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Endoscopic rescue strategy for basket-stone impaction.
A 64-year-old man underwent ERCP for a 17-mm common bile duct stone at a local hospital. A mechanical lithotripter (StoneSmash, Boston Scientific, Marlborough, Mass, USA) caught the stone, but crushing was not achieved, and the mechanical lithotripter became impacted in the bile duct. The mechanical lithotripter was cut close to the handle, and the endoscope was removed through the mouth.
Rescue using a transoral endotripter failed, and a nasobiliary drain was inserted. The patient was transferred to our institution with the wire of the lithotripter protruding from his mouth. On admission, a CT scan showed pneumoretroperitoneum and a pseudoaneurysm of the papillary artery (Fig. 1). In a second ERCP, an endoscope was passed alongside the sheath of the mechanical lithotripter and a previously inserted nasobiliary drain. The basket wire was cut using argon plasma coagulation at the duodenum, enabling extraction of the body of the mechanical lithotripter, but the impacted metallic wires and entrapped stone remained in the bile duct (Fig. 2).
Figure 1CT on admission just after the first ERCP.
Figure 2Cholangiography via endoscopic nasobiliary tube. After endoscopic cutting of the wires of an impacted mechanical lithotripter using argon plasma coagulation, wires with a stone remain in the bile duct.
Because cholangioscopy was not available in our institution, we stopped and waited for the arrival of a cholangioscope. Endoscopic nasobiliary drainage was performed to monitor the situation in the bile duct by cholangiography and to detect bleeding from the pseudoaneurysm. After the second ERCP, duodenal and biliary bleeding from the pseudoaneurysm of the papillary artery occurred and was successfully controlled by transarterial embolization. In a third ERCP session, endoscopic lithotripsy was attempted using peroral “mother-baby” cholangioscopy (CHF-B290, Olympus, Tokyo, Japan) under continuous ductal irrigation with normal saline solution.
The cholangioscope pushed the large stone up to the hilum, creating space next to the stone. Simultaneously, a guidewire through the working channel of a “baby” cholangioscope accidentally entangled the remaining metallic lithotripter wires. The remnant lithotripter wires were then extracted in a through-the-scope manner via the working channel.
Through-the-scope extraction minimized the risk of trauma. A holmium-yttrium aluminum garnet laser lithotripsy device (VersaPulse, Lumenis Ltd, Yokneam, Israel) via a working channel successfully crushed the hard bile duct stone (1 joule, 5 Hz), and the crushed stones were retrieved (Fig. 3; Video 1, available online at www.VideoGIE.org). The patient was discharged home uneventfully. Four months later, he underwent laparoscopic cholecystectomy.
Figure 3Peroral cholangioscopy. A, Before crushing the common bile duct stone using a holmium laser. B, After crushing. C, Extracting crushed bile duct stones.
Unexpected impaction of the basket may severely damage the bile duct, blood vessels, pancreas, and duodenum, necessitating invasive procedures. In cases of failed mechanical lithotripsy, catheter intervention, large-balloon dilation, electrohydraulic lithotripsy, and laparotomy are reported as rescue options.
This is the first report of cutting the metal wires using argon plasma coagulation in the duodenum, facilitating nonsurgical interventions to remove an impacted basket stone.
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