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Choledocholithiasis with large bile duct stones greater than 10 mm are at increased risk for failure of traditional endoscopic extraction techniques. One extraction method for large stones is the use of a wire basket to grasp the stone, crush the stone, and then extract the pieces. Occasionally, lithotripsy basket wires can become embedded within the stone, or the wires may fracture. If the wires become embedded, typically an extra-endoscopic mechanical lithotripsy device is used to forcibly crush the stone. When extra-endoscopic mechanical lithotripsy cannot be used, cholangioscopy with laser or electrohydraulic lithotripsy (EHL) has been described. Here we present a case in which cholangioscopy with EHL was used as a rescue technique for an impacted lithotripsy basket (Video 1, available online at www.VideoGIE.org).
Case Report
A 68-year-old woman who had undergone a cholecystectomy 15 years earlier experienced intermittent right upper-quadrant abdominal pain. Abdominal US showed common bile duct (CBD) dilation to 18 mm, with mild intrahepatic biliary dilation. MRCP showed 2 CBD stones measuring 14 mm and 17 mm, respectively. She was referred to our institution for further management.
ERCP was performed. The initial cholangiogram showed 2 large filling defects measuring 14 mm and 17 mm (Fig. 1). Biliary sphincterotomy and balloon dilation of the ampulla was performed to 11 mm. Mechanical lithotripsy was then attempted. One of the 2 stones was grasped easily within the lithotripsy basket (Fig. 2). Attempts at mechanical lithotripsy resulted in breaking of the basket wires, with the basket impacted over the bile duct stone. Mechanical attempts to free the basket wires, including opening and closing the basket wires, were unsuccessful because the wires were embedded within the stone. The endoscope was then removed in such a manner that the basket wires were exiting the patient's mouth. Extraendoscopic salvage mechanical lithotripsy was considered but not attempted because of the acute angulation at the ampulla, the relatively small ampullary orifice, and our concern that salvage lithotripsy could result in duodenal perforation. Smaller 8.5F and 10F through-the-scope rescue lithotriptor devices were unavailable.
Figure 1Fluoroscopic image demonstrating 2 large common bile duct stones.
The duodenoscope was re-inserted into the duodenum. The digital cholangioscope (Spyglass DS; Boston Scientific, Natick, Mass) was then advanced into the bile duct over a guidewire, alongside the impacted basket (Figs. 3 and 4). A large impacted stone was visualized and successfully broken into fragments by the use of electrohydraulic lithotripsy. The cholangioscope was then removed, and the basket could be removed from the bile duct. Multiple balloon sweeps were performed in the bile duct, with removal of a large amount of stone debris. A cholangiogram showed that 1 large bile duct stone remained. At this time, two 10F plastic bile duct stents, 8 cm long, were placed in a transpapillary fashion.
Figure 3Still image within the common bile duct demonstrating impacted stone within the lithotripsy basket.
Figure 4Fluoroscopic image demonstrating the cholangioscope within the lithotripsy basket, in direct apposition to the bile duct stone before electrohydraulic lithotripsy.
Mechanical lithotripsy is a commonly used technique for the management of large bile duct stones, with an adverse event rate of around 3% to 4%. Biliary stone basket impaction is the most common adverse event that may occur during mechanical lithotripsy of large bile duct stones, occurring in 1.7% of cases in 1 study. Various techniques to release the impacted stone and basket have been described, including extraendoscopic mechanical lithotripsy, surgical intervention, extracorporeal shock wave lithotripsy, laser lithotripsy, and EHL. Here we describe the use of digital cholangioscopy and EHL to facilitate the removal of an impacted bile duct stone and basket.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
Endoscopic video demonstrating cholangioscopy with electrohydraulic lithotripsy to rescue an impacted large bile duct stone within a lithotripsy basket.
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