Basket Case: Fluoroscopy-Free Capture and Retrieval of Biliary and Pancreatic Duct Stones

Excerpt

A 72-year-old woman was evaluated for severe epigastric pain associated with nausea and diaphoresis. Her past medical history was significant for cholecystectomy 3 years previously and multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures for the management of recurrent choledocholithiasis. Vital signs were notable for a heart rate of 79 beats/min, temperature of 37.1 °C, blood pressure of 96/69 mm of Hg, and respiratory rate of 16/min. Physical examination revealed mild right upper quadrant tenderness, without other abnormality. Laboratory studies included normal total bilirubin (0.7 mg/dL), AST 48 U/L (normal < 40), ALT 59 U/L (normal < 60), and alkaline phosphatase 179 U/L (normal 40–130). Imaging with magnetic resonance cholangiopancreatography again indicated choledocholithiasis, with marked dilation of the common bile duct to 2.4 cm. ERCP performed with anesthesia support revealed a large peri-ampullary diverticulum, a dilated common bile duct and common hepatic duct up to 2.8 cm, prominent intrahepatic bile ducts, and multiple large oval gallstones within the bile duct (Fig. 1a). The stones were fragmented using a 3-cm wire lithotripsy basket. Papillary large balloon dilation was performed to 18 mm, and stone fragments were then extracted with balloon sweeps. Some residual stones could not be successfully extracted as the bile duct diameter exceeded that of the largest available stone extraction balloon (15–18 mm). The patient developed recurrent oxygen desaturations, and consequently, a decision was made to terminate the relatively lengthy procedure (46-min duration, 7.4 min fluoroscopy time) following the placement of a double-pigtail plastic biliary stent.

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