The title of this video is impaction of a cholangiopancreatoscopy-guided retrieval basket during treatment of a pancreatic duct stone. First-line treatment options for chronic pancreatitis patients with pancreatic duct stones include ERCP and or extracorporeal shockwave lithotripsy. Pancreatoscopy-guided lithotripsy including laser lithotripsy or electrohydraulic lithotripsy enables the treatment of pancreatic duct stones under direct visualization. The cholangiopancreatoscopy-guided retrieval basket is a device inserted through the cholangiopancreatoscope to allow for a capture and removal of stones under direct visualizations. This case involves a 68-year-old male with painful chronic calcific pancreatitis complicated by pancreatic duct stones. An ERCP was performed with initial pancreatogram demonstrating a dilated pancreatic duct and multiple large intraductal stones. Following sphincterotomy and balloon dilation, an impacted stone was found in the head of the pancreas, blocking the advancement of any device past the stone. Pancreatoscopy-guided lithotripsy was performed with EHL to fragment most of the stones, but one large stone refractory to EHL remained in the head. An attempt was made to remove the stone with the cholangiopancreatoscopy-guided retrieval basket, which became impacted within the duct. After several unsuccessful attempts to remove the impacted basket, repeat pancreatoscopy-guided EHL was performed through the basket as a salvage maneuver, fragmenting the impacted stone and eventually freeing the retrieval basket. To facilitate performing pancreatoscopy and removal of the pancreatic duct stones, we begin with balloon dilatation of the pancreatic duct orifice. With the EHL probe preloaded, we then advance the pancreatoscope side-by-side the guidewire into the pancreatic duct. We encounter several pancreatic duct stones, for which we perform electrohydraulic lithotripsy to fragment the stones. As we further advance the pancreatoscope into the pancreatic duct, we find a large impacted pancreatic duct stone. Despite using three EHL probes set at medium to high power, electrohydraulic lithotripsy was unsuccessful in sufficiently fragmenting the stone. As EHL was ineffective, we elected to use the cholangiopancreatoscopy-guided retrieval basket, which has a catheter 1 mm in diameter and has a 15 mm basket diameter that can accommodate stones up to 10 mm in size. We begin opening the basket past the stone and pull the basket back to capture the stone. The parachute design of the basket allows it to fully envelop the stone. Once a firm grasp of the stone is achieved, we begin withdrawing the pancreatoscope and the basket out of the duct. Upon withdrawing, however, we encounter significant resistance as the basket remains in place with the pancreatoscope withdrawing. We realize that the basket has become impacted within the duct and gradually increase the force with which we pull the basket and the pancreatoscope. As we more forcefully pull, eventually the pancreatoscope is pulled back into the duotoscope with the basket still in the pancreatic duct, as seen with the basket wire still visible on pancreatoscopy. As seen endoscopically, the basket wire is visible side by side the guide wire. In an attempt to free the basket, we performed several balloon sweeps over the guide wire with an 8.5 mm balloon and an 11.5 mm balloon, which were unsuccessful in removing the basket and only resulted in the balloon popping. We then attempted to use a hot biopsy forceps to grab the basket wire and pull it out of the duct, but this resulted in only tearing off parts of the wire from the basket. With this pulling, more of the basket wires are exposed, and to obtain a firmer grip, we next utilized a raptor grasping forceps to pull the wires to remove the basket. This is also unsuccessful in freeing the impactor retrieval basket, but this results in disconnecting the basket from the basket catheter, as seen here when we repeat balloon sweeping. Further balloon sweeping attempts resulted in the balloon popping, but in doing so, space was created between the basket wires. Using this opportunity to go between the basket wires, we then performed balloon dilation of the pancreatic duct orifice to help facilitate removal of the basket. Utilizing the raptor grasping forceps again, we are able to pull more of the basket wires out of the pancreatic duct. As the basket catheter is no longer connected to the basket, we are able to remove the basket catheter from the pancreatoscope and repeat pancreatoscopy with the EHL probe preloaded into the pancreatoscope. We immediately find the impacted stone within the basket wires and repeat electrohydraulic lithotripsy. Interestingly, electrohydraulic lithotripsy is much more successful with the stone entrapped within the basket, and with 5,000 shocks under high power, the impacted stone was sufficiently fragmented. As seen on pancreatoscopy, the end of the basket is able to be seen, which despite being detached from the catheter, still maintained its parachute shape. With the stone fragmented, we are then able to grasp the enmeshed basket wires with a hot biopsy forceps, and as seen under fluoroscopy, we are then able to remove the basket completely out of the pancreatic duct by removing the duonoscope from the patient's mouth. The entangled basket wires are shown here. We completed the procedure with balloon sweeping of the stone fragments and placement of the 7 French stent. This technique highlights how the cholangiopancreatoscope can be advanced next to an impacted cholangiopancreatoscopy guided retrieval basket to perform introductal lithotripsy and free the basket from the stone. As shown, basket capture of the stone may also facilitate lithotripsy, as stone fragmentation was significantly easier once the stone was in the basket. Endoscopists should be mindful of the impaction of the cholangiopancreatoscopy guided retrieval basket, particularly when removing large or impacted stones. Cholangiopancreatoscopy guided introductal lithotripsy offers a salvage maneuver to free an impacted retrieval basket, potentially allowing for a non-surgical option.

cholangiopancreatoscopy-guided retrieval basket

pancreatic duct stone

chronic pancreatitis

ERCP

lithotripsy