Conflicts of interest: The authors declare no potential conflicts of interest.
Shomei Ryozawa, Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan. Email: email@example.com
We report the successful retrieval of an impacted mechanical lithotripsy basket. In a patient with two large common bile duct stones, the basket with the entrapped stone was impacted within the mid-common bile duct. We then attempted to use another mechanical lithotripter; however the central wire of the basket fractured at the handle portion. Grasping a few wires of the impacted basket with rat-tooth forceps allowed the wires of the basket to slip away from the stone. The present report describes the safe and effective use of rat-tooth forceps in the management of an impacted lithotripter basket.
Endoscopic retrograde cholangiopancreatography (ERCP) is highly effective for the treatment of choledocholithiasis.1 On rare occasions, stone extraction baskets can become impacted in the common bile duct if they capture a stone that is too large to remove via traction and if the basket and stone complex cannot be separated to allow just the basket to be removed from the patient. A variety of endoscopic, radiological, and surgical techniques have been used to remedy this situation. With the advent of mechanical lithotripters, stones captured within an impacted basket are either crushed or the wires of the basket broken to release the trapped basket. We present here a novel method for retrieval of an entrapped mechanical basket where the central wire of the basket fractured at the handle portion during an attempt to use the Soehendra through-the-scope (TTS) lithotripter.
A 69-year-old woman presented initially to another local hospital with right hypochondrial pain and fever. Ultrasound imaging showed a dilated common bile duct (CBD) containing two large stones. The patient was referred to our hospital for further management. ERCP showed two large CBD stones measuring 2.5 cm in diameter (Fig. 1). After endoscopic sphincterotomy, a basket mechanical lithotripter (XEMEX crusher catheter LBGT-7420S; Zeon Medical, Tokyo, Japan) was inserted to engage the stone (Fig. 2, Video 1). The stone was extremely hard to crush; hence, the basket with the entrapped stone was impacted within the mid-CBD (Fig. 3, Video 2). The outer sheath covering the basket had been removed leaving the bare wires exposed. We then attempted to use another mechanical lithotripter (Conquest TTC lithotripter cable and Soehendra lithotripter handle; Cook Endoscopy, Winston-Salem, NC, USA) to either crush the stone or break the fibers of the basket. However, on cranking the lithotripter, the central wire of the basket fractured at the handle portion (Video 3). The duodenoscope was reintroduced and rat-tooth forceps (FG-8L-1; Olympus, Tokyo, Japan) were inserted through the accessory channel. Care was taken to ensure that few wires of the impacted basket were grasped with the rat-tooth forceps (Fig. 4, Video 4). This was achieved and then the trapped basket was disengaged from the stone. The patient underwent choledocholithotomy and was discharged uneventfully.
ERCP with endoscopic sphincterotomy followed by Dormia basket deployment has gained wide acceptance as the method of choice for bile duct stone extraction. However, endoscopic stone removal becomes challenging and sometimes impossible in the presence of a large stone. Mechanical lithotripsy has been successfully used in 80–90% of cases to crush CBD stones that are too large to remove by conventional methods.2,3
Stone extraction baskets can become impacted in the common bile duct if they capture a stone that is too large to remove via traction and if the basket and stone complex cannot be separated to allow just the basket to be removed from the patient. Various nonsurgical methods have been described to deal with this problem including extended sphincterotomy, awaiting spontaneous passage of the impacted basket and stone after successful biliary stent placement, use of an extra-endoscopic mechanical lithotripter, extracorporeal shock wave lithotripsy,4,5 endoscopic pulse-dye laser6 and transhepatic choledochoscopic lithotripsy.7 However, some of these rescue procedures are not widely available in many parts of the world and most require considerable expertise to achieve a successful outcome.
At endoscopic stone removal it is essential to have suitable accessories available, particularly the extra-endoscopic mechanical lithotripter or the newly developed TTS lithotripters,8,9 in the event that entrapment of a basket occurs. In our patient we first attempted to use the Soehendra TTS lithotripter, but the central wire of the basket fractured at the handle portion, which made further attempts with this type of device impossible. We describe here a simple but novel method that may be attempted by others facing a similar predicament. Grasping a few wires of the impacted basket with rat-tooth forceps allowed the wires of the basket to slip away from the stone. The simplicity of this maneuver makes it a worthwhile first-line salvage technique before subjecting the patient to more complicated and invasive procedures.