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“Post-cut”: An endoscopic technique for managing impacted biliary stone within an entrapped extraction basket

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Abstract

Background and study aims

Ampullary impaction of an entrapped stone-basket complex is not an infrequent yet challenging event during endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study is to evaluate the feasibility, safety, and efficacy of “post-cut” for the management of such scenarios.

Patients and methods

Patients with impacted biliary stone with an entrapped basket during ERCP at West China Hospital, Chengdu, China, from October 2004 to August 2014 were included in this retrospective study. Adequate biliary sphincterotomy was performed in all cases before attempted stone basket removal. Using free hand needle knife techniques, the authors extended the sphincterotomy along the long axis of the distal common bile duct to manage the biliary stone-basket impaction. In comparison with “pre-cut”, the authors coined the term “post-cut” referring to this technique. The feasibility, safety, and potential complications of post-cut were analysed.

Results

“Post-cut” was performed in consecutive 10 cases of impacted biliary stone within an entrapped extraction basket. The size of the removed stone ranged from 6 mm to 13 mm. The length of post-cut is 2 mm to 4 mm. The impacted basket was easily retrieved in all patients without complications, including bleeding, perforation, and pancreatitis.

Conclusion

“Post-cut” is a feasible, effective, and safe endoscopic technique when impaction of a biliary stone with an entrapped extraction basket develops.

Introduction

Ampullary impaction of an entrapped biliary extraction basket with a stone occurs not infrequently during endoscopic retrograde cholangiopancreatography (ERCP), with an estimated incidence between 0.8% and 5.9% [1], [2], [3], [4]. The existing endoscopic techniques and options include emergency mechanical lithotripsy after cutting the basket cable using a Soehendra mechanical lithotriptor, extracorporeal shock-wave lithotripsy (ESWL), endoscopic laser lithotripsy, large-balloon dilation of the biliary orifice, and surgery [4], [5], [6], [7], [8], [9]. However, these options usually significantly prolong the procedural time and costs, subject the patients to additional endoscopy even operation. In this study, the authors describe and report a “post-cut” technique for the retrieval of impacted stones and entrapped baskets. In contrast to “pre-cut”, which is performed to gain biliary access [10], the authors coined the term “post-cut” after an adequate biliary sphincterotomy has been performed, before attempted stone removal or subsequent endoscopic interventions. The aim of the study is to evaluate the feasibility, safety and efficacy of post-cut in for the treatment of 10 cases of impacted biliary stones within an entrapped extraction basket.

Section snippets

Patients

From October 2004 to August 2014, 3540 ERCPs were performed in 2655 patients with choledocholithiasis at the West China Hospital, Chengdu, China. The included study patients met the following criteria: ERCP was performed with a therapeutic duodenoscope (TJF240, Olympus, Tokyo, Japan) and a stone entrapped basket with a stone impacted in the ampulla treated with “post-cut”. Retrospective analysis was conducted in 10 included patients (7 men, 3 women; median age 64 years; range 35–80) (Table 1,

Results

From October 2004 to August 2014, the authors performed ERCP in 2655 patients with choledocholithiasis at West China Hospital, and 21 patients developed stone-basket impaction during ERCP. In 10 patients (7 men, 3 women; median age 64 years; range 35–80) with stone-basket impaction, (Table 1, Table 2; Fig. 1) ERCP was performed using a therapeutic duodenoscope with a large working channel (4.2 mm in diameter). Post-cut was carried out in all 10 patients. Of these patients who received post-cut,

Discussion

Endoscopic biliary sphincterotomy coupled with balloon dilatation of the ampulla and distal common duct is standard for stone extraction in choledocholithiasis [11]. Common ERCP-related complications include post-ERCP pancreatitis, post-sphincterotomy bleeding, perforation, and cholangitis [12]. Although ampullary impaction of entrapped stone-basket happens infrequently, it often leads to significantly prolonged procedural time, additional interventions, costs, and even operation. Managing

Funding

None.

Ethical approval

The work was approved by the appropriate ethical committees related to the institution in which it was performed and that subjects gave informed consent to the work.

Competing interests

No conflict of interest.

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