Pancreatic sphincterotomy allows removal of a fractured stone basket trapped in the pancreatic duct after lithotripsy

A 57-year-old woman presented with recurrent epigastric pain. Computed tomography of the abdomen revealed a 26-mm pancreatic stone obstructing the main pancreatic duct (MPD) in the body portion ([Fig. 1]). We performed three sessions of extracorporeal shockwave lithotripsy (ESWL) using a third-generation lithotripter (Delta Compact II; Dornier MedTech, Weßling, Germany). Up to 5000 shocks were delivered per therapeutic session on a scale of 1 to 6, with a frequency of 120 shocks/min. Endoscopic retrograde cholangiopancreatography (ERCP) was routinely performed to remove the pancreatolith after ESWL to avoid steinstrasse. After sphincterotomy, we attempted to remove the pancreatolith with an eight-wire basket (MB5-2X4-8; Wilson-Cook Medical Inc., Bloomington, Indiana, USA); however, the basket became trapped by the calculi near the pancreatic orifice at the papilla ([Fig. 2]). The first solution we thought of was mechanical lithotripsy, and as we feared, the wires broke near the handle of the lithotripter ([Fig. 3 a, b]). Attempted reduction of the calculi with forceps and re-cannulating the MPD both failed. We employed a DualKnife (KD-650U, Olympus Corporation, Tokyo, Japan) to extend the sphincterotomy by approximately 3 mm. With the exposure of the trapped pancreatolith, forceps removed part of the calculi at the papilla. A guidewire was then successfully passed through the fractured basket and pancreatolith complex, and the impacted complex was retrieved with a balloon (AMH-RBT; Anrei Medical, Hangzhou, China). Following this, the fractured basket was also successfully removed by forceps ([Video 1]). The fragmented pancreatolith was also successfully removed by balloon and the patient was discharged uneventfully.

Fig. 1 A radiopaque stone within the dilated pancreatic duct seen on computed tomography.

Fig. 2 The basket with the entrapped stone was impacted within the pancreatic duct at the papilla.

Fig. 3 a A captured pancreatolith with mechanical lithotripsy being performed. b The basket fractured at the handle portion of the lithotripter and the wires fell into the digestive tract.

Video 1 Procedural steps of attempts to remove the trapped basket.

Here, we report a successful retrieval of an impacted basket with the entrapped pancreatolith. Although the situation may have been reported in the literature [1] [2] [3], the operative procedure was thrilling and fascinating. We have shown that sphincterotomy extension is safe and effective in the management of this condition.

Endoscopy_UCTN_Code_CPL_1AK_2AF

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 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: 1896-1902
• 2 Cho MK, Song TJ, Park DH. et al. Extracorporeal shock wave lithotripsy allows successful endoscopic removal of a fractured stone basket trapped in the pancreatic duct. Endoscopy 2016; 48: E65-E66
• 3 Ryozawa S, Iwano H, Taba K. et al. Successful retrieval of an impacted mechanical lithotripsy basket: a case report. Dig Endosc 2010; 22: S111-S113

Publication History

Article published online:
30 August 2023