Biliary sphincter dilation: a novel approach for management of a biliary basket impaction

We read with considerable interest the study by Misra & Dwivedi [1] concluding that large-diameter balloon dilation of the sphincterotomy site is an effective procedure for removal of bile duct stones that cannot be extracted by endoscopic sphincterotomy and conventional extraction devices. Their study inspired us to apply, for the first time, their technique in the management of an impacted biliary basket.

An 85-year-old man with cholecystectomy and choledocholithiasis was referred to our department for endoscopic retrograde cholangiopancreatography (ERCP). The major papilla was small without a visible intraduodenal segment of common bile duct (CBD) and was located on the edge of a medium-sized diverticulum. The CBD was easily cannulated; cholangiography demonstrated two squarish stones, measuring 10 and 12 mm in diameter. The length of the endoscopic sphincterotomy was the maximum possible. After mechanical lithotripsy, almost all fragments were removed, with the exception of a relatively large fragment that could not be withdrawn into the duodenum, and the Dormia basket was impacted in the intraduodenal part of the CBD. The basket handle was cut off and further attempts to extract the trapped basket with a mechanical lithotriptor and a foreign body forceps failed. A straight 7-Fr 7-cm stent was placed alongside the impacted basket to achieve biliary drainage. The stent was removed 3 days later and a super-stiff hydrophilic guide wire (Jagwire; Microvasive, Boston Scientific, Natick, Massachusetts, USA) was placed in the CBD. Dilation of the biliary sphincter was done using a controlled radial expansion (CRE)-guided balloon (diameter 15 mm) (Microvasive) ([Fig. 1]).

Fig. 1 Controlled radial expansion (CRE) balloon dilation of biliary sphincter. The wires of the impacted basket are seen in the upper part of the endoscopic sphincterotomy site (arrow).

Following dilation, both the basket and the impacted stone were easily removed with a foreign body forceps ([Fig. 2]).

Fig. 2 Easy removal of impacted basket and trapped stone.

The patient had an uneventful post-procedure course and was discharged 24 hours later.

Endoscopic extraction of bile duct stones may be complicated in 0.8 % – 5.9 % of the procedures by impaction of the Dormia basket with captured stones or rupture of the traction wire during mechanical lithotripsy [2]. Reported management strategies include the use of a mechanical lithotriptor to capture the first basket and crush the stone [3], extracorporeal shockwave lithotripsy [4], endoscopic laser lithotripsy [5], or other similarly sophisticated methods. However, some of the “rescue” procedures are not widely available in many parts of the world, while most of them require considerable expertise to achieve a successful outcome.

Despite the limited experience, endoscopic sphincterotomy plus large-balloon dilation appears to be simple, safe, and effective for removing bile duct stones [1] [6]; the simplicity of this technique makes it a worthwhile first-line salvage method for an impacted biliary basket, that may avoid subjecting the patient to more sophisticated or complex endoscopic or surgical procedures.

Competing interests: None

References

• 1 Misra S P, Dwivedi M. Large-diameter balloon dilation after endoscopic sphincterotomy for removal of difficult bile duct stones.  Endoscopy. 2008;  40 209-213
• 2 Payne W G, Norman J G, Pinkas H. Endoscopic basket impaction.  Am Surg. 1995;  61 464-467
• 3 Garg P K, Tandon R K, Ahuja V. et al . Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones.  Gastrointest Endosc. 2004;  59 601-605
• 4 Sauter G, Sackmann M, Holl J. et al . Dormia baskets impacted in the bile duct: release by extracorporeal shock-wave lithotripsy.  Endoscopy. 1995;  27 384-387
• 5 Neuhaus H, Hoffman W, Classen M. Endoscopic laser lithotripsy with an automatic stone recognition system for basket impaction in the common bile duct.  Endoscopy. 1992;  24 596-599
• 6 Kim G H, Kang D H, Song G A. et al . Endoscopic removal of bile-duct stones by using a rotatable papillotome and a large-balloon dilator in patients with a Billroth II gastrectomy (with video).  Gastrointest Endoc. 2008;  67 1134-1138