Successful endoscopic management of fractured Dormia basket during endoscopic retrograde cholangiopancreatography for choledocholithiasis.

Editor,

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable tool in pancreaticobiliary evaluation and treatment. ERCP has become the mainstay in the treatment of choledocholithiasis through sphincterotomy and trawl of the common bile duct with either a balloon or a metal basket being used to retrieve stones. Complications of ERCP and sphincterotomy have been reported to occur in five to ten per cent of cases1–3, and range from minor bleeding to severe pancreatitis. We report an unusual complication of ERCP with basket fracture and retention followed by recovery of the retained basket at second ERCP.

Case report

A 61-year-old gentleman presented with a 10-day history of nausea, right upper quadrant discomfort, dark urine and pale stools. He had a past medical history of ischaemic heart disease and peptic ulcer disease. There was no history of liver disease or gallstones and no risk factors for jaundice. On examination he was apyrexic, icteric and was mildly tender in the right upper quadrant without rebound or guarding. There were no stigmata of chronic liver disease. Initial blood investigations showed Hb 13.4G/dl, WCC 6.34 THOUS/uL, Bilirubin 175umol/l, AST 164 U/L, GGT 603 U/L, ALP 215 U/L. Urea, electrolytes and albumin were within normal limits. Ultrasound scan (USS) of abdomen was performed the day following admission and showed a calculus within the lower common bile duct (CBD). The CBD and intrahepatic ducts were dilated.

As a result of these findings, an ERCP was arranged. ERCP was carried out 4 days following admission. Technique of conscious sedation was employed using midazolam and pethidine. Midazolam was titrated to 7mgs and pethidine titrated to 50mgs. Despite this the patient remained agitated throughout the procedure.

Findings were as follows: Ampulla was normal. Pancreatic duct was normal. CBD was dilated to 10–12mm. A single CBD stone approximately 8mm in diameter was present.

An 8mm sphincterotomy was performed. A Dormia basket was placed around the stone. The stone was successfully engaged into the basket (fig.1) but the basket could not be pulled through the ampulla. Subsequently, crushing of the CBD stone with the external lithotripter was attempted. However the patient became extremely agitated and lithotripsy had to be terminated. The end of the impacted basket was cut, the polyethylene sheath was removed and the endoscope withdrawn. It was noted that a portion of the wire had fractured off. The endoscope could not be passed back into the stomach due to the patient's ongoing agitation and the procedure was abandoned.

Fig 1

ERCP image of stone engaged in Dormia basket.

There was a strong clinical suspicion of retained basket fragments and the patient was commenced on IV ciprofloxacin. Repeat fluoroscopy with oral contrast confirmed retained basket in the CBD (fig 2).

Fig 2

Videofluroscopy image showing contrast in duodenum and fractured basket fragment in CBD.

A second ERCP under general anaesthetic was performed. Cholangiogram demonstrated single calculus which was removed along with the retained fragment of basket (see fig 3). The remaining metal fragment was grasped with a further Dormia basket and removed (fig 4). The patient had no complications post-ERCP and is currently awaiting laparoscopic cholecystectomy.

Fig 3

ERCP image of basket fragment engaged in second Dormia basket

Fig 4

Fragment of fractured basket removed from CBD

Discussion

Traction wire or basket fracture, often following stone impaction, is an unusual complication of ERCP and in the past has been managed surgically4. Biliary stenting leads to increased risk of cholangitis by disrupting sphincter of Oddi function5. Retained metal fragments are likely to similarly disrupt sphincter of Oddi function with subsequent high risk of cholangitis.

Conclusion

We have demonstrated successful medical management of basket fracture with intravenous antibiotics and repeat ERCP facilitating endoscopic removal of the retained fragment. In experienced endoscopic teams this should be considered as an alternative to surgery.