UCLA, David Geffen School of Medicine Los Angeles, CA
Kush Fansiwala, MD1, Elissa Lin, MD2, Adarsh M. Thaker, MD3 1UCLA, David Geffen School of Medicine, Los Angeles, CA; 2UCLA, Los Angeles, CA; 3David Geffen School of Medicine at UCLA, Los Angeles, CA
Introduction: Retrieval baskets are a common device used to extract biliary stones during endoscopic retrograde cholangiopancreatography (ERCP). Basket-related complications can include impaction around a stone. To manage this, specialized baskets were developed with a break-away tip to assist basket removal. Here, we describe a case of failure of the tip disengagement of an impacted Trapezoid retrieval basket (Boston Scientific, Marlborough, MA) and a rescue technique to manage this unexpected situation.
Case Description/Methods: A 43-year-old woman with severe choledocholithiasis with incomplete stone removal on prior ERCP presented for repeat ERCP. Cholangiogram showed a narrow common bile duct (CBD) with upstream dilation and multiple filling defects, including one very large stone. Multiple balloon sweeps failed to clear the duct. A digital cholangioscope was advanced into the CBD and electrohydraulic lithotripsy (EHL) was performed to break the distal-most stones. The largest stone was unable to be reached due to downstream fragments. These could not be balloon swept from the duct so basket sweeps were attempted, but the largest stone was inadvertently captured. The stone and basket became impacted in the mid duct. Mechanical lithotripsy (ML) was attempted with the basket, but the stone remained intact and the fail-safe break-away tip failed to disengage. Instead, the handle of the basket snapped. To troubleshoot, the basket wires were cut near the handle. The scope was then removed entirely and reinserted beside the wires. The cholangioscope was then passed alongside the wires and additional extensive EHL was performed until the impacted stone was finally reached and fractured, releasing the impacted basket. After additional stone removal, two plastic biliary stents were placed to maintain drainage. Approximately one month later, the patient eventually underwent repeat ERCP with stent removal and definitive clearance of the stones.
Discussion: Although basket impaction of large stones is not uncommon, there are fail-safe mechanisms, including mechanical lithotripsy and break-away tips. The failure of both of these does not appear to have been previously reported with this basket. Rescue options for other baskets also include manipulation of severed wires and argon plasma coagulation to cut the wires. This case describes another option: cholangioscopy with EHL beside the basket wires to reach/fracture the stone and free the basket.
Figure: Fluoroscopic Findings
Disclosures:
Kush Fansiwala indicated no relevant financial relationships.
Elissa Lin indicated no relevant financial relationships.
Adarsh Thaker: Apollo Endosurgery – Consultant, Speakers Bureau. Boston Scientific – Consultant, Speakers Bureau.
Kush Fansiwala, MD1, Elissa Lin, MD2, Adarsh M. Thaker, MD3. A0435 - Failed Break-Away Tip Mechanism of Impacted Stone Retrieval Basket During Endoscopic Retrograde Cholangiopancreatography, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
