Tailored Cholangioscopy for Symptomatic Cholecystitis: A Size-Based Approach to Stone Management

Monday, March 31, 2025

4:50 PM – 4:55 PM CT

Location: Music City Center, 202 A

Abstract Presenter(s)

Maxwell Lohss (he/him/his)

Medical Student
University of Pittsburgh School of Medicine, United States

Author/Co-author(s)

Franklin Iheanacho, BA

Medical Student
Warren Alpert Medical School of Brown University, United States
AG

Anish Ghodadra, MD

Assistant Professor
University of Pittsburgh, Department of Radiology, Vascular and Interventional Radiology Division, United States
JC

Jared Christensen, MD

Clinical Assistant Professor
University of Michigan, United States
Shantanu Warhadpande, MD

Assistant Professor, Vascular and Interventional Radiology
University of Michigan Medical Center, United States
Daniel L. Kirkpatrick, MD (he/him/his)

Assistant Professor of Radiology, Division of Vascular and Interventional Radiology
University of Michigan, United States

Learning Objectives:

Differentiate between acalculous and calculous cholecystitis to guide appropriate follow-up strategies.

Apply size-based cholangioscopy techniques, selecting tools and methods tailored to stone size.

Evaluate post-procedure indicators, including cystic duct patency, to guide tube management and removal.

Background: Symptomatic cholecystitis presents a significant challenge, especially for patients unsuitable for surgery due to comorbidities. The initial management involves percutaneous cholecystostomy via a transperitoneal or transhepatic approach. Following stabilization and discharge, patients return for a clinic appointment within 2-4 weeks. For acalculous cholecystitis, a capping trial is initiated. For calculous cases, cholangioscopy is performed using a size-based, tailored intervention strategy. This approach aims to optimize outcomes and reduce the need for repeat procedures, offering practical insights beyond standard guidelines.

Clinical Findings/Procedure Details:
Small Stones ( < 5mm): After upsizing to a 12-16 French peel-away sheath, aggressive irrigation using a two-catheter technique (flush and balloon catheter) is employed, followed by basket retrieval. The internal diameter of the sheath facilitates direct removal, with residual fragments targeted using a SpyGlass DS Direct Visualization System (Boston Scientific, MA, USA).

Medium Stones (5-20mm): Electrohydraulic lithotripsy combined with basket extraction is used with the Spyglass system. Access is upsized as needed, with a 16 French sheath commonly employed.

Large Stones ( >20mm): Advanced techniques, including laser lithotripsy via a rigid Olympus endoscope (Olympus, Tokyo, Japan), are often necessary. This requires a 24 French sheath and general anesthesia, necessitating a second procedure [1]. Stones are fragmented and removed using a basket and irrigation.

Post-procedure, the cholecystostomy tube is replaced, capped, and assessed at a 2-week follow-up. Lab results and cystic duct patency (assessed via cholangiography) determine if the tube can be removed.

Conclusion and/or Teaching Points: This approach, tailored to stone size, optimizes outcomes in calculous cholecystitis management, reducing the need for repeat interventions. As cholangioscopy becomes more widely adopted, tailoring the approach to stone size shows promise in reducing procedure time and the number of devices required while also minimizing procedural burdens on patients, ultimately speeding up the timeline for tube removal and recovery.