Safe recovery of a fully fractured basket in the bile duct using endoscopic papillary large balloon dilation

Traction wires are occasionally fractured while endoscopic mechanical lithotripsy is being performed for bile duct stones. Various methods have been used to crush the bile stones during the rescue of an impacted basket including a transoral endotripter [1], laser or electrohydraulic lithotripsy under cholangioscopy guidance [2] [3], or extracorporeal shock wave lithotripsy [4]. In most cases, fractured wires are recovered by pulling their distal ends outside of the bile duct after the impacted basket has been released. However, if all the wires have fractured in the proximal portion of the bile duct, what then is a suitable method? We describe the successful recovery from the bile duct of a fully fractured basket using endoscopic techniques.

A 74-year-old man underwent endoscopic mechanical lithotripsy for bile duct stones following endoscopic sphincterotomy at another hospital. The bile duct stones were partially crushed; however, all the wires of the basket section were fractured and the proximal part remained in the bile duct. He was referred to our hospital for recovery of the fractured basket after placement of a biliary duct endoprosthesis ([Fig. 1]).

Fig. 1 Radiographic image showing the fractured basket beside a biliary duct endoprosthesis.

Endoscopic retrograde cholangiography was performed using a side-viewing video duodenoscope (TJF-260V; Olympus Medical Systems, Tokyo, Japan) and revealed stones within the fractured basket ([Fig. 2]). Therefore, we performed endoscopic papillary large-balloon dilation (EPLBD) to prevent damage to the peripapillary bile duct by the tips of the wires ([Fig. 3]; [Video 1]). EPLBD was performed using a CRE wire-guided biliary balloon dilation catheter (Boston Scientific Japan, Tokyo, Japan) with a maximum diameter of 18 mm. Before proceeding, we confirmed that oozing of blood from the papilla due to the balloon dilation had stopped spontaneously.

Fig. 2 Image during endoscopic retrograde cholangiography showing bile duct stones within the fractured basket.

Fig. 3 Duodenoscopy showing the dilation of the papilla by inflation of a large balloon.

Endoscopic papillary large-balloon dilation (EPLBD) being performed to safely recover the fractured basket.

An extraction balloon catheter (EXP71820P; Zeon Medical, Tokyo, Japan) was used next to remove the bile duct stones. The fractured basket was then inverted and moved closer to the papilla ([Fig. 4 a]). Finally, we used alligator forceps (FG-47L-1; Olympus Medical Systems) to recover the fractured basket ([Fig. 4 b] and [Fig. 5]; [Video 2]). No procedure-related complications were observed during endoscopy. Although reports have described the management of basket impaction via EPLBD [5], the recovery of a fully fractured basket is rare.

Fig. 4 Images during cholangiography showing: a the bile duct stone and the fractured basket being moved closer to the papilla with an extraction balloon catheter; b alligator forceps in the bile duct grasping the fractured basket.

Fig. 5 Duodenoscopy showing the fractured basket after its recovery from the bile duct.

The bile duct stones are removed by an extraction balloon catheter and the fractured basket is moved closer to the papilla. Finally, alligator forceps are used to recover the basket.

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Competing interests: None

• References

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