Laparsopcic removal of an intraductal ERCP stone retrieval basket following guide wire fracture

Abstract

Background: Gallstones within the common bile duct are a common cause of biliary obstruction. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and stone retrieval using either balloon catheters or wire basket devices is the gold standard treatment. Methods: We present the case of an 85 year old lady who presented with obstructive jaundice and deranged LFTs. Ultrasound confirmed choledocholithiasis and common bile duct (CBD) dilation. She proceeded to ERCP and sphincterotomy where multiple CBD stones were noted, the largest measuring 12 mm. Prior to removal using a wire basket device an attempt was made to crush the largest stone. In doing so the guidewire fractured with the basket and stone still within the common bile duct. A rescue mechanical lithotriptor was used in an attempt to clear the duct unsuccessfully. Further attempts to remove the stone and basket through the sphincterotomy were also unsuccessful and the patient proceeded to laparoscopy. Results: A four port laparoscopic approach was used with x1 12 mm umbilical port and x3 5 mm epigastric and right subcostal ports. A longitudinal choledochotomy revealed several stones and the wire basket. The wires were cut using scissors and the basket was retrieved along with the large impacted stone. Proximal and distal ducts were cleared using a fogarty balloon catheter. The CBD was closed using interrupted intracorporeal vicryl sutures and a T-Tube was inserted. A cholecystectomy was then performed and the specimen along with the wire basket and stones were removed using an endobag through the umbilical port. The T-Tube was brought out though one of the right subcostal ports. The patient returned to the ward and had an uncomplicated post op recovery. The T-Tube was removed several weeks later following a satisfactory tube cholangiogram. Discussion ERCP is the gold standard of treatment for the removal of common bile duct stones, with a success rate of over 95%.(1) Wire basket retention as a result of stone impaction within the basket and less commonly as a result of guide wire fracture occurs in 0.6% of cases. (2). Management of these complications can involve the use of balloon catheters, further mechanical lithotripsy techniques and in the setting of an impacted stone, extracorporeal shockwave lithotripsy (ESWL). However if these endoscopic methods fail then surgical intervention is indicated. Conclusion: Intraductal ERCP wire basket retention following wire fracture can be safely and effectively managed laparoscopically when traditional endoscopic methods have failed. This is associated with a significantly reduced level of morbidity when compared to traditional laparotomy and in specialist centres it should be considered as a first line treatment in such cases. (we have excellent video for this case that was not available at the time of this submission but will be accessible in the coming days)