Majority of bile duct stones can be managed effectively with ERCP with sphincterotomy with or without sphincteroplasty. However, larger or harder bile duct stones may require additional interventions. Mechanical lithotripsy using lithotripsy basket can be an effective tool for management of difficult bile duct stones. While usually very safe, common complications related to lithotripsy basket include bleeding, perforation, and pancreatitis. An impacted lithotripsy basket with a capture stone is an unusual complication that poses a special challenge for endoscopists. Herein, we present the video case of management of impacted lithotripsy basket after failed rescue transoral lithotripsy using cholangioscopy-guided electrohydraulic lithotripsy followed by extraction of basket using a devised pulley mechanism. A 52-year-old male underwent ERCP in a community hospital for a 9mm bile duct stone. Despite sphincterotomy, stone could not be extracted. A mechanical lithotripsy using lithotripsy basket was attempted, but the wires of the basket fractured at the handle outside the mouth and the basket could not be removed despite traction. Basket removal was attempted after sphinctroplasty using a 15mm balloon dilation, but this was not successful either. A rescue lithotripsy using a transoral lithotripter was subsequently attempted using the free basket wires from the patient's mouth, but the basket wires fractured again at the handle of the rescue lithotripter. With less than 10 inches of wire exposed, further rescue mechanical lithotripsy was not possible. Temporary biliary plastic stents were placed for biliary drainage and the patient was transferred to our center for cholangioscopy-guided removal of impacted basket. A repeat ERCP was performed approximately 24 hours after impacted basket. We could visualize a long linear ulceration extending from the sphincterotomy site all the way up the duodenum and stomach to the esophagus caused by the tension from the impacted basket wires. In order to introduce the cholangioscopy into the buttock, we first performed balloon dilation of the distal CBD. However, on minimal insufflation of the balloon catheter, we could visualize a deep tearing of the linear ulceration caused by the wire tension. Therefore, we promptly stopped insufflating and aborted any more dilation. The cholangioscope was then introduced into the bile duct. We could visualize a hard bile duct stone with the basket wires impacted around it within the bile duct. In order to free the lithotripsy basket wires from the stone, cholangioscopy-guided electrohydraulic lithotripsy was performed to fragment the hard CBD stone into small pieces. After lengthy lithotripsy, the stones were fragmented enough and we could visualize the intact lithotripsy basket. The cholangioscope was then withdrawn and we planned for removal of the freed lithotripsy basket. Given the lengthy pressure ulceration that was caused by the wire tension, removal by pulling on the lithotripsy basket wires from the patient's mouth was not possible as it would apply significant tension, potentially causing further ulceration, tear, or even perforation. Therefore, we initially attempted removal using a grasping forcep. However, the grasping forcep could not adequately hold on to the wire and kept slipping off from it. In order to safely remove the lithotripsy basket while minimizing pressure on the wire-induced ulcer, we improvised a pulley system to redirect the force vector away from the ulcer. By grabbing the basket wires using grasping forcep and pushing it deeper into duodenum towards D3, we can use the grasping forcep as a pulley that can redirect the vector of pulling force as shown by the red arrows. We created a pulley system in which pulling on the exposed basket wires from the patient's mouth results in distal or downward force on the impacted lithotripsy basket away from the linear ulcer. As shown, using our pulley system method, we could safely extract the impacted lizard gypsy basket without any additional tools or risking trauma to the mucosa. After basket removal, we performed limited balloon sweeps of the bile ducts to extract fragmented CBD stones and placed a temporary biliary plastic stent to ensure adequate biliary drainage. The patient tolerated the procedure well without any adverse events. He was discharged home after monitoring for 2 days. The patient had resolution of his symptoms with normalized liver enzymes. He underwent elective cholecystectomy as an outpatient 8 weeks afterwards and is well without any further complications. Mechanical lithotripsy using a lithotripsy basket can be an effective treatment of difficult bile duct stones. However, impaction of lithotripsy basket can rarely occur and poses a special challenge to endoscopists along with causing significant morbidity for the patients including wire induced ulcers. Number of endoscopic therapies are available for management of impacted biliary stone basket. Cholangioscope guided treatments like electrohydraulic lithotripsy can be an effective treatment especially when other options are ineffective. Once the basket is freed, endoscopists must consider safe basket extraction method as to not cause trauma during extraction. A pulley system as shown in our case can be an effective and cost effective method to extract the basket.

ERCP complications

cholangioscopy

electrohydraulic lithotripsy

bile duct stone

pulley system