend teaching every single patient about their surgery.
STEVEN SCHWAITZBERG: If you look on the stomach, you can see I'm talking about the critical view of safety and a few other things for the patient. Consent is an opportunity to build a therapeutic relationship with your patients. Next slide.
ALFRED CHAHINE: Dr. Schwaitzberg, Rox has a question about whether you do that only for a cholecystectomy or for all--
STEVEN SCHWAITZBERG: No, I do it for everything, Rox. Natasha has been in my clinic. I do happen to do endocrine surgery as well and hernias. I do it for everybody. But I started showing the videos for cholecystectomy and hernia, and now I video the consent session for everybody, unless the system happens to be down, and then I don't feel good about it. I do what I do, but I can't record it occasionally. So I spend a lot of time on consent.
STEVEN SCHWAITZBERG: I think it's because I believe-- and you go, well, where did this all come from? I spent five years as the chair of the IRB. And if anybody has done a protocol, IRBs are all about consent. The truth of the matter is, the surgeon's the most conflicted person in the room and stands the most to gain by talking a patient into surgery. I don't have anything to hide.
STEVEN SCHWAITZBERG: I'm more than happy to show the world what I said to the patient. That's a personal choice. The culture of safety. Live in a culture of safety, recognize danger. So if anybody says, well, he probably just does easy gallbladders, I have one of the largest series in the United States of doing laproscopic cholecystectomy, when I was at Tufts, in cirrhotics because we had a liver transplant service.
STEVEN SCHWAITZBERG: That's an operation that really gets your attention. Next slide. This is not the case you want to do a year or two after you graduate. Just because you're thrilled that somebody sent you a gallbladder, I implore you, don't do a cirrhotic by yourself. Your conversion rate will be high. Your return to OR rate will be high.
STEVEN SCHWAITZBERG: And it is an unnecessary-- there's no case, there is no payment that is worth this level of aggravation. Next slide. This is an opportunity to exercise its wisdom and judgment. This is where you call a senior partner for help. I'm not saying you can't book the case, just don't do it by yourself.
STEVEN SCHWAITZBERG: Next slide. So I'm committed to the critical view of safety. This is from the SAGES Safe Choly program. The critical view of safety has three components. If you graduate from your residency and you can't recite this chapter and verse, then your program failed you. The hepatocystic triangle is cleared to the fat and fibrous tissue.
STEVEN SCHWAITZBERG: The common bile duct and the hepatic duct do not need to be exposed. The lower one third of the gallbladder is separated from the liver to expose the cystic plate. The liver bed and two and only two structures can be seen entering the gallbladder. So that's almost true, but occasionally the cystic artery divides into anterior and posterior. So it's true-ish.
STEVEN SCHWAITZBERG: And so there's always an exception to the rule. The SAGES Safe Coley program was the brainchild of Michael Brunt, who was SAGE's president a little bit after me. And he and I had been in conversations where I reviewed 53,000 lap cholies and discovered that the injury rate among surgeons who were less than seven years from their residency is three times higher than that of their more senior surgeons.
STEVEN SCHWAITZBERG: So have a method. A safe coley, critical view of safety, for one thing. Next slide. This is my lifelong consistency. So the reason why I go back to this because I wanted to show you, yes, I actually do lift up the cystic plate in each and every case. Next slide. So here's my question for you-- all right, campers, is this the critical view of safety?
STEVEN SCHWAITZBERG: Yes or no.
ALFRED CHAHINE: Let's hear it, folks.
STEVEN SCHWAITZBERG: All right. No, no, no, no. You are all correct. Next slide. I am an obsessive dissector, and this is the same patient. If you look at where those arrows are, you would have been right on top of the common bile duct and you would have cut the right hepatic artery in half. And you can see the right hepatic artery is traveling right under the gallbladder and the cystic artery comes off more anteriorly Dissect, dissect, dissect.
STEVEN SCHWAITZBERG: Use the easy cases to serve as your dissection teacher for the hard cases. Next slide. Recognize danger. Chronic cholecystitis, as seen in this picture, if you look at the blue arrows on the left side, that's 1 centimeter measured. I had already taken the artery, as I said I do sometimes.
STEVEN SCHWAITZBERG: In fact, the curved line is the common bile duct. The trap here is excessive tension on the short cystic duct pulling the common bile duct into the clips. So you can see in that picture of afterwards, you can see that the common bile duct is intact, and that I took it very close to the bile duct with complete visualization the whole time. Next slide.
STEVEN SCHWAITZBERG: If you fail to do this, this is how you can get a non-tract transectional injury. You can see there are clips where the arrows are often associated with a bile leak because you don't have a good purchase. So one of the things that you should do before you take the cystic duct is to take all the tension off. Take all the tension of the cystic duct so you can let that common bile duct retract and make sure that you're putting it around the cystic duct and not onto the common bile duct because you've pulled it up into the wound.
STEVEN SCHWAITZBERG: Avoid the risk of a transectional injury. Next slide. OK, a big, fat cystic duct. Tell me what your favorite ways of dealing with this big, fat cystic duct is. Let's get some more brave people. I don't bite too much.
STEVEN SCHWAITZBERG: Brandon goes, endoloop. What else? Hem-o-Lock clips. Maybe. Come on, there's too many silent people on there. Be brave.
STEVEN SCHWAITZBERG: Feedback is a gift. Make the call. It's scary to think about, but stapler. Thanks you, Katie. Yes, scary to think about it. I do get scared if I feel inclined to use a stapler that I'm making a mistake.
STEVEN SCHWAITZBERG: I agree with that completely. Anybody else? All right, so let's see what our choices are. Next slide. So you got choices. You could clip it with the regular clip and pray. I don't think that's a very good strategy because you look at it carefully, and when you go to these M&Ms and you hear about these cystic duct leaks and they said, oh, yeah, the duct was really big, but I thought it was OK, that's just defending stupidity.
STEVEN SCHWAITZBERG: You can get a bigger clip. If you're one of those folks that uses a 5 millimeter clip applier, then a bigger clip is not a bad idea. There are some pretty big clips. One thing about the 5 millimeter clip appliers, I don't love them because I've done a lot of clip studies, and the variability of holding power is pretty great in a 5 millimeter clip applier. Yes, you can use a stapler.
STEVEN SCHWAITZBERG: Yes, you can hand tie. Yes, you can use an endoloop. Next slide. This is a really good time for a cholangiogram, just to be safe, to take down that fear factor from when you want to use a stapler. Next slide. So, yeah, you can do a free tie of the cystic duct.
STEVEN SCHWAITZBERG: And so here's an example. We're doing an extracorporeal tie of the cystic duct. You're going, why did you do that? Didn't you have a stapler? I was in a really cost-economic mood. And a 3-0 silk is, or maybe that was a 2-0 silk, a 2-0 silk is like under a dollar. And so we solved the problem for under a dollar.
STEVEN SCHWAITZBERG: If you use a stapler, and I just spent a dollar, any takers on how much a 30 millimeter, 3 centimeter linear cutter, pick your favorite brand, costs to take this duct? And I say common-- from Alfred, the 5-millimeter stapling devices. Yeah, that's done by the guy from Colorado, Steve Rothenberg. That's his group.
ALFRED CHAHINE: That's right, yeah.
STEVEN SCHWAITZBERG: I'm a failed pediatric surgeon wannabe. I know all those guys. Yeah, a lot of money. $750, probably a little high. $300 to $500 is probably a good guess. So in a world where somebody might hold you accountable for the cost of your operation, a buck looks pretty good. This is a standard extracorporeal technique.
STEVEN SCHWAITZBERG: It's right out of the FLS playbook. And everybody who's going to do a gallbladder should be able to do an extracorporeal tie or an endoloop because these are FLS skills, an endoloop is about $40, and that you have the skill to do it. And, in fact, if you haven't done an extracorporeal tie in a while, use this as an opportunity to practice.
STEVEN SCHWAITZBERG: Next slide. Another choices is endoloop. You're saying, wait, what's that other tie? Did you not have faith in your extracorporeal tie? No, we were just creating teaching slides, so we did both. But the trap is avoid the temptation to pull the cystic duct out too far unless you know you really have a lot.
STEVEN SCHWAITZBERG: Because, again, you don't want to create that partial thickness injury. It is a very secure way to do it. It's about $40 compared to a stapler. And it is cheaper than getting out a second clip applier, no matter what. Next slide. At the end of the case, if you look in the upper right-hand corner, you'll see this round thing.
STEVEN SCHWAITZBERG: That is a flexible ovarian retractor. I use it and lift it up. Ashley asks, did you clip above the cut and then place the endoloop? Yes, on the keeper side, I just threw a clip on. I didn't care that much, but you could tie both sides or do endoloops. But if you have the clip applier, it's usually good enough.
STEVEN SCHWAITZBERG: Or then when I go to retract it, I grab that part with my retractor. Good question, Ashley. But at the end of every case, I elevate the liver. Sometimes you have to pull down the colon. And I look and make sure that my clips are hemostatic and in place. Next slide. Cholangiography, important skill for all surgeons.
STEVEN SCHWAITZBERG: This is a Reda catheter going in. Next slide. Here's the cholangiogram. Oop, do we have too many? So you got spared the question. But the first cholangiogram is unacceptable. If you can't demonstrate the upper ductal system, you cannot leave the operating room without an upper cholangiogram.
STEVEN SCHWAITZBERG: You might as well just get out your checkbook if there's an injury. So there's a number of things that you can do to get this cholangiogram to come up. So anybody have some ideas about how you can get that second cholangiogram-- this is the same patient, you can see that-- how do we get a better cholangiogram? And the short answer is not scored harder.
STEVEN SCHWAITZBERG: Ashley goes, glucagon. That actually won't help you. That will hurt you because it will reduce the pressure on the other end. Good thought, though. Any other takers? Morphine. Some people have tried morphine to try to increase the pressure at the sphincter of Oddi.
STEVEN SCHWAITZBERG: Any other takers? Because none of these are the correct answer yet. None of these were the answer for this cholangiogram yet. So the cheapest solution--
ALFRED CHAHINE: There you go.
STEVEN SCHWAITZBERG: There you go, Katie. Well, Katie has been with me. We did a case where we put the patient in Trendelenburg recently. So, yes, you stand the patient on their head and let gravity help you. Good call, Rox9007. So, yes, let gravity be your friend and stand the patient on their head. We were actually doing an ERCP with a gastroenterologist, and they couldn't get the cholangiogram, so we said, stand the patient on their head.
STEVEN SCHWAITZBERG: And it was like, wow. He actually came to the EOR. We were doing a transgastric ERCP, and they actually walked out of the operating room with a tip. So this is incredibly important. Next slide. I used an Olsen clamp. There's a variety of different methods.
STEVEN SCHWAITZBERG: I happen to like the Olsen clamp. If you use the Olsen clamp, turn it upside down. It works better. Next slide. Again, that's a bad cholangiogram. Next slide. A good cholangiogram. I must've put two slides in.
STEVEN SCHWAITZBERG: Next, keep going. How often do you do cholangiograms in your practice? Well, the short answer is not as often as I should, and that's for a couple of reasons. One, I have the skill, so I don't need to practice. But the reason why I'm sort of embarrassed that you asked this question-- because I've got my residents keeping me honest-- I should do it more often, if for nothing else to make sure that everybody in my program can do a cholangiogram.
STEVEN SCHWAITZBERG: And I'm going to comment on that in a second, but I do it selectively. If you get good at it, it adds about 10 or 15 minutes to the case. But there are days where I feel like I should just do a cholangiogram for the experience with my team. You need to learn how to read the cholangiogram, for sure. So that's the other part of the equation, Ashley, is if you don't do cholangiograms, you can't learn to read the cholangiograms.
STEVEN SCHWAITZBERG: And there you can see, this is a real patient, an extra little duct traveling around, and there it is, the hepatocystic duct. Next slide. One of the things that puts cholangiography in jeopardy is indocyanine green. And I think ICG is great. I have no conflicts to report about anything related to ICG.
STEVEN SCHWAITZBERG: And despite the fact of having done more than 2,000 with a bile duct injury, I use it every single case. Because why wouldn't you want more information? A vial of ICG is about $120. You could split into 10 doses, you could do this for $10 or $20 a case. And that also has impacted the rate of cholangiography. I use it to see the common bile duct. I often have the ICG running when I put my clips on so I can see the bile duct.
STEVEN SCHWAITZBERG: There's some new technologies that will be looking through tissue, but as you can see, the artery is right next door, and maybe we'll have a new critical view of safety one day, two and only two structures, and one of them doesn't light up. And if I ever am in a mood to waste a little extra ICG, sometimes I'll just flash the artery just for fun just to demonstrate that you can use it to find the artery as well. 25 milligrams in powder diluted in 10 CCs, give a half a CC.
STEVEN SCHWAITZBERG: I started off by giving 2, then 1, now a half. A half is plenty. Next slide. So we're going to play a video. I've sped this up, and we'll see if this works. I'm always leery about using videos in someone else's system. Give it a moment. I'll click.
STEVEN SCHWAITZBERG: There we go. Let's see what happens. Give it a moment. And so this is running a little bit more quickly. And I just want to make a few comments. This is not going to be the world's hardest gallbladder. As you can see, this is a highly edited video. I use these scallop graspers.
STEVEN SCHWAITZBERG: I use [INAUDIBLE] to strip down the peritoneum. Pull, pull, pull. Notice I don't use any cautery in here. I use very little cautery during this whole thing. I use a lot of spreading. I use a lot of lifting of the peritoneum, of creating pockets. You see that little bit of bleeding?
STEVEN SCHWAITZBERG: I don't care about it. It's all going to stop. Here's a peanut. And for the love of God, please don't spin your peanuts while you're using it. Eventually you'll just pick up some little vessel and twist it right off and cause more bleeding than it's worth. The key to making the surgery safer, I think, is the posterior dissection.
STEVEN SCHWAITZBERG: So I open it up anteriorly, I open it up posteriorly. Here we are using a hook. Hook is your finest right angle. Use all your basic fuse principles of dissection, current density to make these devices work for you. I open it way up because I'm going to do a good cystic plate dissection every time, so I do this early. This is not me operating. But it's what we do every time.
STEVEN SCHWAITZBERG: You can see, we're starting to get the structures. Just sweeping things down, not so hard that you rip things off. Now we're opening up the plate on the other side. One of the things I would suggest that all of you consider doing is record your surgeries. Record your laparoscopic surgeries and go back and look at them.
STEVEN SCHWAITZBERG: There is the window being formed. Continue to dissect. A lot of people would just take the structures here, but I'm too obsessive to do it at this point. I'm going to drag the fat down. But by recording your surgeries, you can learn to become a better surgeon. I have spent a lot of time in video. I was a video editor for surgical endoscopy for 15 years.
STEVEN SCHWAITZBERG: I've literally reviewed every video that came to SAGES for the journal. And I learned so much surgery by watching other people operate and by watching myself operate. It's horrifying. I go, I can't possibly be that clumsy. Here's the dissection of the artery. Don't be afraid of it.
STEVEN SCHWAITZBERG: I use a right angle. I love my right angles. 5 mm and 10 mm right angles. I'm not afraid to dissect. This is the way you build fine motor skills. I'm going to open up a little bit of the plate in the back. You got to take the stuff anyway. And I'm always looking for a posterior cystic artery.
STEVEN SCHWAITZBERG: The only patient that I have ever taken back to the operating room was a patient with a sickle cell disease. I was actually in Saudi Arabia, of all places. And here's the ICG. You can see it nicely. We gave it a pre-op. Notice the artery is not lighting up. I'm going to use the peanut.
STEVEN SCHWAITZBERG: I'm going to find the common bile duct. There it is down there. So now I know the common bile duct's pretty far away. And then I'm going to clip the artery, two below and one above. Usually I put the bottom one on first. Clip then divide. Seems like common sense.
STEVEN SCHWAITZBERG: I like sharp scissors. I don't like reusable scissors. I got burned. You can see the artery pulsing. I got burned by a pair of scissors that wasn't very sharp. I'm going to relax. You see, I'm going to relax a little bit on the cystic duct. Relax, relax, relax.
STEVEN SCHWAITZBERG: There it goes. And the scissoring of the bad scissors knocked the clips off, and I had to go chase a bunch of bleeding. I was able to control it laparoscopically. This is an edited video. I went back and saw where the common bile duct was. Leave a nice cup on your clips so you're not cutting flush. These are the little details or the difference between a leak or not.
STEVEN SCHWAITZBERG: And you're off and running. Sometimes I leave the ICG on while I'm doing the dissection. It's kind of pretty. I play around with the [? gain ?] and this and that. Madison, why don't we go to the next slide. I already showed you that I lift the liver up. I put it in an Endo Bag and take it out. Next slide.
STEVEN SCHWAITZBERG: To drain or not to drain, that is the question. And when I was a resident-- I'll answer your question in a second, Robert-- when I was a resident, we used Penrose drains on everybody. And now it's pretty uncommon for me to drain. But when I drain somebody, I have a reason. So if my reason is it looks a little bloody, I just want to get the blood out, then I leave that drain in for a day or two and pull it out.
STEVEN SCHWAITZBERG: If I'm worried about a bile leak or the clips are not very secure, it was the best I can do, then I'll leave it on much longer. So Robert asked about the spatula. So I did my first thousand lap cholies with a spatula. And then I went to and was operating in Brazil and they didn't have a spatula, and somebody handed me a hook. And I like the hook for doing the dissection around the bile duct.
STEVEN SCHWAITZBERG: And then sometimes I'll switch to a spatula to take the gallbladder out. This is really all about understanding current density. So sometimes I'll use the back of the hook the way I would use the spatula. But if you really want to use high current density with a high level of precision, pointing the point of the spatula right at your target tissue is great. But I did a thousand with a spatula.
STEVEN SCHWAITZBERG: It's great for taking out the gallbladder. And you can also use the spatula to kind of push a little. Or you can use the flat side of the hook. So there's nothing wrong with the spatula. It's all about your personal technique. Thanks on the video. Next slide. What happens after surgery? Leaks.
STEVEN SCHWAITZBERG: Duct of Luschkas can be found in 10% of patients. It was described in 1863. A lot of what are called Luschka leaks are probably hepatocystic duct leaks, which is not quite the same thing. And, of course, there's the vaunted cystic duct stump leak. In my series, I reported on 1,500 lap cholies in my own series. The leak rate was about a half a percent.
STEVEN SCHWAITZBERG: And getting back to that question of the Hem-o-lok clips, I personally don't love it. It's used a lot in robotics. But when I wanted to go find the data to support my personal bias, the Hem-o-lok clips performed fine. But if you ever read the literature on doing renal transplantation, there is a black box warning because they often cut flesh with these clips and they're at risk for falling off.
STEVEN SCHWAITZBERG: Any clip you cut flush is at risk for falling off. Hem-o-lok clips can be useful in some circumstances. Next slide. If you have a leak-- here's a 60-year-old man-- what's your test? My test? ERCP every time.
STEVEN SCHWAITZBERG: But when a patient comes back with an elevated bilirubin or some pain-- because I am so obsessive about the critical view of safety and not creating a non-transectional injury, I'm usually pretty cool about it because I know I have not cut the bile duct in half. I just know I haven't for sure because I've dissected it out completely. ERCP is both therapeutic and diagnostic.
STEVEN SCHWAITZBERG: Some people use a HIDA scan to good effect, but my go-to test is an ERCP. And then I want to know if there's a collection. Next slide. Here's an ERCP, another one showing a bile duct leak in a patient who had a pretty fat cystic duct. Next slide. And here's something that I've done occasionally.
STEVEN SCHWAITZBERG: There was a fellow in Rhode Island named Joe Amaral. He used to use a HIDA scan, and he said if he got an early leak, he went back and reoperated on them. And I go, wow, that's ballsy. And I had an occasion to consult on a patient who had been operated on by a surgeon who went on vacation. And the medical student came up to me and said truthfully he thought the surgeon had clipped a piece of fat and not the cystic duct.
STEVEN SCHWAITZBERG: And I go, huh, the cystic duct's going to be wide open. It was about five or six or seven days out, I went back and reoperated on the patient. You can see the clip. None of them were actually on the cystic duct. I found the cystic duct, shot a cholangiogram and closed the thing laparoscopically. Next slide. So that's an option.
STEVEN SCHWAITZBERG: If you do have a bile leak, please, please, please, drain both sides. There is a certain amount of morbidity and mortality associated with these minor ductal leaks. You want to drain the collection to avoid a septic event. Next slide. This is going to bring us to the end of the hour. I apologize for being four minutes over. There are so many things that we can talk about for cholecystectomy and biliary obstructions.
STEVEN SCHWAITZBERG: It's a great topic. And I will be thrilled to entertain any questions that you might have.
ALFRED CHAHINE: Dr. Schweitzer--
STEVEN SCHWAITZBERG: Any questions?
ALFRED CHAHINE: --we only have a few more slides to go if you want to finish the rest, but it's up to you.
STEVEN SCHWAITZBERG: OK, well, let's go one more module then. I'll be quick. We'll talk about benign biliary obstruction. The trap here is ignoring the possibility that they have hepatitis. I can't tell you the number of times you get a consult from a medical service, and the SGOT and the SGPT, otherwise known as the AST and the ALT, is like 700 and the alk phos is like 100.
STEVEN SCHWAITZBERG: So like the patient has hepatitis. So nothing more fun for a surgery resident than to tell the medical resident their patient has hepatitis. Not every painless jaundice is a malignancy. Some strictures occur slowly. There can be choledochoceles, benign strictures. Lemmel syndrome. I had never heard of Lemmel syndrome.
STEVEN SCHWAITZBERG: I looked it up. I found it in the SCORE curriculum. It is an obstruction from a duodenal diverticulum, just to show you that I really did come prepared to give this lecture. There are patients who have primary choledocholithiasis. This has been more commonly seen in East Asia, occasionally associated with liver fluke disease. When I was at Tufts, the hospital was literally in Chinatown, and I did a number of partial hepatectomies for what was then termed at that time oriental cholangiohepatitis.
STEVEN SCHWAITZBERG: And it was more common in the left lobe for some reason, so we would do left lateral segmentectomies and sew to the biliary tree directly. It was kind of cool. Mirizzi syndrome, where a stone in the cystic duct occludes the common bile duct. Those can be very difficult cases, a lot of inflammation. Really think hard about shooting a cholangiogram. And these are really important.
STEVEN SCHWAITZBERG: Some of the patients with benign biliary obstruction, including the malignancies, will have an elevated PT. And some of these are associated with gallstone pancreatitis. One of the things to keep in mind is most patients who get diagnosed with gallstone pancreatitis don't actually have pancreatitis. What they really have is a one-time amylase leak. And the half life of amylase is about 24 hours.
STEVEN SCHWAITZBERG: So you'll find that their amylase of 1,000 is 500 the next day, 250 the day after, and 125. Those patients don't have pancreatitis. They can be operated on during that same admission. Next slide. The real danger that I want to sort of finish up this section with is missing cholangitis. And you never want to miss a patient with cholangitis.
STEVEN SCHWAITZBERG: It'll break your heart because these patients get really sick. This is a clinical diagnosis. Everybody knows what Charcot's triad is. Somebody named Reynolds said, I want something named after me. So he came up with adding mental status and hypotension. Now it's Reynolds pentad. There's a Tokyo classification for this. But the truth of the matter is, is that sick people are sicker than patients who are not so sick.
STEVEN SCHWAITZBERG: This does not require creating scores for this. You should be able to figure out in your surgical residency who is sick. And the basic pathophysiology of this is gram negative infection under pressure. The other clearest example of gram negative infection under pressure is a gram negative urinary tract infection behind a kidney stone. Gram negative infection under pressure causes phenomenal sepsis, endotoxic shock, and time matters.
STEVEN SCHWAITZBERG: Next slide. Decompression is mandatory. And this can be a massive problem. I'm sure anybody who's been a resident for more than a month, Joe, has run into the problem of, you think you have a problem, that has a patient with cholangitis, it's Saturday and you can't get an ERCP. That's a nightmare.
STEVEN SCHWAITZBERG: It's a nightmare for the resident. It's a nightmare for the surgeon. ERCP isn't always possible. If it happens in a gastric bypass patient, it may not even be doable. Your go-to procedure is PTC, and then you find you can't get an IR on the weekend. And now it's all about you. Next slide.
STEVEN SCHWAITZBERG: Oops, that's the end. Go back one. Actually, go forward, go forward. There we go. You got to learn how to do a common bile duct exploration. And this is a classic board question. As an associate examiner of the boards, it is pretty common to get a common bile duct, how do you do it?
STEVEN SCHWAITZBERG: Even if you've never done one, you should know the steps. This is a view through choledochoscopy. Know how, call for help, and if you can't do the first two, this is an indication for an immediate transfer, even if it's 2 o'clock in the morning. The clock is ticking. You want to avoid gram negative endotoxic toxic shock. And nobody will fault you. If you are covering an ER all by yourself, you've got a job in the community, there's nobody to help you, get that patient out of your hospital, even if it's the middle of the night.
STEVEN SCHWAITZBERG: Your patient will thank you. And even the person receiving the transfer will thank you because earlier intervention is less work for everybody and produces a better clinical result. And that should be my last slide. Next slide. Thank you.
ALFRED CHAHINE: Thank you so much.
STEVEN SCHWAITZBERG: Thank you, everybody. Thank you to the board for the privilege of doing SCORE School. If you have any questions, I'm findable on the internet. It's schwaitz@buffalo.edu. Be safe, be committed to your patients. Take a little bit of-- oh, hi, Mary-- take a little bit of extra time developing the critical view of safety.
STEVEN SCHWAITZBERG: Every minute you spend is an investment for both you and your patient. Because invariably, somebody's going to come back with abdominal pain, somebody's going to come back with a bile leak and their bilirubin will be 3, and you'll go, I had the critical view of safety. This is either a retained stone or a bile leak. I can deal with these things and all will be well in the world. Thank you so much.
STEVEN SCHWAITZBERG: And that's it.
ALFRED CHAHINE: Thank you, Dr. Schwaitzberg. And thank you, everybody. We're going to stop the recording right now. Have a good night. See you next week.
STEVEN SCHWAITZBERG: Take care, everybody. Thank you.
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