2015-02-09 21:27:36 UTC

Technique for Retrieving Basket and Lithotripter During ERCP

Feb. 5, 2015

The Clinical Gastroenterology and Hepatology image of the month features the case of a 27-year-old woman with a prior cholecystectomy who underwent ERCP for abdominal pain and choledocholithiasis, resulting in several complications.

A 27-year-old woman with a prior cholecystectomy underwent ERCP for abdominal pain and choledocholithiasis. After biliary sphincterotomy, a flower basket was used to grasp and retrieve a 15-mm mid–common bile duct (CBD) stone. However, the flower basket became impacted in the CBD. Then, the distal CBD was dilated using a 15-mm CRE balloon dilator (Boston Scientific, Natick, MA). Despite this, the basket could not be pulled out. The outer plastic sheath of the basket was removed and a Soehendra mechanical lithotripter then was inserted alongside the basket wires into the CBD and mechanical lithotripsy (Cook Medical, Winston-Salem, NC) of the stone was attempted. The lithotripter also became impacted in the CBD over the basket and could not be pulled out. The presence of the impacted basket, lithotripter and wires in the CBD precluded placement of a stent, but there was good bile drainage seen. Because of the prolonged efforts and complexity, it was elected to terminate the procedure. The basket and lithotripter wires were cut and secured at the patient’s mouth with an adhesive tape. The patient was placed on a liquid diet along with broad-spectrum antibiotics for prophylaxis against cholangitis. ERCP was repeated after three days and attempts to drag the impacted devices and stone with an extraction balloon were unsuccessful. Electrohydraulic lithotripsy (EHL) then was performed using Spyglass (Boston Scientific) and the stone was fragmented. The impacted basket and lithotripter could be pulled out of the bile duct by using a rat-tooth forceps, passed under endoscopic and fluoroscopic guidance (Figure). An extraction balloon was swept to clear the residual stone fragments. A 10F 10-cm plastic stent was inserted temporarily for four weeks to ensure biliary drainage and the patient did well.

What makes this case unique? Read the full discussion on this case in Clinical Gastroenterology and Hepatology.

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