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Covered metal stent as a rescue therapy for impacted Dormia basket in the biliary tract.

Dear Editor,

Choledocholithiasis usually requires therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and multiple attempts of stone extraction. Standard treatments include endoscopic sphincterotomy followed by passage of a balloon catheter and/or Dormia basket catheter until complete clearance is observed via cholangiography. However, sometimes, unexpected outcomes are obtained: one of the most discouraging technical adverse events is impacting a retrieval basket around a large bile duct stone (1,2). If stone extraction fails and Dormia basket rests are trapped in the bile duct, rescue therapies, such as Soehendra mechanical lithotripsy, intraductal or extracorporeal lithotripsy, or surgical approach, are needed (3).

In this paper, we reviewed the case of an 84-year-old male who underwent ERCP for cholangitis caused by a large CBD retained stone. During the procedure, the stone was captured by the Dormia basket; however, unfortunately, this rested impacted and fixed in CBD. To ensure biliary drainage, a naso-biliary tube was placed above the trapped basket and a metallic traction wire was passed through the nose.

New ERCP was once performed at our tertiary referral center. Despite multiple but useless attempts even via Soehendra lithotripter, Dormia basket rested trapped in an "hallow" of the distal CBD. Moreover, the small diameter of the pre-papillary CBD did not allow for safe endoscopic large balloon papillary dilation (EPLBD). The Dormia catheter wire was then placed into the gastric lumen, and a fully covered self expandable metal stent (FCSEMS) with a long retrieval string (Niti-S Kaffes type Taewoong Medical, South Korea) 60*100 mm was placed across the Dormia basket (Figure 1).

Fifteen days later, ERCP was repeated and the FCSEMS was removed. Simultaneously, the Dormia basket was easily retracted outside the ampulla of Vater and the stone, reduced in size, and skipped out in the duodenum. No AEs were recorded.

Endoscopic treatment of difficult choledocholithiasis often represents a challenging situation, even for an expert endoscopist.

Historically, mechanical lithotripsy was the widest used technique in the management of difficult choledocholithiasis; however, it was burdened with complications ranging from 3.6% to 35% (2,3).

Various complications were recorded, including trapped basket surrounding a stone, fracture of basket wires or the main operation wire, malfunction of mechanical lithotriptor crank handle, and ductal injury. Among these, impaction of the Dormia basket was the most common (3).

Rescue therapies include the enlargement of sphincterotomy, EPLBD, extracorporeal, intraductal (laser or electrohydraulic), or mechanical lithotripsy. If these therapies fail, surgery is the last choice to release the trapped Dormia basket and remove biliary stones (1,3).

Nowadays, the temporary use of FCSEMS represents an effective option in the treatment of choledocholitiasis (2). In fact, first Cirefice and more recently Hartery reported an efficacy of approximately 85% of temporary placement of FCSEMS as a key-point in the treatment of patients with difficult biliary stones (4,5). In this scenario, we thought that the use of FCSEMS could be a suitable choice even in the case of a trapped Dormia Basket, thus providing quick biliary drainage, carrying to stone fragmentation or size reduction with continuous rubbing between the stone and the metal mesh of the stent. Moreover, FCSEMS placement is relatively easy, inexpensive, and widely available, not precluding any further treatments.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept--G.G., P.C., A.C., H.B., F.P.Z., R.S., R.C.; Design--G.G., P.C., A.C., H.B., F.P.Z., R.S., R.C.; Supervision G. G., P.C., A.C., H.B., F.P.Z., R.S., R.C.; Resources--G.G., P.C., A.C., H. B., F.P.Z., R.S., R.C.; Materials--G.G., P.C., A.C., H.B., F.P.Z., R.S., R.C.; Data Collection and/or Interpretation--G.G., P.C., A.C., H.B., F.P.Z., R.S., R.C.; Analysis and/or Interpretation--G.G.; Literature Search--G.G., P.C., A.C., H.B., F.P.Z., R.S., R.C.; Writing Manuscript --G.G.; Critical Review--G.G., P.C., A.C., H.B., F.P.Z., R.S., R.C.

Conflict of interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES

(1.) Chandrasekhara V, Khashab MA, Muthusamy VR, et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32-47. [CrossRef]

(2.) Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig Endosc 2013; 25:376-85. [CrossRef]

(3.) Thomas M, Howell DA, Carr-Locke D, et al. Mechanical lithotripsy of pancreatic and biliary stones: complications and available treatment options collected from expert centers. Am J Gastroenterol 2007; 102:1896-902. [CrossRef]

(4.) Hartery K, Lee CS, Doherty GA, at al. Covered self-expanding metal stents for the management of common bile duct stones. Gastrointest Endosc 2017; 85:181-6. [CrossRef]

(5.) Cerefice M, Sauer B, Javaid M, et al. Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos). Gastrointest Endosc 2011; 74:520-6. [CrossRef]

Giuseppe Grande [1], [ID] Paolo Cecinato [2], [ID] Angelo Caruso [1], [ID] Helga Bertani [1], [ID] Francesco Paolo Zito [1], [ID] Romano Sassatelli [2], [ID], Rita Conigliaro [1], [ID]

[1] Gastrointestinal and Digestive Endoscopy Unit, Sant'Agostino Estense Hospital, AOU Modena, Italy

[2] Gastroenterology and Digestive Endoscopy Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy

Corresponding Author: Giuseppe Grande; giuseppegrande1984@gmail.com

Received: February 25, 2018 Accepted: June 4, 2018 Available online date: November 19, 2018

DOI: 10.5152/tjg.2018.18028

Caption: Figure 1. The Dormia catheter wire was then placed into the gastric lumen, and a fully covered self-expandable metal stent (FCSEMS) with a long retrieval string 60*100 mm was placed across the Dormia basket
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Title Annotation:LETTER TO THE EDITOR
Author:Grande, Giuseppe; Cecinato, Paolo; Caruso, Angelo; Bertani, Helga; Zito, Francesco Paolo; Sassatelli
Publication:The Turkish Journal of Gastroenterology
Date:Mar 1, 2019
Words:941
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