This report presents a 64-year-old male who underwent successful rescue using a nonsurgical endoscopic approach to remove an impacted mechanical lithotripter basket, due to a 17-mm common bile duct stone. The basket impaction occurred at an outside hospital, and rescue using a transoral endotripter failed. The patient was transferred to our institution for management with the wire of the lithotripter protruding from his mouth. Computed tomography scan on admission showed pneumoretroperitoneum and a pseudoaneurysm of the papillary artery resulting from previous management. Endoscopic retrograde cholangiopancreatography (ERCP) with argon plasma coagulation successfully cut the wires in the duodenum and enabled extraction of the body of the lithotripter. After the ERCP, duodenal and biliary bleeding from a pseudoaneurysm of the papillary artery occurred and was successfully controlled by transarterial embolization. At a subsequent ERCP session, endoscopic lithotripsy was attempted using peroral “mother-baby” cholangioscopy (CHF-B290, Olympus, Japan) under continuous ductal irrigation with normal saline. A holmium-yttrium aluminum garnet laser lithotripsy device (VersaPulse, Lunemis Ltd, Israel) introduced through the working channel successfully crushed the bile duct stone, and the stone fragments were retrieved. The patient was discharged home uneventfully. Four months later, he underwent laparoscopic cholecystectomy.
Endoscopic cutting of the metallic wire with argon plasma coagulation has been reported, but there are few articles reporting cutting the wires of an impacted metallic lithotripter in the duodenum. We believe this non-operative rescue is a viable option in the event of stone-basket impaction during ERCP.
ERCP-associated management is considered to be a high-risk procedure compared to other gastrointestinal endoscopic interventions. In particular, basket impaction may result in further serious adverse events such as perforation and bleeding resulting in the need for invasive interventions. Rescue after basket impaction using cholangioscopy and laser lithotripsy is one therapeutic option. However, medical facilities in Japan do not always have a cholangioscope readily available. This report shows that cutting the wire of an endoscopic mechanical lithotripter with an argon plasma coagulation device can resolve wire protruding from the mouth after basket impaction. Unlike cholangioscopy, many medical facilities have argon plasma coagulation available. Before performing rescue endoscopy, perforation and bleeding should be excluded. We recommend this strategy in case of stone-basket impaction during ERCP.
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