Emergency digital cholangioscopy-assisted electrohydraulic lithotripsy for basket impaction with an entrapped bile duct stone

Basket impaction with an entrapped common bile duct stone (CBDS) is among the most challenging complications occasionally encountered by endoscopists during endoscopic lithotripsy ^{1 2} . Even with the availability of various devices including a salvage lithotripter, the management of basket impaction sometimes fails, which may necessitate more invasive surgical interventions ^{2 3 4} . Herein, we report a case of basket impaction successfully managed by emergency cholangioscopy-assisted electrohydraulic lithotripsy (EHL).

A 68-year-old man presented with jaundice due to a CBDS. Endoscopic retrograde cholangiopancreatography was performed for a 1-cm CBDS. After endoscopic sphincterotomy, a basket catheter (Medi-Globe 8-Wire Nitinol Basket; Medico’s Hirata Inc, Osaka, Japan) ( Fig. 1 a ) was inserted. Although the CBDS was easily captured within the basket, it could not be retrieved from the papilla. Furthermore, the entrapped CBDS could not be disengaged from the basket, resulting in complete basket impaction ( Fig. 1 b ). After cutting the basket catheter’s outer sheath with the basket wire left in place, a dilation balloon was gradually inflated to dilate the biliary orifice to 12 mm; however, the balloon waist did not disappear ( Fig. 2 ) and the impacted basket could not be extracted. Because the use of a salvage lithotripter with a noncompatible basket had a risk of wire fracture at an unpredictable site ⁵ , emergency cholangioscopy-assisted EHL was planned. After removal of the duodenoscope leaving only the wire, the duodenoscope was immediately reinserted along the wire. Peroral cholangioscopy using the SpyGlass DS Direct Visualization System (Boston Scientific, Natick, Massachusetts, United States) was performed ( Fig. 3 a ). The impacted CBDS within the basket was clearly visualized ( Fig. 3 b ) and crushed by EHL (Lithotron EL27; Walz Electronik, Rohrdorf, Germany) ( Fig. 3 c ). The fragmented CBDS and basket were successfully extracted by using a retrieval balloon catheter ( Fig. 4 , Video 1 ). The postoperative period was uneventful and the patient was discharged at 4 days post-admission.

Fig. 1.

a A photograph of the lithotripsy basket catheter (Medi-Globe 8-Wire Nitinol Basket; Medico’s Hirata Inc, Osaka, Japan). b A fluoroscopic image showing the impacted 8-wired basket with an entrapped bile duct stone (arrowhead).

Fig. 2.

Endoscopic papillary large balloon dilation using a balloon dilator (balloon diameter 12mm, REN; Kaneka Medix, Osaka, Japan). The large dilation balloon was gradually inflated under fluoroscopic guidance; however, the balloon waist did not disappear (arrowhead). a Endoscopic image. b Fluoroscopic image.

Fig. 3.

a A fluoroscopic image of the digital cholangioscope (SpyGlass DS Direct Visualization System; Boston Scientific, Natick, Massachusetts, United States) inserted within the impacted basket. b A cholangioscopic image of the bile duct stone (arrowheads) and basket wire (arrows). c Crushing of the stone by electrohydraulic lithotripsy.

Fig. 4.

The fragmented stone successfully extracted by using a retrieval balloon catheter (Extractor ProRX; Boston Scientific). a Endoscopic image. b Fluoroscopic image.

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Emergency cholangioscopy-assisted electrohydraulic lithotripsy for basket impaction with an entrapped bile duct stone.

Video 1