Endoskopik basket sıkışması-nadir bir ERCP komplikasyonu: olgu sunumu

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ntroduction
Endoscopic retrograde cholangiopancreatography
(ERCP) is a necessary method to diagnose pathologies
of the pancreatic and biliary systems (1). ERCP plays
an important role in the treatment of choledocolithiasis when combined with sphincterotomy and stone
retrieval (2). Complications of ERCP have been reported to occur in 5-10% of the cases (3). Endoscopic
basket impaction is a rare and an unusual complication of ERCP (4,5). We herein report a successful
removal of an impacted endoscopic basket from an
elderly patient with choledocolithiasis by surgical
exploration.
Case Report
A 65-year-old male patient admitted to our clinic
with a 8-week history of right upper quadrant pain,
nausea, vomitting and jaundice. Abdominal ultrasonography showed multiple gallbladder stones, dilated intrahepatic bile ducts and a common bile duct
extending to 15 mm. Laboratory studies included a
total white blood cell count of 8 x 10
3
/mm3
, serum
alkaline phosphatase of 294 IU/L and a total bilirubin
level of 12.3 mg/dL. The patient was referred for ERCP.
Common bile duct (CBD) was visualized easily and
cholangiography revealed a dilated CBD and filling
defect of a 20 mm stone (Figure 1). Sphincterotomy
was performed without difficulty, a Dormia extraction basket was then placed, the stone was encircled,
but, following multipl attempts, the basket could not
be withdrawn into the duodenum. Therefore surgical treatment was decided and the patient underwent
laparotomy with cholecystectomy, and bile duct exploration. The basket and the stone were disimpacted
and delivered through a longitudinal choledochotomy (Figure 2). The wires leading to the basket were
cut, the proximal end of the device was withdrawn
via the mouth, and the basket, with the stone, was
extracted via the incision. Choledochoscopy revealed
* Department of General Surgery, Gülhane Military Medical Faculty
Haydarpaşa Training Hospital, İstanbul
Reprint request: Dr. Ali İlker Filiz, Department of General Surgery, Gülhane
Military Medical Faculty Haydarpaşa Training Hospital, Üsküdar-34710, İstanbul
E-mail: dralifiliz@yahoo.com
Date submitted: June 30, 2008 • Date accepted: November 21, 2008Volume 51 • Issue 4 Impacted biliary basket • 255
no residual stone or fragment. A T-tube was inserted,
and the choledochotomy was closed. Postoperatively
the patient made an uneventful recovery and a Ttube cholangiogram, which was performed on the
5th day was normal. Total bilirubin levels decreased
to the normal ranges and the patient was discharged.
After 2 weeks T-tube was removed.
Discussion
ERCP, sphincterotomy and stone extraction is
currently the best method for the management of
choledocholithiasis (2). Common complications of
this procedure include bleeding, perforation, sepsis,
cholangitis and pancreatitis. Rare complications such
as endoscopic basket impaction were seen uncommonly (5). Thus far, few cases of endoscopic basket
impaction have been reported within the hepatic
ducts, mid-CBD, gallbladder, and at the ampulla of
vater (1). Reported management strategies of impacted biliary basket with a captured stone after ERCP
have included endoscopic or surgical procedures (6,7).
Various nonsurgical options including endoscopic
lithotripsy, extracorporeal shock waves have been
suggested to deal with this problem (1,8). However,
these methods are not widely available, and if these
procedures fail, surgical intervention with CBD exploration is required (1,9).
In conclusion, decision of the treatment strategy
in choledocolithiasis is very important and should
be adapted to the patient’s general health status. The
treatment modalities including surgical approach are
various, and we herein describe our choice without
complication and successful outcome.