Percutaneous gallbladder stone extraction: Upsize fundal cholecystostomy access to 18-24 Fr peelaway sheath. Occlude cystic duct w Fogarty balloon. Saline infusion via flush catheter/Klein pump. Balloon sweeps of cystic & common bile ducts. SpyGlass & lithotripsy PRN. #IRad

Answers to some questions from the crowd: 1) These are patients referred by surgeons who deem them to be high operative/anesthetic risk for lap/open cholecystectomy, usually due to comorbidities. This procedure can be performed with moderate or deep sedation/MAC, avoiding GETA.

2) This procedure happens no sooner than 4 weeks after percutaneous cholecystostomy to allow cutaneous tract maturation, but I prefer 6-8 weeks with pigtail catheter upsizing from 10 Fr to 14 Fr at the 4 week cholecystogram.

3) If the cystic duct is patent at 4 week fluoroscopic drain check, the drain can be pulled; however, the recurrence rate of acute calculous cholecystitis is ~20-30%. Number & size of gallstones taken into consideration.

4) Upon procedure conclusion, a 14 Fr pigtail drainage catheter is replaced & left open to bulb drainage for at least 72 hours, with mature tract & purse string suture to mitigate leakage & peri-procedural antibiotics to mitigate infection. If biloma forms, then CT drainage PRN.

5) After 72 hours, a drain capping trial is initiated, & fluoroscopic drain check performed at 1 wk. If all good, 14 Fr pigtail can be removed or downsized to 10 Fr & removed 1 wk later, depending on tract healing. If leakage, a balloon-retained MIC gastrostomy tube is useful.

6) Thanks for reading! This procedure addresses a large unmet clinical need, & our armamentarium of tools in #IRad is rapidly evolving.

Very neat, and similar to maneuvers we do in the operating room during lap chole with a transcystic bile duct exploration! Obvious question...why no chole? I understand when pts are not surgical candidates (although this is dubious) but that GB will not work normally again.

Amazing work. Is this fogarty via separate access for flush? And what are those sticks you are using to pull put those stones?

Thank you! In the video, the 5.5 Fr Fogarty is OTW through the peelaway, alongside a 5 Fr Omni Flush catheter to infuse saline & use its recurved shape to also pull stones out. The wire external to the sheath is a safety wire across cystic/common bile ducts & in small bowel.

Very interesting. What do you do about the tract at the end regarding bile leak and do you do this with both transhepatic and direct approach?

Pros & cons to both transhepatic & transperitoneal. Key is fundal access towards cystic duct; antral access makes working angles more difficult but not prohibitive. TP has lower bleeding risk but is less stable than TH, necessitating a well matured tract prior to intervention.