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Intraoperative Cholangiography Guidelines: Routine, Selective, or Never? · Behind The Knife: The Surgery Podcast

• BTK IOC === Speaker: [00:00:00] Hi there, BTK listeners. I'm Nicole Petka, a general surgery resident at Emory University, and I'm here with one of your all-time favorite BTK stars, Dr. Jason Bingham, who practices as a general and bariatric surgeon. Speaker 2: Thanks, Nicole. So today we're gonna be diving into the SAGES intraoperative cholangiogram guidelines. These are brand new, hot off the press, and, uh, they've gotten quite a bit of attention. Um, I'm sure everybody's seen it blow up their med Twitter feed and, uh, everybody seems to have an opinion on them. So, uh, we're talking about what it means for surgeons and how the committee arrived at these recommendations. So we invited the authors to help us understand in this case-based discussion. So Nicole, do you wanna introduce our guests? Speaker: Of course. So our first guest is Dr. Emily Miraflor. She's a general and colorectal surgeon at UCSF East Bay who served as the senior lead for the IOC guidelines. Next we have Dr. Kevin Ohiak. He's a professor of surgery at Case Western Reserve University School of Medicine, and is an HPB and minimally invasive foregut surgeon at the MetroHealth System in Cleveland, Ohio. He [00:01:00] also serves as the chair of the SAGES HPB and Solid Organ Committee. And then last but not least, we have Dr. Dena Shehata. She's one of the SAGES guideline fellows and is one of the two first co-authors on these guidelines. Emily, Kevin, Dena, welcome to Behind the Knife. Speaker 3: Thank you so much. It's great to be here. Happy to be here. Speaker 4: Thanks so much for having me. Speaker 2: Right. So let's get right into it. So we, we've kind of designed this to be a little bit of a, a case-based discussion. So we're gonna use a series of clinical scenarios and, uh, how to apply these guidelines in our real-world practice. So let's say that we're called about a, a, you know, a forty-year-old otherwise healthy woman who, you know, presents to the emergency department with right upper quadrant pain after having a big Thanksgiving dinner. She has, uh, nausea and some emesis. She's febrile. Her labs do show, uh, leukocytosis, but her bilirubin is normal. She got a right upper quadrant ultrasound, which shows some pericholecystic fluid, uh, that's consistent with acute cholecystitis, and her common bile duct [00:02:00] measures six millimeters. So you plan on taking her to the OR for a lap chole, um, but here's the key question: Are you going to perform a, an IOC? Speaker 3: So based on this guideline, this patient would fall into a group where performing an IOC is favored. She's an adult. She's undergoing a lap chole for benign biliary disease, and in this case, the panel conditionally suggests performing an IOC in addition to the standard safe surgical technique. The analysis used to support this guideline found that an IOC has a lot of benefits. It can help, uh, identify unexpected aberrant biliary anatomy, biliary leaks or bile duct injury, and of course, common bile duct stones. It may also decrease the need for postoperative imaging, which is an advantage and can reduce the rate of retained stones. So for this s-scenario, the guideline-supported answer is yes, IOC should be considered, and I'd have a low threshold to perform one. But we should emphasize that this is a conditional recommendation. The evidence is rated as low [00:03:00] certainty, meaning that it's not a mandate. A conditional recommendation means that the evidence points in favor of an IOC, but the evidence is low certainty, so the guideline preserves the clinical judgment of the surgeon. In practice, this decision to-should take into account a variety of things like patient-specific factors, how clear is your critical view, surgeon experience, what are your local resources, and of course, how feasible is it to perform an IOC in your setting? Speaker 4: I'll just add that, uh, the key practical nuance is that with a normal bilirubin and a six-millimeter common bile duct lowers the suspicion of a CBD stone. But with six millimeters, you might think maybe the patient passed one because it's not exactly in the four to five range. But that doesn't eliminate the value of an IOC because it, it's not just about stones. As Emily said, it's about clarifying anatomy, potentially recognizing a bile duct injury during that index operation. In acute cholecystitis like this patient has, as you know, inflammation [00:04:00] can make the anatomy very difficult to interpret, so the guideline supports much more liberal use of IOC, especially when the critical view of safety is not completely clear or there is a concern for abnormal anatomy, biliary duct injury, or CBD stones. That being said, selective non-use may still be reasonable if the surgeon obtains a very good critical view of safety, preoperative labs were normal as they were, there are no other concerning features and, for example, IOC is not readily available, it's the middle of the night, the team doesn't know what equipment is needed. But in this case, uh, with all else being available, the guidelines supports a low threshold to perform IOC, and I can tell you I would perform an IOC here. Speaker 2: Okay. So let's put in some kind of real-world variables. So we start the case appropriately planning on doing an IOC. But when you call for your X-ray, your X-ray tech is... They're short-staffed. Um, the hospital is [00:05:00] trying to hire people, but they have a bunch of stat things that they have to do, and they're not sure how long before they can make it to your OR. Um, so what do you do? Are you waiting? Speaker 3: So this is exactly where the conditional nature of the recommendation comes into play. So the guideline does favor doing an IOC, but it also explicitly recognizes that resource availability, C-arm access, fluoroscopy requirements, and local feasibility can affect one's ability to implement these guidelines. So if the C-arm is broken, the guideline doesn't mean that you ha-- just have to wait indefinitely until the C-arm comes back into play, um, and that you can't proceed. The next step here would be to reassess the clinical situation. If the critical view is-- of safety is clear, there's no concern for a bile duct injury, the suspicion for common bile duct stones is low, it's reasonable to proceed without using an IOC, using safe standard cholecystectomy techniques. But if you're uncertain about the anatomy, there's concern for a common bile duct injury or concern for common bile [00:06:00] duct stones, the guideline supports using intraoperative biliary imaging. If IOC isn't available, the guideline did look at laparoscopic ultrasound and found that that's an acceptable alternative to IOC as long as the surgeon has appropriate experience and the technology is available, of course. You can use fluorescence imaging with ICG as another imaging tool, but that can be limited in acute cholecystitis because the fluorescence can be a lot harder to see in, um, inflammation, and it requires, of course, the decision to administer ICG much earlier in the patient's course. You can't just give it in the middle of the case. Speaker 4: Yeah, I mean, I'll just throw out my support for intraoperative ultrasound. This was a big part of my practice, uh, in training as an HPB, eventually HPB surgeon. And I have with relatively simple measures, introduced this into a couple of acute care surgeons practices around the country, and I think it's a relatively straightforward knowledge that's needed, but you don't need a C-arm, you don't need radiation. So, uh, I [00:07:00] think y- you know, having some a- availability of a, a way to, to image the bile duct e- either with IOC or ultrasound was found to be better than ICG alone. Speaker 2: Great. So l- let's dive into these guidelines a little bit of the, you know, behind-the-scenes. Do, the guideline recommends routine use of IOC, or I really like what you said, Kevin, selective non-use of IOC. How did the committee arrive at that recommendation, and how should surgeons listening apply what you found into their practice? Speaker 5: So the panel reached that recommendation by looking at the balance of effects. Um, it means the balance of benefits versus the harms in the available evidence that we had. So for routine IOC compared with selective IOC, the potential benefits included better identification of aberrant anatomy, intraoperative identification of CBD stones, uh, bile duct injury, fewer retained stones, less need for postoperative imaging, and fewer postoperative endoscopic interventions. So the [00:08:00] harms of using IOC a routine IOC versus a selective IOC were unsuccessful imaging attempts and possible bleeding. Uh, I say possible bleeding because the causality of bleeding events could not be determined and may reflect a higher case complexity in those cases where IOC was performed and not directly related to IOC. The suggestion of a lower rate of BDI and the ability to detect them intraoperatively rather than postoperatively largely contributed to our recommendation. Uh, but overall, the panel judged the desirable effects to be greater than the undesirable effects, so the guideline conditionally suggested routine IOC rather than selective. And that's because the appraised evidence was directionally supportive of routine IOC, but the certainty of, of that evidence was low. Uh, so surgeons should apply this the recommendation in the context of the patient and the setting as was stated by, uh, Dr. Mirflor and Dr. El Hayek. Speaker 4: Jason, what, what I think, you know, this means in practice as, as a reader of the guidelines is that a surgeon who [00:09:00] may want to perform routine cholangiogram They're encouraged to do so. Uh, they now have, uh, firepower behind their decision to routinely perform it. For those who have very good reason to only perform it selectively, the guidelines allow for that flexibility in their practice. And, and let's be honest, for those who fully reject the idea that IOC should be done routinely, we're not gonna convince those people to do IOC routinely. They're not even doing it probably selectively, and nor would a well-run randomized controlled trial for that matter. There are surgeons who are just not gonna change their practice, and they're gonna have their reasons for not doing that. But I would say there may be a surgeon out there who's wondering, "Should I start doing this routinely? I wanna start identifying biliary, uh, defects. I wanna start identifying, uh, aberrant anatomy. I wanna start identifying choledocholithiasis." These guidelines support that decision. If they wanna go to their chair and say, "I wanna start [00:10:00] doing this routinely," they're not gonna get yelled at at M&M for doing a routine cholangiogram. So our job at SAGES is now to provide the tools to allow that to happen, and, and that's step two with this. Speaker: Yeah, I think that's a great breakdown of how surgeons in practice can really kind of start applying these. You guys touched a little bit on one of the great debates regarding the selective versus routine use of an IOC, and I often hear surgeons who routinely use IOC argue that it makes you better prepared for performing and interpreting the IOC when you actually need it. So is there any evidence to support that side of the argument? Speaker 5: Well, that would be a great question to answer, but unfortunately, uh, we did not find any direct comparative evidence showing that routine IOC definitively improves surgeon proficiency or interpretation accuracy. However, the panel acknowledges this as a reasonable practical consideration. Basically, if you only perform IOC rarely, you may be less comfortable with the steps, assessing the image quality, troubleshooting, and interpretation. Speaker 3: And I'd like to just jump in and say, um, I'm also a residency [00:11:00] program director, so it's really important to me that my residents learn this skill. And like any skill, practicing it routinely is one way of making sure that you're ready to perform the skill in all scenarios. As part of the systematic review to support the guideline, we looked at how often cholangiograms were unsuccessful or took ex- excessive amounts of time, and I can't cite specific numbers off the top of my head, but it should be no surprise that when you look at the discrete data for these individual papers, those papers in which a routine IOC was performed, they did not take a lot of time and they had higher success rates. So I think that although that's not statistically significant in terms of there's not enough data out there to, um, to bolster the argument statistically, intuitively it makes sense that if you do this more often, you're gonna be better at it, and not just you, but also your OR team will be better at it as well. And lastly, speaking specifically to gaining experience with IOC interpretation, there's a number of educational resources that I recommend that my residents use, including a great video called The Culture of Safety in [00:12:00] Cholecystectomy, and there's a specific section dedicated to cholangiogram interpretation, and I have found that very helpful. Speaker 2: Yeah, I'll just put in a plug for the safe cholecystectomy course. It's extremely useful, uh, especially for, you know, people looking to bring laparoscopic bile duct exploration into their practice and, you know, how to, you know, build a common duct exploration cart, you know, for your OR. Um, it's, it's a fantastic course, so I, I would recommend anybody who's able to attends that. Let's take this, you know, one step further. Uh, let's say you've convinced me I wanna be a routine IOC guy. When I look at implementing that change, what are some of the pitfalls? What are some of the things I need to watch out for? What are some of the, the risks that, uh, come along with changing from a selective to a routine practice? Speaker 4: Yeah, that's a great question, Jason. I, I think like any practice, there is a learning curve to IOC for the surgeon and for the OR team. I think probably the most common problem in the beginning is bubbles, air bubbles in the [00:13:00] tubing- Mm-hmm ... that can lead to false positive, and that would be for a CBD stone. And based on the guidelines, this can occur in up to a third of all cases. So in the beginning, the surgeon may need to be really involved in the setup of the cholangiocatheter to ensure there are no bubbles. They might have to be a little more involved than just give me the cholangiocatheter. Along the same lines, misinterpretation of the cholangiogram can lead to unnecessary interventions, either in the OR, you know, performing an unnecessary bile duct exploration, or afterwards, an unnecessary ERCP. So th-that's been probably one of the biggest criticisms of routine cholangiography, is that people say, you know, it's gonna lead to more bile duct explorations that weren't needed or more ERCPs. And that may end up being the case in the early phase of someone's learning curve. So spending time going through old cholangiograms, finding someone who's doing them frequently is vital to help you build up your, your repertoire and understanding how to do it. Within the SAGES HPB Solid Organ Committee, we're in talks, [00:14:00] uh, about creating an IOC repository with interpretation tips. This would potentially be added to the safe cholecystectomy modules that you mentioned. Those will help people as they do them in practice. Another risk is damage to either the cystic duct or the common duct in the setting of small ducts or friable tissue or a stiff catheter. So you really have to be careful with the types of catheter you're using. Do they have a metal, uh, stylet in them that could potentially puncture the back of a bile duct? In these cases where it's a little bit more friable tissue, it may be safer using another technique like either ultrasound or ICG. And finally, IOC involves radiation exposure to both the patient and everyone in the room. So certainly you have to wear well-fitted lead, and you need to figure out ways to minimize how often the C-arm is active. And I do know, uh, we alluded to this earlier, that for listeners in California, there is a hurdle of requiring, uh, licensing to actually do the IOC, so that severely limits its application in [00:15:00] California. Speaker: Yeah, those are great points to be aware of. And I know the availability of the C-arm and the staff required to perform an IOC is limited for some institutions. So what advice would you have for a hospital maybe in a low resource setting trying to implement this who might not have access to these resources 24/7? Speaker 3: I'd like to answer that question 'cause, uh, I can give you advice from my lived experience. I work in a public facility. It's a trauma center, it's a safety net hospital, and we have I would say limited funding sources. So although I work in a large city, we often consider ourselves to be low resource. Sometimes our resource limitations manifest as a lack of equipment, the C-arm is broken, lack of staffing, we don't have a C-arm tech, or multiple services are needing to use the same shared C-arm. But that doesn't mean you can't do an IOC. In those cases, we're usually able to use a flat plate. It works very well, and it also means that I don't need to use that fluoroscopy license that I worked so hard to get because you don't need a fluoroscopy license [00:16:00] for a flat plate IOC. And I can tell you that that fluoroscopy license is a significant barrier for a lot of people. It's difficult to get and difficult to maintain. Um, but with a little creativity, we're able to ensure that we do provide that equitable care to our patients that centers with alternative funding streams have. Speaker: Yeah. Thank you for sharing. That's actually a great workaround that I didn't necessarily think of. Now I wanna go back to that original case scenario we were talking about, and I'm gonna change it up a little bit. So let's say this time we have a twenty-eight-year-old who's an otherwise healthy female, but she's twenty weeks pregnant. She comes in with the exact same symptoms, so right upper quadrant pain, nausea, emesis, fever, and her labs show a normal bilirubin. The ultrasound for her shows acute cholecystitis and a normal common bile duct. So your team's taking her for a lab chole. Does she also need an IOC with her procedure? Speaker 3: So for this particular scenario of a pregnant patient, the guideline recommends not performing a routine IOC due to the risks of radiation exposure. So in this situation, the data did favor a more [00:17:00] selective approach as opposed to a routine IOC. You can shield the lower abdomen to limit radiation exposure to the pelvic organs for a pregnant patient, but it's important that you know that you need to shield the underside of the patient, not the top of the patient, 'cause the radiation is coming from below. But the reality is is that a fair portion of the radiation exposure is actually coming from internal scatter that you can't shield for. So in that case, a laparoscopic ultrasound would be a better option if you are comfortable with that technique. Speaker 2: So one more change-up. So let's say we have an eleven-year-old who comes in with the same symptoms, do the exact same workup, acute cholecystitis, uh, normal common bile duct, no abnormalities in the LFTs. Uh, so what's the recommendation for IOC in pediatric patients? Speaker 4: Thankfully, this is another population, uh, that the, the guideline looked at, and this is one population where knowing ultrasound would be helpful, whether that's for a IOC or even for workup in the first place. Uh, while the guidelines recommend that IOC can be used in [00:18:00] pediatric patients, it's reasonable to err on the selective side to prevent radiation exposure in this population Interestingly, for our last SAGES Stories podcast episode, we actually interviewed SAGES Guideline Chair Bethany Slater, who also is a pediatric surgeon. She spoke about this very topic, noting that in-- even in her system there's a variability in the availability of a-advanced imaging such as MRCP that can't always be done immediately or advanced en-endoscopy like ERCP for pediatrics. And so some of these patients need to be shipped, you know, to another hospital across town or another city, and that's a, a great deal of stress for the patient and their family. So if you can identify choledocholithiasis in the OR on that 11-year-old, you could greatly improve the timeliness for that patient to get both the cholecystectomy and the bile duct cleared. Again, this is assuming you know how to do bile duct exploration. And so this is another [00:19:00] area that I know Bethany and her group is, is trying to build up within the pediatric surgery population to avoid things like post-operative ERCP. So especially as surgeons become more comfortable with performing minimally invasive bile duct exploration, having all the tools in your toolbox is valuable. Ultrasound, IOC, ICG, transcystic bile duct exploration techniques. And I think that's what these guidelines do. They suggest that the more tools we have, the better outcomes for a patient, and it also is highlighting that we need more evidence on this radiation risk of IOC to balance the diagnostic accuracy with safety. Speaker: So this has been a great discussion going through all the different patient populations. I can't help but think about some of the cases where I've really struggled to get the catheter into the cystic duct to perform the IOC, and maybe that's because I'm still in training, but I think a lot of people who are newer to this technique might have that same feeling. So it seems much easier to be able to give ICG and just use fluorescence imaging to see the anatomy. Is it possible to use that instead of an [00:20:00] IOC? Speaker 5: That is a good question. It is a real challenge. IOC, after all, is a technical skill, and getting the catheter into the cystic duct can be difficult, as you said, especially in inflate cases or if you're early in training. And again, ICG with fluorescence imaging can feel much easier because it does not require that cannulation of the cystic duct or the use of fluoroscopy or coordinating with X-ray staff. But based on the guideline, when we assessed ICG with fluorescence imaging, uh, we did not see that it was a direct substitute for IOC when IOC is feasible and available. So for the comparison of IOC versus fluorescence imaging with ICG, the panel conditionally suggested IOC over ICG with fluorescence imaging for laparoscopic cholecystectomy, and this decision was largely driven by a few outcomes like intraoperative identification of bile duct injuries, uh, intraoperative identification of stones and the need of second imaging techniques, among others. ICG mainly helps with visualization of anatomy, but we have to [00:21:00] emphasize that it requires a second imaging technique when there's a clinical concern, and it also limits ability to intervene if abnormality is found later. Uh, but that being said, the, the panel and the guidelines, it acknowledged that fluorescence imaging with ICG is still better than, uh, no intraoperative imaging, even though that was not the main focus of this particular key question. Speaker 3: I'll just jump in with my program director hat on again. The fact that it can be difficult to learn how to do IOCs is one reason why residents need continued exposure to it. When something is hard to do, you shouldn't just give it up. You have to keep practicing it, and then you get the skill set, and it becomes easier. And so for that reason, the guideline does emphasize that general surgery residents should continue to be trained in both the performance of IOC as well as the interpretation of the actual cholangiogram itself. I wouldn't want the trainees just to give up on doing IOCs just because ICG is easier. It is definitely easier. It's just a flick of a button on the scope, and it can be a useful adjunct, but it doesn't replace learning how to do an IOC and learning how to interpret an IOC. There's some practical limitations of ICG, too. It [00:22:00] has to be given ahead of time. The visualization might not be helpful at all in cases of acute cholecystitis, and it doesn't give us any information about what's going on inside of the duct, for example, if there's the presence of a common bile duct stone. So the practical answer is yes, ICG can be helpful, especially when you can't do an IOC, but it doesn't replace an IOC as the preferred imaging modality when an IOC is, is available. Speaker 2: So this has been a great breakdown of the SAGES guidelines, and, you know, SAGES guidelines are, are my go-to. But are there other societies that have looked at this? Do they have recommendations on intraoperative imaging for benign biliary disease? And if so, how do the SAGES guideline compare with what other societies are saying? Speaker 4: Yeah. So th- you know, I looked at this. Th- this is really a first of its kind and most up-to-date guideline with the most recent comparative data. However, I will say that the ASGE, which is a gastroenterology society, has a two thousand and [00:23:00] nineteen guideline on the role of endoscopy in the management of choledocholithiasis. So again, seven years old. But as you can imagine, it heavily favors strategies such as ERCP over lap chole with bile duct exploration. And I think what these SAGES guidelines do is set up those who wanna justify a surgery-first approach for these patients, especially in patients where they're found incidentally, which, as everyone knows from the literature, can be as frequent as five to ten percent. That being said, what I really love about these SAGES guidelines is that it sets up a number of future research questions that could help strengthen an update for these guidelines in the future. So I'm sure there's some eager research fellows out there. You have four good study recommendations at the end of each of these key questions. So you have four, "If we had these RCTs, this would strengthen the guideline," you know, already curated for you. So go ahead and get those [00:24:00] RCTs done, and when the SAGES Guideline Committee reviews that literature in three years, maybe we can make some stronger recommendations regarding these issues. Speaker: Yeah, that's great. The other thing when I was reviewing these guidelines is I thought it was really interesting that you incorporated the patient perspective into this. Can you guys talk a little bit about what patients think regarding if they have imaging during their lap chole? Speaker 5: Yeah, so that's one of my favorite parts to highlight, and it's part of our efforts to make our guidelines more, um, robust and also reflective of patient values. For this particular guideline, we had one patient, uh, who was interviewed who had undergone laparoscopic cholecystectomy. And in the interview, when the patient was asked about her preferences, she said that she would prefer the imaging method that was least likely to miss a problem during the index surgery, even if it meant a longer operation or a small amount of radiation exposure or possibility of the imaging attempt being unsuccessful. Her main concern was avoiding an overlooked issue that required her to have additional procedures or another hospital [00:25:00] stay or, you know, complications after the surgery. Speaker 3: Yeah, I also think it's really important that we take into account the patient perspective. When we're making these guidelines, we have a group of experts that are in a room, and they're kind of making some assumptions about what are important outcomes to patients and what is most valued by patients. And sometimes we're wrong, or I found myself being wrong anyway. One clear example of that was in our common bile duct injury guideline. The patients were interviewed, and I, I had thought that the patients would really value a minimally invasive approach. Thus, I thought we would be recommending more IR and endoscopic repairs. But one of the patients was very emphatic that they would have preferred a one-and-done kind of treatment, even if that meant a maximally invasive approach. So where I thought the minimally invasive stuff was really cool, the patient experience didn't re- necessarily value that. Speaker 2: All right, so we're getting close to wrapping up. I do have one more question I, I kinda wanna pose to the group. So I'm gonna put myself out there, and in full transparency, I [00:26:00] am a selective non-use of IOC guy. So basically, the way I approach patients is I'm looking for any excuse to do an IOC, you know, so small stones, if there's any LT abnormalities, if there's any dilation, if I have any suspicion for, you know, common duct stones. You know, I'm s- I'm spoiled. I always have a robot available to me, so I do all of them on the robot. Uh, I use ICG every time. I feel like that's very effective to help me with anatomy. So, uh, you know, I've read the guidelines. That's kinda still where I land, given these conditional recommendations. Uh, I still kinda land on the selective non-use. So do I need to change my practice? Can you change my mind? I'm I'm, I'm not that old yet. I s- I, I'm still willing to change. Speaker 4: So I'm gonna jump on your robotic thing here because I've recognized is that a lot of surgeons, as they've shifted from lap to robotic and especially in cholecystectomy, that they've moved away from IOC. So even when there was a selective use [00:27:00] laparoscopically, there's no doubt that it's harder to do with a four to five-arm monster, uh, hovering over the patient. Now, you gotta fit a C-arm over that as well. I mean, these robots are overengineered for what we're gonna do, especially for a Coley, right? I'm not saying you should never-- you shouldn't use the robot for cholecystectomy, but if the use of a new tool has changed someone from selective to no longer because they're now gonna use ICG, which we know is not as good at identifying stones, then I do think that has been s- a surgeon that's moved away from what they would have done if they were doing it laparoscopically. And I've been called into ORs of Q care surgeons who've been doing robotics have shifted. I know they would've done it, an IOC, but because they're robotic, they're not gonna do it, and they're using ICG, and it's a bad case. They can't see the ICG. They gave it too quickly. They gave too much of it. It's not something that should be used to replace [00:28:00] intraoperative imaging. These guidelines say that, and real life says that. So what do I recommend? I think this is where ultrasound comes in. It's definitely easier. You need a 10 port. You drop in a drop-in probe. If you have a urologist at your hospital, you have ultrasound. You ask your HPB surgeon to come train you on two or three cases, it will change your life because you will now have ICG and ultrasound. You don't have to worry about getting that C-arm over the arms of the robot But what I would say is that I really will push people to do some intraoperative imaging routinely that's not ICG. And I do robotic cholecystectomy. I did two of them today. I do ICG and IOUS routinely. Laparoscopically, because I still do laparoscopic cholecystectomy, I do routine IOC. So my residents are learning both IOC and IOUS. Speaker 2: I agree with you 100%. It is possible to do, uh, IOC easily on the robot with the right room setup, um, and the right port placement without undocking any [00:29:00] arms. It's possible to do an IOC on the robot in five minutes, so I agree with you 100%. That should not be a, a limiting factor. Kevin, have you tried microdosing? It's like 0.1 milligrams. Speaker 4: So I u- I do, uh, 1.25. Okay, so you're saying 0.1. Speaker 2: Yeah, it's like a homeopathic dose. It's crazy. They put a paper out, and, uh, I've started doing it, and it's, uh, you don't have to worry about the timing as well. They give it as a rolling back, and you don't get that bright liver. And I was skeptical because it d- they have to, like, dilute it. It seems like- Oh ... a totally homeopathic dose, but it works, 0.1 milligrams. Speaker 4: Wow. Okay, I'll try it. Speaker 2: All right. I'm gonna press you a little bit on the data for the comparison between ICG and IOC. Obviously, it's not equivalent in identifying common duct stones, but a- as far as defining the anatomy, what did you find in the data just as an adjunct to your critical view of safety? Speaker 5: We did have identification of aberrant anatomy as an outcome that we assessed for this key question. However, we had only one observational study that reported the frequency rates of aberrant anatomy, and because both arms [00:30:00] had absence of events, the meta-analysis could not be estimated. Basically, we cannot make a conclusion about difference in aberrant anatomy because of the limited evidence that we had. Speaker 2: Last question and then we'll wrap up. Did, did you guys come across any data or did you consider cost to, to the hospital system for routine versus selective use? Speaker 5: No, unfortunately, our guidelines do not assess cost directly. We do mention it in additional consideration as a, a thing to keep in mind, but it was not assessed directly from the evidence. Speaker 2: All right. That's a, that's another study out there for somebody- Yeah ... who, who wants to, wants to look at that. All right. So just to wrap things up, great discussion, by the way. It was awesome. Um, but what are some key takeaways that we should, uh, we should take away from our discussion, the guidelines, a- and the cases we discussed today? Speaker 5: So the key message is that the guideline supports IOC, th- which was one of our recommendations for this guideline, particularly when anatomy's unclear, inflammation is present, there's concern for a duct injury or retained stones. But at the same time, as we discussed in [00:31:00] this, uh, podcast, that this is a conditional recommendation. So the guideline favors IOC just because the evidence was directionally supporting IOC, but it's not a mandate. It does not remove clinical judgment and factors such as anatomy, surgeon experience, and local resources still matter. For special populations, such as pregnant and pediatric patients, uh, a more selective approach is appropriate because, uh, the risks and benefits may be different. We also discussed alternative imaging modalities, uh, that have a role here, like laparoscopic ultrasound and ICG fluorescence, uh, and can be used as, uh, useful adjuncts, but they answer different questions, and they are not and should not be considered a substitute for IOC. As mentioned by one of the speakers today, training also matters, so routine IOC may help maintain surgeon and team proficiency, and residents should continue to be trained in both performing IOC and interpreting IOC. I think the main goal of this in the guideline the overarching goal is safe [00:32:00] cholecystectomy. So if IOC is unavailable or not feasible, surgeons, uh, should focus on obtaining, uh, reassessing the critical view of safety and using alternative strategies when appropriate, uh, just as mentioned by the case scenarios that we had today. Speaker: Well, it's been really great talking with all of you and getting a better understanding of how we apply these guidelines to our clinical practice. So Emily, Kevin, Dina, thank you so much for joining us today. And to our listeners, thank you for tuning in. Until next time. Speaker 3: Dominate Speaker 4: the day. Dominate the day. Dominate the day.