Surgical removal of a severed Dormia basket from the bile duct.

from the bile duct A 63-year-old man, with a body mass index of 32kg/m2, was admitted with obstructive jaundice due to cholecysto-choledocholithiasis. He was febrile and had had subcostal pain for at least 3 weeks. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the presence of stones in the common bile duct (CBD). Papillotomy was carried out and stone retrieval commenced with a Dormia basket. One stone became entrapped in the Dormia basket and it was impossible to remove it through the papilla. A Soehendra mechanical lithotripsy device was advanced over the Dormia basket with the intention of fragmenting the stone. However, the stone did not fracture on application of force (●" Fig.1). On increase of the level of force applied, the Dormia basket deformed (●" Fig.2) and eventually fractured, with its tip and the embedded stone remaining in the distal CBD. Following surgical consultation, open CBD exploration was scheduled. During the procedure, there was evidence of severe and subacute cholecystitis and cholecystectomy was carried out. The area surrounding the bile duct was severely inflamed, and longitudinal choledochotomy was carried out in the supraduodenal portion of the duct. A pair of Randall forceps was advanced distally to retrieve the severed Dormia basket with the embedded stone; additional proximal and distal passes of a biliary Fogarty catheter allowed retrieval of additional stone material (●" Fig.3). The bile duct was closed with a conventional 14-Fr T-tube (Kehr type). Postoperative serum amylase levels pointed to pancreatitis, as a sequela of the transpapillary manipulation. When doing lithotripsy using a Dormia basket, care should be taken to keep the wire loops under fluoroscopic control. Stones that are 2cm in diameter or larger are prone to becoming embedded in the wire loops during removal [1]. In addition, cholecystitis and/or cholangitis may induce inflammatory changes in the CBD, leading to stiffness and deformation of the duct, which reduces the working space between the stone and the wall of the CBD [2]. Once distortion of the Dormia basket, similar to the that described herein (see●" Fig.1), has occurred, impaction or rupture becomes very likely, and it may be better to consider alternative ways of widening of the papilla or fragmenting the stone. In some cases, use of a second basket or shockwave lithotripsy can help remove or fragment the entrapped stone [3,4], but once the basket beFig.1 Advancing a mechanical lithotripsy device over the loops of a Dormia basket, with the intention of fragmenting the entrapped stone. The patient was a 63-year-old man with obstructive jaundice due to cholecysto-choledocholithiasis.