Revolutionizing Gallstone Treatment: A New Approach with Dr. John Smirniotopoulos

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Dr John Smirniotopoulos Contact: https://www.medstarhealth.org/doctors/john-boldog-smirniotopoulos-md

In this episode, Dr. John Smirniotopoulos discusses a groundbreaking gallstone removal procedure that does not require gallbladder removal. He explains the minimally invasive technique, the diagnostic processes involved, and the importance of patient education regarding gallbladder health. The conversation also covers the role of Ursodial, considerations for pregnant and postpartum patients, and the risks associated with the procedure. Dr. Smirniotopoulos emphasizes the need for dietary changes post-procedure to maintain gallbladder health and prevent future complications.

Transcript

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Welcome back to the Gallbladder Diet Podcast. Today's episode is a really special one, and honestly one I've been looking forward to for a very long time. We have a very exciting guest joining us who's pioneering something truly groundbreaking here in the US, a gallstone removal procedure that doesn't require removing the gallbladder. So Dr. John Smirniotopoulos is an interventional radiologist at MedStar Washington Hospital Center and MedStar Georgetown University Hospital. He specializes in minimally invasive treatments for a wide range of conditions. And right now he's the only doctor in the US offering this procedure to asymptomatic gallbladder patients. And his ongoing research is helping shape what could be the future of gallstone treatment. And as many of you know, for the past six years, I've specialized in gallbladder health and post-gallbladder surgery care. I've obviously heard whispers about this procedure for years, but it's really never been the standard approach here in the US. And so what's made this especially exciting over the past year is that Dr. Smyrna Otopoulos and I have actually shared a few of the same patients and clients, which finally gave me the courage to reach out and bring this conversation to all of you. There's been so much growing interest in this option and I hope today's episode shines a light on its potential alternative for people who want to get rid of gallstones without removing their gallbladder. So with that, let's dive in. Dr. John Smyrna Otopoulos, welcome to the show. We are so excited to have you here. I know I just shared a little bit about your background, but I would love for listeners to hear it from you. What inspired you to get involved in this gallstone removal procedure? And how did your journey begin in this field? Yeah. Well, thank you for having me. Thank you for reaching out. Um, you know, it's been a nice experience helping patients out and I'm glad that we have some shared patients together, because the questions I often get is what do I do once the stones are gone to prevent new stones or reduce my risk of stone formation? And I think, um, that is incredibly valuable for our patients, for biliary health and gallbladder health in general. And, and as you mentioned, Um, I'm an interventional radiologist. And for those who may not know what that means is after medical school, go through about six years of postgraduate training and I do minimally invasive procedures using image guidance. we use ultrasound, fluoroscopy, which is live X-ray, CAT scans, MRI, and we work all over the body, which also means we work with a wide variety of disease processes. We also have a lot of collaboration with other specialties within medicine. So in 2020, uh right during COVID, of course, we started seeing a rise in cholecystostomy 2 placements. And what that is, is it's a drain that goes from the skin into the gallbladder to help relieve a gallbladder infection. And those are patients that maybe would not be eligible or at the time could not undergo a cholecystectomy. And we, and our specialty, have been doing this routinely for decades, but we started to see a bump in it. more recently during COVID because of the cancellation of elective procedures at the time. What we found is that, you know, patients were coming back to us for an exchange of their drain, which is pretty routine. Um, they may be living with it indefinitely because they may have other comorbidities that would never allow them to have a surgery. And therefore it was a cycle of every three months. They'd come to have the drain evaluated and exchange if they had gallstones that are there. And let's say we did an evaluation and the gallbladder, which empties and gets bile from the cystic duct is open. uh They could theoretically have the drain removed, although someone who's had an infection with a stone in place, their risk of a recurrent infection is up to 30%. So in 2020, we started getting a little bit more uh involved and into how do we maybe clear the stones so that a patient could therefore get the tube removed. And that's really when colonoscopy which had already been done in some places, but I think that's when it really started to take off. And at the same time, Boston scientific got FDA approval for their spyglass discover Calangioscope, which is a short version of what the gastroenterologists use. And really what it allows us to do is go from skin to gallbladder and evaluate the stones. And we kind of had this nice at the time, all things being what it was in 2020 during COVID, but we had a nice way to help treat patients to find a definitive solution so they could get their tubes out. What this then evolved to more recently are patients who have colic or symptoms of their gallbladder, quote unquote, gallbladder attacks with or without infection, but it's due to stones seeking maybe a different way to treat the stones without having surgery. And to preface that gallbladder surgery, gallbladder removal has been done for decades and decades and decades. and it's getting more and more also minimally invasive with robotic assist surgery. Laparoscopic's been done for a while. Those are the small little cameras that go in. To put it in context, both my parents, both my in-laws had their gallbladders out over the past 20 years and they're all doing pretty well. ah It's commonly done, but it's not for everyone. And so we have patients that are looking into what else maybe could be done to get rid of the stones and keep the gallbladder, assuming that the gallbladder is going to perform its function. And that's where we started expanding. Our indication for the procedure for this Galston removal using a camera or scope. Really more recently, the volume has just kind of gone way up as I feel, as you mentioned, people are learning more about the procedure and then just seeking out our treatment. So it's been a nice progression over the past five plus years of where we started doing this in very sick patients who would really never have surgery to now moving into an even more elective population that. are weighing what possibilities are out there for their gallbladder health. Yeah, definitely. It's quite fascinating to see it because like similar, that's what, you know, when I researched it in the past, it was only offered for very elderly, correct, and very sick population. Yep. And that's where a lot of the research is too, because that's what was, you know, that was the first, I guess, group of patients that were the ones that we just had so many of that were easy to treat. And really I'm not the only one that does that in the country. Many institutions have colon geoscopy, which is the term of camera going into the gallbladder. And that's becoming more and more routine for that patient population. Yeah, and that's what's fascinating is like the more asymptomatic population, you know, it's hard for us to make the decision of wanting to do surgery when possibly our gallbladder is, we're not dealing with chronic gallbladder attacks, right? So a lot of us are trying to seek all these different options and it can depend on timeline of what we do and it's just minimal. And so it's just so fascinating to see that. this procedure is starting to grow a lot of awareness is what it feels like in the gallbladder world. Can you share like the basics of the procedure like procedure 101? Yeah, yeah. So in general, put this in context, I'm the only one, at least that I know of in the United States and one of a few, think, in the world that is doing this for patients that have just symptoms of abdominal discomfort from the gallstone, where we would go in percutaneously, meaning through the skin, and remove the stones with a camera in the same day, and there'd be a second stage to it. And so we've kind of taken the steps. That we had for the sick patient population where they would get a drain. would wait several weeks, then bring them back and put the camera and take the stones out, wait another few weeks, maybe put the camera back in, or at that point, remove the drain. We've kind of shortened that. so how it works, essentially the, as I tell all my patients, the first day is the big day. Uh, and so we do that in our practice with anesthesia. want everyone to be nice and comfortable in a sleep, because it can be stimulating. You're going from nothing, right? going into your body to having me go with a camera. And what we do is we use ultrasound and we use a live X-ray to guide a needle from the skin into the gallbladder. Through that needle, we'll inject a little bit of IV contrast dye, but it's actually not in the IV. It's actually going to go into the gallbladder itself. So doesn't really hit the circulatory system. The reason we like that and we need that is one, I can see it under X-ray, but two, it allows us to see how the gallbladder is at least preliminarily functioning. Meaning that if the contrast eye is leaving the gallbladder through the cystic duct, we know that the cystic duct is not occluded at the time of the commencement of the procedure. And we can follow that contrast down. We can also get a very preliminary look in terms of strictures, how the gallbladder expands with contrast. It gives us a very, very brief, quick snapshot of the gallbladder in general. Once that's done, everything sharp starts to come out and we do everything over some wires. And some balloons actually to help stretch the skin and then stretch the entryway to the gallbladder to about a one centimeter diameter. put a little plastic tube in it's called a sheath and through that we can fit the camera and we now have a wide variety of cameras we work with. I will need to give credit to my colleague Dan Marchalek, who's a urologist, who's really helped build a lot of the program with me as well, because we've taken some. Cameras that were traditionally used for the urology world and are using them. for a different purpose now as well as some of the tools, but we sometimes will use those cameras to really identify those big stones. Once we see the stones in the gallbladder visually, we have a wide variety of tools to destroy the stones and remove them. Even simple irrigation is enough to remove some of the small stones, but sometimes the big stones need a little bit of, um, a little bit of flavor to get rid of them. So we can use something called EHL, which is like a hydraulic device. It's called lithotripsy, meaning to break the stone. kind of uh use energy to destroy the stone. We can use a laser to destroy the stone as well. And then we can use a dual energy system, which is a more rigid system that all this fits through the camera. But what it does is that it uses ultrasound frequency to actually break up the stone and then it suctions out the stone fragments at the same time. Really, it depends on the number of stones, the size of the stone. Uh, then when we start talking about, oh what about stones that are maybe in the neck of the gallbladder or cystic duct, we get even more creative with our wire techniques and where the camera goes and the certain balloons that we can use and lasers we can use. So we have a lot of tools at our disposal for that initial procedure. We do our best to get rid of all the stones in that first procedure. Um, it's not a hundred percent guaranteed, but really about 95 % or more. get the stones out that first procedure. Once the stones are clear, what we do is we take everything out and we leave a small drain behind. The drain, the gallbladder drain sits in the gallbladder and then goes to the skin and we put a little stitch to keep everything in place and we connect a little plastic bag to help the gallbladder empty. The reason that's important. You can imagine a gallstone irritating the gallbladder. Me with my tools and with Dr. Marchalak assisting occasionally as well. 100 % we're going to have some irritation of the gallbladder and it's going to cause inflammation. need the gallbladder to essentially rest and recover and empty. Um, now when that bag comes off is very dependent on patient to patient. Um, a couple of different things play a role. You know, you don't have to necessarily be walking around with a bag connected to a drain, but certainly in the first 24 to 72 hours, we do encourage that the patients typically come back three weeks later, sometimes a little sooner, sometimes a little later. For a second evaluation, is typically, if we're confident that the stones were removed, we inject some contrast dye under x-ray, just make sure everything is flowing naturally, and there's no leakage of contrast, meaning there's no leakage of bile, because contrast would replicate the bile. If that's the case, everything looks good and healed, the entire tube comes out that second visit, and then we put a little dressing on there, a little, really just some gauze. and some clear dressing that stays on for two days and that comes off and that's it. We don't really like stitches or sutures to close everything. I actually like there to be a little bit of leakage onto a piece of gauze for about 24 hours as everything just kind of decompresses and heals up on its own. Occasionally, I do need to have a patient come back to put the camera back in if I'm at all concerned that there are still residual stones or if we've had to do quite a bit of manipulation. at the neck of the gallbladder and the cystic duct to remove stones. The cystic duct is almost its own category of intervention here. But if I feel that we're, you know, disrupting that doctor, we're doing something to, to cause inflammation. may make this a three step process or rather than two step, just to allow more recovery, allow more healing time for the cystic duct. The chances of us having to do that are rare, but it does happen. Uh, so that's why anytime I talk to a patient, I kind of. have a warning a little bit that it may be two procedures, it may be three procedures until everything is gone. Okay. And do you typically, I have two questions for you. Do you typically have specific diagnostic testing that, or certain steps that people typically take before this procedure? Because I know for a couple of our shared clients, patients, a little bit about the process, but can you share if there's like specific testing that you find more? uh Yeah, yeah. I feel like almost everyone comes to me with an ultrasound. You know, the, it's a very common story. They've had pain. They went to saw their primary care physician that ordered an ultrasound, or maybe they went to the emergency room because they're having so much pain, but almost everyone has an ultrasound. And oftentimes that may be enough to diagnose, especially a large stone. In some cases, I will request what's called an MRCP. It's an MRI image. And what it does is it focuses on the gallbladder. The pancreas shows me the ducts. I kind of request that on a case by case basis, if I see anything under the ultrasound that looks just not very clear to me and keep in mind that when there's an ultrasound, it's, you know, it's a sonographer and they're moving back and forth and uh respiration and how much you ate that day can all play a factor into their visualization. Even bowel gas can cause artifact. And so while it's generally enough, sometimes I do like to have an MRCP to really give me a complete picture. I especially want that if someone has a lot of small stones and I'm worried about any stones that may be in the common bile duct or cystic duct, it helps me plan a little bit more for the procedure itself and also give a set of expectations about, okay, is this going to be one procedure? Am I going to do one procedure with a little bit more manipulation or is it maybe just a single or two single large stones? And we're pretty confident this will be a one procedure thing. Ultrasound and then if I can an MRI. Okay, do you find with the MRCP you can get actually the size of gallstones? Yeah, definitely. Yeah, and it's a great, you know, it's a great question. ah And so I talk about this a lot with my residents who uh I teach that our ultrasound, which the technology for ultrasound, you know, over the past 30 years has advanced tremendously. a fantastic tool. It's readily available. It's inexpensive. uh But again, there's artifact that plays a role. And we often see the day of the procedure, the stones are maybe larger or there's certainly more of them that was found on the ultrasound. An MRI is always going to be more sensitive and more specific, meaning more accurate for the size of stones and number of stones and location of stones. Okay. Going back to the MRCP or when you're in there, because this is a common question I get asked all the time, is how do you know it's a gallbladder polyp versus a gallstone? Because I've had a couple people have this, you know, with uh ultrasounds, sometimes the accuracy of the testing's really a lot more minimal. have you seen that be the case between polyps and gallstones? Yes. And so actually that's a time when I would request an MRI as well as if I'm thinking, okay, maybe this is a polyp and not a stone and the MRI would give us more information. One, uh, kind of, guess, quick way to diagnose it under ultrasound is stones are always going to be dependent. They're always going to kind of layer. And so if a patient were to move during the ultrasound exam, they should move kind of with gravity at that point, whereas a polyp will really kind of stick out ah against the wall and will not move. And MRI would give a little more information as to that. Um, and then there's another pathophysiologic condition called adenomyomatosis. What that is, is those are actually dilated ducks in the gallbladder, their little glands. And they can also mimic stones. They're going to look more like a constellation of stars in a way. That's kind of how I describe it is there. It's like stars in the sky. So there's lots of them, they're twinkling, but they're not dependent. They're not layering. They're kind of in the wall around the gallbladder, all of those things, stones. polyps adenomyomatosis are always going to be easier to characterize and classify under an MRCP. Okay, that's good to know. And then you had mentioned that this procedure can actually be done for stones in the gallbladder neck. What about um, bile duct stones or for people post surgery getting reoccurring bile duct stones? this, is this procedure, can it be done and is it less invasive than an ERCP? That, so this is a great question. Um, and I would say, you know, our gastroenterology colleagues that do ERCP, um, especially where I work are fantastic. Work, with one individual very frequently, his name is Stanley Petrak and he's amazing. And I would always ask him his opinion for a bile duct stone because he can just get places very simply. There's no drain behind, you know, we're not going through the skin. It's all. through the oral cavity, but there's certainly certain instances where he can't get the cameras there. And a good example is if someone has maybe different anatomy uh or if they've had like a bypass surgery in the past, then there's a very strong chance he can't get there. And that's actually one of the first cases I did when I got back to DC after I worked as an attending physician in New York was a patient with bypass surgery. had their gallbladder removed during that surgery. And it developed a stone in the duct. the way we approach that is similar to the gallbladder. Again, we do interventions on the biliary system, the bile ducts quite frequently for a lot of different reasons, but we go in with a needle into the duct. Same general steps. We can take a small, uh, curvable camera, uh, which in this case I would use spy glass again, which was the FDA approved device. and that can track into the duct and we can identify those stones and remove those stones, whether it's mechanical, laser, or what have you there. So yes, it can be done and I have done it. Okay, that's interesting. And then I know a couple of our shared clients and patients, they are on Ersodial. So do you usually use Ersodial to prep patients before? So another great question, and I get this a lot, is the data behind, if we look at ursodial in two different categories, I think it helps clarify things. If we look at it as a medicine to dissolve gallstones that are there, I think the data is very heterogeneous and meaning that it's a little bit all over the place. It's not that it's necessarily gonna cause harm. But what I tell patients is, oh if we want to try ursodile, we're going to take it twice a day with meals, usually breakfast and dinner and really with that meal itself. And we're going to get another ultrasound in X number of months or even a year, knowing that the ultrasound may look identical to what it does now. It may or may not really do anything. You know, it's really like a toss up a coin in some instances. About 97 % of our patients have cholesterol as a majority of their stone composition. So we send all our stones for chemical analysis. So 97%, which is what I would expect. I do ask patients to take ursodial after the stone removal because there is data from the bariatric surgical literature, suggesting that ursodial prevents new cholesterol stones from concentrating in the gallbladder. So while not a requirement to take the Ursudial before this procedure, sometimes it is beneficial just to have it because I would like a patient to take it after the fact. And that way it's one less medication to pick up from the pharmacy. They can already start it. ah But it's not a requirement. uh That being said, of course I will help them get a prescription once they come see me if they don't already have one. Okay, understand. Yep, that makes sense. And then, can this procedure be done for pregnant or postpartum mothers? Yeah. So I would say no for pregnant mothers. There is an anesthesia event associated with it. We are taking an elective procedure and making it just higher risk during pregnancy. That being said, know cholecystectomy can be performed during pregnancy as well, depending on the trimesters for removal of the gallbladder. However, that would be probably in the more, not critical, but a state where there's an infection that's there. I've also placed the gallbladder drains, the colostomy tube in pregnant patients with an active infection as well. But I would personally not feel great about doing this procedure during pregnancy. Now after pregnancy, yes. And I've done it for now many patients that are in the postpartum state. Our system is great if they want to spend the night with us. I had the pumping machines there with the moms as well. so. We have fridges that are available and we've definitely, you know, had a fair number of patients at this point that are postpartum and, know, maybe they are waiting until the baby's born and they want to just take care of this, or maybe they are concerned that if they have a subsequent pregnancy, they might have an infection and therefore need to have something more urgently done. Correct, yeah. That's the biggest concern for most moms is that, you know, if they do go to plan for a second baby and they already have gallstones, how can they, what are their options, right? So usually with most postpartum moms, we're just using diet lifestyle modifications. And a lot of them do use Ursodile actually during that time. But it's nice to know that they have another option. Can they do this while breastfeeding or is it typically advised to stop? No, they can do this while breastfeeding. They'll be, um you know, it's more the anesthesia actually at that point. And while they're taking any of the post-operative medications that they may want to consider a pump and dump during that time period. But again, we had breastfeeding mothers come and get the procedure done and they'll pump uh while they're in the, while they're staying with us. And then you talked a little bit about cholesterol gallstones. Now, is there a way we have obviously pigment gallstones that is this procedure not recommended? Because usually for pigment gallstones, surgery is advised. So how do you handle pigment stones? Are you able to diagnose that before, move forward with the procedure? Yeah, so it's a great question because being able to diagnose the pigment versus non-pigment stones is actually very tricky in pre-op imaging. Unless something is truly calcified around the stone, so there's a lot of calcium around there, it's very difficult to tell stone based on the composition. I can tell you though, when it's usually one stone that's two centimeters or larger, that likely is going to be cholesterol based. But I've treated pigment stones before. And when we send it for chemical analysis, majority of these stones still have cholesterol at their core and they develop pigment around the cholesterol. And so the ones that are not cholesterol-based have been pure calcium oxalate-based, which is similar to what you develop in a kidney stone. So it's a little bit different terms of its composition, but we would handle the stones in the same fashion. Okay, so interesting. And then can you cover risk factors for this procedure? Yeah. So the risks of the procedure itself. So, and this is, I feel one of the more important discussions I have with patients and what I spend, you know, like probably a third of the conversation on is, is risk. Cause every procedure has risks. This is a newer procedure, you know, for this elective patient population. Um, so we're still learning about it. We're still studying it. Um, in my opinion, infection by far is the biggest risk associated with it. We're going into a system, the biliary system, which file, you know, should be somewhat. However, your system communicates with the gut and the gut has bacteria. So there's absolutely a possibility of gut bacteria causing an infection with the biliary system, um, as well as the skin, because we're going from the skin to the gallbladder infection being sepsis or bacteremia, meaning, bacteria goes into the bloodstream requiring antibiotics infection due to any leak from the tube itself causing what we call a, uh, peritonitis. So that's irritation of the abdominal lining. or a biloma, meaning like an abscess formation with bile infection of the skin, like a cellulitis. So to me, those are the biggest risks associated with it. There is a smaller risk of what we call a non-target organ injury, meaning that an organ other than the gallbladder is injured. And I think when you and I first spoke, I may have mentioned this, but we intentionally go through, if we can, a small piece of the liver from the skin to the gallbladder, often the gallbladder is kind of nestled. Uh, with the liver there, and we actually like that. It's how we place a lot of our drains and the gallbladder because the liver offers protection. allows healing and it reduces risk of bile leakage. And when we get post-operative imaging on patients, you know, whether it's three months or years after the liver, you'll never have known that we're even in there. It just regenerates. while we go through maybe five millimeters, but other organs that we are concerned about, and we always obviously look out for a right kidney, the right colon. The small intestine and then the right lung as we breathe down can sometimes get in the way. so that is a small risk, but it's, you know, something I discussed with patients. And the last risk is bleeding. Bleeding requiring me as an interventional radiologist to go stop the bleeding using small catheters and wires uh is a theoretical risk. I personally have not seen my practice, but if you were to go look up, you know, gallbladder drain and bleeding risk, I'm sure you would find, you know, a statistic. Um, but I haven't seen it, but I always discuss it as, as a theoretical possibility. So bleeding infection, non-target organ injury, and then bio leakage as well as part of the infection paradigm are all risks that I discussed with patients. Yeah, definitely. And when can you not do the procedure? So is there specific patients that you've come across that usually stop the procedure or diagnose the gallbladder? Yeah, yeah. And so this is important because, um, you know, as we're doing more and more and we see people from all over the country, all over the world, we're getting to see a large variety of gallbladder types. there's, um, one case thus far in our practice where we did that initial first step with a needle, did the injection. It didn't look right to us. And we say, we're going to stop. Um, and the reason is there was scarring of the gallbladder. but it wasn't where the stone was located. The stone was still impacted and still scarring, but this was a completely separate area of scarring. nothing else was adorned about the gallbladder except that. But to me, what that says is without an object being there, such as a stone causing the scarring, there has been such chronic inflammation at that point that even if I remove the stone, which theoretically would have caused the scarring initially, That impacted stone was elsewhere. It wasn't in that same plane. We said, you know, this gallbladder may not heal from just removing the stone that is currently elsewhere in the gallbladder itself, not where the scarring was. And we said, honestly, the best thing to do is really have another discussion with your surgeon about removal. And just to put that out there, every patient I see has seen a surgeon. And if they haven't, I have them set up with our surgeons at my hospital who uh not only support and understand what we do, but we've had patients that we've talked to about the procedure and they talk to the surgeon, they say, you know, I actually think I'm just going to have the surgery and that's okay, ah you know, if the patient wants to do that at that point. that's a part of our process. We'd like to have a lot of players involved. And so that way everyone can make the best decision that makes the most sense for them. Yeah, that makes sense. With the risk factor for the procedure, so you mentioned some of the scarring, what about wall thickening? Yes. So interestingly, you know, we obviously see wall thickening in the preoperative ultrasound. Occasionally if someone's had a gallbladder attack, they've gone to like the emergency room and they've had active inflammation at that point, but not an infection. Sometimes we see the day of the procedure, um, as well. And so it doesn't really, uh, change what we're going to be doing for the procedure, but we do make a note of it because we can go in with a camera and then maybe say, okay, there's wall thickening and there's. what we call like a cobblestone appearance with a gallbladder. I there's clearly inflammation that's going on. And the important part about that is noting if that goes away, uh, during the subsequent procedure, if you get rid of the stone, you get rid of the source of inflammation. Does the internal gallbladder, uh, the mucosa become a normal mucosa? Does the wall thickening go down? And we've seen that in our practice. We've seen wall thickening get better. And it may be that we were just catching it at that certain point of time, it would have gotten better anyways. But we've also seen the gallbladder mucosa go from that cobble stone appearance, which again is just chronic hit of stone after stone causing inflammation, go back to a normal fluffy gallbladder mucosa. interesting because I find with clients um often once they have wall thickening their gallbladder is more reactive. So you find it's really an inflammatory component of the gallbladder. Yeah, definitely. it's a wall thickness is often a secondary sign of inflammation or even infection. But the interesting thing is we see that in patients that have, you know, they have a history of this, but you wouldn't expect the day of the procedure for them to have that. But we've absolutely seen that. And you've seen the wall thickening go away. That's so fascinating. It's definitely interesting. I'm learning so much. So I also, I have loads of questions for you, but I did ask um my community on gallbladder.nutritionist on Instagram and my gallbladder saver society membership for questions that they want to ask you. So I'm going to go over to those and make sure we cover some of those. m So obviously, where can we get this procedure done? Yeah, so uh I'm based out of Washington, DC. And so uh I operate out of MedStar Washington Hospital Center, MedStar Georgetown University Hospital. But we primarily do this at MedStar Washington Hospital Center in DC. And is this right now, you're the only physician that's offering this in the US. That I know of, yeah. We call it the ghost scope procedure. We're kind of it. Myself and then again, I partner with Dr. Daniel Marchalak of the Urology Service. We bring in kind of the big gun urology tools to bust up these stones. Kind of like they do for kidney stones. Yeah, exactly. It's so awesome. And then can you work with patients all over the world? Yes, and we do. We work with patients on multiple continents at this point and obviously throughout the United States as well. So awesome. And once the procedure is done, have you ever seen it change the gallbladder in any way? I guess more, I think this question is more like seeing it go in more of a negative way. And this could be the infection piece, but just was curious. Yeah, so it's interesting. ah We've seen the gallbladder recover and, you know, kind of go from a chronic inflammation, really dilated distended gallbladder to just going to what we call as a normal gallbladder. I think we have to be careful when we get ultrasounds too early, because what uh we'll see is some artifact on the ultrasound. And that may, it's oftentimes called a stone, but really what it is, is some of the gallbladders there's a little bit of cholesterol deposition in the wall that we can actually see with the camera. And that causes artifact as well, in addition to where the camera went in. And so a lot of what we see is in three months, if it's called a stone ah or even thickening of the wall, when we get the year ultrasound uh to just kind of keep an eye on things recovers. So I haven't seen something directly get worse because of the procedure, but in cases where we're trying to actually maybe avoid the procedure in a case of like adenomyomatosis, which is again, that kind of dilated gland. um Even if we, they have stones, if that's an underlying issue, there is a chance that getting rid of the stones is not going to solve all the issues because adenomyomatosis that kind of think of it like a clogged pore. And if there's lots of that there, that actually may be the cause of the symptoms. And so that's another question is, you know, what if my symptoms don't go away? you know, is it maybe that that's there and we find it, you know, it's not as apparent on the pre-op imaging, then we clear out the stones, clear out the inflammation and there's actually adenomyomatosis that's underlying that is addressing most of the concerns. Very interesting. Yeah. And I think it goes back to, I see this happen quite often where clients get rid of the gallstones and they still present like upper right quadrant pain, sometimes even gallbladder attacks. And it's what you call gallbladder dyskinesia or biliary dyskinesia, where there's poor function of the gallbladder. And since 2020, there's been a huge rise in poor gallbladder function. think we talked about this, that at the root of poor gallbladder function is often inflammation. um And so that's another avenue, because I struggle with that all the time, where I have more of a poor functioning gallbladder. And even sometimes out of like working on inflammation and diet and lifestyle support, the pain is still kind of there. And I haven't done more testing in a while because I'm in my pregnant postpartum years, but I'm definitely going to follow up with an MRCP this time and get more accurate testing. And a HIDA scan and you know, some of your clients may be familiar with the HIDA scan, H-I-D-A, that is a nuclear medicine scan. And unlike an X-ray, what it does is it's a radio tracer that's injected. So rather than a beam being shot onto you, that actually shoots the beams outward. What it does is it allows us to see how the liver is functioning for this radio tracer and then how the biliary system is functioning as well. uh Additionally, we can get what's called an injection fraction of the gallbladder and above 35 % is acceptable below 35%. We start talking about chronic colic cystitis or biliary dyskinesia, like you're saying, and it may be more of a function of the gallbladder being able to essentially not take in the bowel so much as squeeze the bile out, use the muscles to really just inject the bile. Correct, yep. Yep, it's definitely interesting. And then you have what you call like hyperkinetic, which I think is the one that we still don't quite understand. And that's anything over some say 75%, some say 80%. But typically this population of gallbladder diagnosis, they usually report more like that chronic upper right quadrant pain and a lot of the gastrointestinal symptoms associated to gallbladder issues. So. in taunts of fats and bloating and gas and sometimes reflux. Again, we can talk about, you know, how to support gallbladder function and how we go about that if we can actually restore the function. But I do always feel like gallbladder inflammation is at the root a lot of times of why the gallbladder is poor functioning. So it's definitely interesting. uh One thing I didn't ask about the procedure. So we have gallbladder sludge, which is kind of the precursor before gallstones form. does this procedure help with that or do you usually find with people with gallbladder sludge like using Ursodial instead to get rid of the sludge? Yeah, I personally wouldn't want to do this procedure just for sludge itself. I feel that it's, you know, I've seen sludge on ultrasounds and we with the stones, we come in and there's stones. Yes, but the sludge is gone. And I've seen one patient in particular where we did the procedure. They had sludge come back at I think three months and then we said, okay, let's do a little ursodial. Let's do some hydration. And then a year the sludge was gone. So I look at sludge often as kind of an ebb and flow of the stasis of the bile itself. know, if it's bile is going to be static, meaning it's there, you're going to have the minerals of the bile being there. It's going to show up on your ultrasound or even MRI. But a lot of things can factor into that. And I like to really be as conservative as possible when it's just sludge. And like you said, either ursodial, if you mix that in with hydration, eight to 10 glasses of water a day, incorporate some citrus into that as well. I have seen sludge as well as actually symptoms improve uh over time. I personally would not recommend this procedure just for sludge. Yep, that makes sense. And are there gallstone size restrictions for this procedure? uh Great question. So no, we've done them from as small as you know, you can think of to I think five and a half centimeters is our largest Which is larger than a golf ball The challenges with smaller stones and lots of them That's when I often bring patients back for what I call a second look with the camera Just to make sure we got everything because they can move around They can kind of hide in the folds of the gallbladder. They can also be moved towards the cystic duct and find their way out of the gallbladder and biliary system itself. So the smaller stones present a little bit more of a technical challenge, but it does not restrict the procedure. Okay, so this kind of leads me to the next question. So the patient doesn't necessarily need to have a certain number of gallstones. Can it be performed on like one? Yes, and we've done it on one, and we've done it on a wide range of that one size stone if they're symptomatic from that stone. Okay, and are there any age requirements that the patient needs to be? Yeah, above 18 in ah our system, you know, I would steer away from the pediatric population, um but above 18, and we don't necessarily have an upper uh limit of age. uh Again, when we were initially doing this procedure years ago on those sick patients, a lot of our patients were, as you mentioned, elderly, and we were certainly performing this on patients in their nineties who just needed a better quality of life. um I would say everyone's, you know, everyone's different. ah It's a case by case discussion and um we kind of don't really age restrict patients out, but we do discuss, you know, how people recover from a surgery in general. It does change as they get older and just what that recovery may look like. Mm-hmm. Yep, definitely. Do you think, in your opinion, that the procedure is more invasive than just removal of the gallbladder? Or do you feel that the risk factors of both are kind of equal? Yeah. So, I mean, it's, we term it minimally invasive because we're kind of going in with one, you know, one access and our procedure time ranges a little bit. We're going from anywhere from like a 30 minute procedure time to occasionally, you know, a couple hours, depending on if we're chasing those small stones. We're still going in through one, you know, quote unquote needle poke or one tiny, what I think is a small incision. But there's risk factors like there is anything else. And so. Um, I don't really, you know, think of the ghost go procedure as a replacement procedure, so to speak, so much as just an alternative way of doing things. and the benefit is that if someone really does need surgery, um, this procedure does not preclude them from having surgery down the road. You know, it doesn't, um, well, what I, we would say jail you out from having something else done. It doesn't also preclude a re-intervention. We never had to do that, but. If we have to go back into the gallbladder as an example, it doesn't stop us from doing that as well. So, there's benefits to it. There's risks to it. Um, like everything in medicine, it's a very personal decision. And my goal when I, when I speak to everyone is to really, uh, just be as transparent as possible about, the risks, the benefits. And kind of make a decision as a collective. I don't really want to lead anyone one way or another. But I want everyone to have as much information at their disposal so they can make the best choice for themselves. Yeah, I can relate to that 100%. So I'm definitely not anti-surgery, but I definitely just want people to feel more educated on whatever choice they make, right, and feel supported. That's the ultimate goal at the end of the day. exactly. And then how to make those healthy choices like you do with your patients after, know, how to maintain if you have your gallbladder or if you don't have your gallbladder, right? How to keep your GI health and your biliary health as optimal as possible. Correct, yeah. And post procedure you had talked about, usually that's more of delicate period of where the gallbladder is more sensitive, you have risk of, I believe you said inflammation or infection. So do you usually advise on specific dietary changes during that time to keep biliary inflammation down? Yeah, so um what I often tell them in the first 24 to 48 hours is, you know, eat some comfort food, just, you know, don't eat something super high fat like a bucket of french fries, uh but eat some comfort food just to kind of get over the hump from the discomfort, because there's going to be discomfort as we give medications to really anti inflammatory medicines primarily, and some nerve modulating medicines like Lyrica to mitigate that, but there's going to be discomfort, but Once we're out of that perioperative hump, usually a couple of days after and the pain is much more controlled, we start talking about, you know, not so much restricting, uh but more of mindful eating at that point. And so many patients are already kind of doing that by the time they come see me, they've reduced, you know, certain fats, certainly not all fats, but certain fats from their diet. ah You know, they're kind of increasing the hydration and things of that nature. And so I... kind of encourage patients to just keep that up. want to have, know, good fats are good, right? So, healthy fats in your diet, because again, your liver is going to make the bile, your gallbladder will store the bile. We need the bile to leave your gallbladder as you know, it comes in, we need it to leave otherwise you will get that stasis, you'll get that sludge and you could get stones. So we discussed that and we discussed the hydration, how important the hydration is as well. And then a lot of patients say, when can they start maybe incorporating trigger foods? So a lot of people have been avoiding certain foods. Cheese seems to be a big one that everyone avoids. And I tell them, I would really wait for the trigger foods until the tube is itself out, really give it that three week plus period to let everything calm down. But then slowly, slowly start incorporating things that maybe you were avoiding previously. But I'm sure you have some great suggestions for. for biliary health and diet and what to do, you know, prepping or after stones are gone. Yep. No, that's a great tip though. It's like go slow because it's the same thing with once someone has their gallbladder actually removed. A lot of patients are told you can kind of go back to how you used to eat and they learned that pretty shortly that they can. so doing that slow introduction of the healthy fats is really, really important. And we can talk about too some like ongoing things um to help. optimize your gallbladder after this procedure is done to keep it healthy and reduce down the risk of gallstones. I just had a couple more questions from the community and then I'm hop over to that. um Can you just, this is a fun question, but can you tell us three interesting things about the gallbladder? Because I feel like you're becoming like a gallbladder guru that you have learned from this procedure and you wish more people actually knew. Yeah. Um, one of the interesting things that I've learned is how the gallbladder can go from that inflammatory state to a more function, like normal functioning, normal looking gallbladder, which. Could call me by surprise. I wasn't sure that was going to happen, but especially earlier on when we were putting the camera in a little more frequently and kind of checking on things, we would see the gallbladder recover. And we always in our specialty knew that. Um, you know, the gallbladder will heal over a certain number of times, at least if we make a small hole, but more of the functional side of it, we weren't sure if that was going to come back. And that was a little bit surprising. Um, when we saw some of these patients would really just chronic inflammation. Come back and their gallbladder looked like a normal gallbladder and it was functioning normally. Yeah. Um, well, another interesting thing that we've found certainly is that. The cholesterol that we form, can find it in stone, but you can also find it, and I mentioned earlier, kind of layering on the wall. And it looks like a cholesterol stasis there. It has a look to it. And we try to clear that off as best as we can. Uh, but that may also be called a stone. If someone gets an ultrasound just based on the artifacts. So it's important to note that while there likely is a stone, there may be a little bit of just cholesterol on the wall itself and cholesterol concentrates in the gallbladder. And then it's just, you know, part of what it does. Um, and then the other part about the gallbladder that I find really kind of interesting is no two gallbladders are the same. Some people have just incredibly large ascended gallbladders with stones in place. Some have contracted gallbladders, but once we clear the stones out, when we see patients down the road, then the gallbladders start looking a little more uniform. They look kind of like normal lining, normal thickness of the wall, normal shape and size. And so I think. The gallbladders, especially someone's been living with stones for a long period of time, the gallbladders tend to stand, they kind of get used to being extended. When we remove the stones, we remove kind of the pressure the gallbladders been fighting against to get rid of the bile. Things start kind of shrinking and the gallbladder starts returning to a more, I guess, standard is what you would call it size. So it's a pretty resilient organ. Um, some ways, and this is not to. make the gallbladder sound horrible, but some people, call it the cockroach of the body because you can do a lot of stuff to the gallbladder and it keeps, you know, kind of coming back. Well, is so, it's kind of weird. I've never heard that one, but it's definitely interesting. Yeah, I remember us talking about this, that you found that the gall butter can regenerate in almost three weeks. And we know like the liver has that regenerative property. And it was just so fascinating to learn that from you because I believed that, but I couldn't ever find the research on it because I would have people that had inflammation and even post-infection. or that we're dealing with back-to-back attacks, execute like kind of a different post-golbert attack diet to bring down biliary inflammation, and it would, but there was, couldn't find the research on it. And so I just was like, oh, this is so interesting to me. It's like full circle. So it's definitely very cool. Where do you see this procedure going? Do you have like other doctors like showing interest in it? We would obviously love to see more of it in the States as an option, but I just was curious if you see it. uh Yeah, so um again, a lot of people in my field, we do colon geoscopy and uh when our society, society of interventional radiology, we have a large registry and we're uh obviously always looking at the data. So those of us that do this kind of do what I initially discussed on the sick patients that would never have the gallbladder out. I think as we start moving towards publishing our data, which should hopefully happen soon, um we're going to see more people getting an interest in it. and a more understanding of it. think we're going to keep, you know, collecting the data. Obviously the big question is do the stones come back, right? And to me, when I say collecting data, that's what we're trying to identify. The safety efficacy, yes, is important, is very important. But also telling a patient, okay, if you have this procedure, this is a percent likelihood and five, 10, 15, 20 years, you're going to have a stone come back. And that part we don't know. And we're still collecting the data. We're still analyzing that. We just don't know yet. But I think as we have that data, as we are looking at the safety and we're kind of publishing and when I go and talk at our national conferences, I think you're gonna see more people interested in it and starting to do it. Yeah, I'm really looking forward to that and seeing it come about. It's really cool. And you mentioned an important thing that it's like, we don't know if once you have, uh you do this procedure, are you going to continue to develop gallstones? So what I usually tell people um is that once you have a gallbladder diagnosis, it requires a long-term diet lifestyle change. Like whether or not... you go on this journey to try to save your gallbladder, improve gallbladder health, or you decide on surgery, it usually requires some dietary change. And I would say the same thing with this procedure is that one, we still don't know, is it going to prevent gallstones down the road ah or what's going to happen with the gallbladder? And so I think the more that you look at it this way, that you did this procedure, you went above and beyond to have it done. It's really important you still emphasize a lot of your diet and lifestyle support to improve your gallbladder, liver, and biliary health since you know your body kind of takes more stress in that area. So uh when we look at like gallstones, because this procedure is mostly done for gallstones, gallstones typically develop from what we call cholesterol supersaturation in bile, where basically the bile becomes too thick. and it becomes super saturated and typically it stems up in the liver. So your liver, has 500 plus functions. One of them is to create a bile substance, but that bile can become super saturated from multiple different stressors on the liver. And then you have a combination of inflammation and poor gallbladder motility. And so at any point you have saturated bile being produced. your liver's not detoxing properly, that saturated bile just goes into the gallbladder. And if you're not releasing out that bile, we're not cycling it out, you have a higher risk of gallstones to develop. So from a integrative perspective, when we try to work on gallstone dissolution or reduce the risk of gallstones developing post this procedure, we want to use targeted diet and lifestyle support to address these root causes of why gallstones developed in the first place. And there's many things that can promote cholesterol supersaturation. So one of the biggest reasons why it's common with females and during pregnancy, postpartum perimenopause years is because of your estrogen levels, the imbalance of estrogen and progesterone. So that's the big risk factor for cholesterol supersaturation and poor gallbladder motility. We have insulin resistance. This is why it's a big issue that's occurring where the gallbladder liver are taking a big hit from any metabolic issues, like gallbladder disease is a metabolic disease. We have issues of uh environmental toxins, viral infections, bacterial infections. You talked about the emphasis of the direct connection between the gut and liver that can also affect biocomposition. So in integrative medicine, we use targeted diet and lifestyle recommendations to address the root cause of gallstones. And so from just like a high level of how can we keep the gall butter healthy and how can we optimize your gall butter post this procedure to reduce the risk of gallstones coming back, we want to think of eating in a way that's very intentional to continue to support your liver and gall butter. And that's obviously eating what I like to simplify it as is eating whole foods over processed foods. The less toxins you put in your body through your diet, the less your liver has to work overdrive to process those toxins and the less likelihood of inflammation up in your biliary system. So at the root, we eat whole foods. So that's the basics of eating animal protein, lots of plant diversity, healthy fats to still keep that bio moving out nicely and keeping that bio healthy. And then we want to emphasize a ton of fiber. So soluble fiber and soluble fiber, a mix of that is really good because fiber acts as a natural binder to improve your biocomposition. So typically when we work on improving your gallbladder liver health, it needs to be a high fiber diet. If you struggle with fiber, this is where working with like myself or another nutritionist to help you can work on that. But typically fiber is kind of a star player in the gallbladder diet because it does help to naturally bind to excess toxins, cholesterol, and estrogen. And the idea is if you have regular bowel movements, we're excreting that out. A big thing too is addressing constipation because that constipation puts pressure on your liver gallbladder area. And if you have gallbladder issues, you probably know firsthand that when you're constipated, you have higher risk of gallbladder pain and gallbladder attacks. That constipation will cause that recirculation of toxins, cholesterol, and estrogen. and cause the vicious cycle of bile supersaturation. So you have to ensure you work on constipation. Hydration you talked about, which is really important. Dehydration can actually cause gallbladder pain and a lot of postpartum mom's breastfeeding. This is a big source of their gallbladder pain and attacks. So you wanna keep that hydration moving because that hydration, most of your bile is also water. And so if you're dehydrated, you're not gonna normalize out that bile composition. Other important things is just looking at your lifestyle, moving your body, reducing down toxins as much as possible. As I mentioned, it's kind of a diet lifestyle change. It's a lot to take in at once if you're new to this, but I think you said a lot of times your patients coming to you have already adopted this lifestyle already. And so you just want to encourage them to keep up with it because... we do run the risk to develop gallstones. Just like if someone dissolves them or if they use earth style to dissolve gallstones, there's no guarantee you won't get them back. And so um the more that you can look at this as a lifestyle change versus a temporary diet, the better off you'll be. So em those are some things you can continue to support within your diet lifestyle to support your gall butter liver health. If you are interested in this procedure or you've done the procedure, you want to work on improving your gallbladder health, maybe work on gallstone sludge or gallbladder function. I cover more in depth, like a step-by-step. What to do, process, nutrition tips, all of that in my Gallbladder Saver Society membership, along with support from myself and many other guest experts. But this has been so fascinating. I'm geeking out. I was so excited to interview you. So this has been just amazing. I have learned so much from the two conversations we've had. So if someone is interested in this procedure, how can they contact you or what are the first steps? Yeah. Um, so, uh, obviously I have a very long last name. Uh, if you were to Google my last name is like John Smyrnautopoulos, you would find my, uh, physician profile page. Otherwise, uh, an easy way to do it, um, a website, go scope health.com. So go scope as in S C O P E health.com. That'll also drive a contact and, happy to always chat and, and, uh, discuss the procedure and. if a patient is the right candidate for it. Thank you, and I will share your contact too in the show notes below. But thank you so much for your time today. This has been awesome. And if anyone has any further questions, please reach out to me at support at gallbetterdiet.com and all of the info and follow-up support options are provided in the show notes below. Thank you so much and I hope you have a wonderful day. Thank you.