LAUSR

Mechanical lithotripsy is effective for removal of large bile duct stones during endoscopic retrograde cholangiopancreatography (ERCP) but is a complex procedure with a risk of complications [1]. The availability of alternative techniques to extract difficult stones (i. e. endoscopic papillary large balloon dilation [EPLBD] and cholangioscopy-assisted lithotripsy) [2] has resulted in a decline in the use of mechanical lithotripsy. Nevertheless, cholangioscopy-assisted lithotripsy is an advanced technique, not widely available, and is still expensive. Complications of mechanical lithotripsy can be challenging to manage. We describe a method of removing a trapped Dormia basket. A 78-year-old woman with a history of recurrent cholangitis underwent ERCP for common bile duct stones. Two stones (10×15mm and 15×20mm) (▶Fig. 1) were seen on cholangiogram. After sphincterotomy and 15-mm EPLBD, the smaller stone was extracted using a Fogarty balloon. The larger stone could not be removed, and intra-endoscopic mechanical lithotripsy was attempted (▶Fig. 2); however, the Dormia wires broke near the handle of the lithotriptor despite being specially designed for mechanical lithotripsy. The Dormia basket was made of Nitinol with a “crimp” that joins the four wires (▶Fig. 3 a). The trapped basket was pulled closer to the papilla, making it possible to visualize the “crimp.” Argon plasma coagulation (APC2; ERBE, Tübingen, Germany; Forced setting, 80W) was then used to trim the two wires between the “crimp” and the tip of the basket (▶Fig. 3 b, ▶Video 1); the trapped Dormia was finally retrieved using another small (10mm) over-the-wire basket (▶Fig. 4). Plastic stents were inserted near the stone and the patient was referred for cholangioscopy-assisted lithotripsy, which was successful. The use of APC to trim the meshes of selfexpandablemetal stents has been reported previously [3] and can be considered for “cutting” other endoscopic devices when necessary for their retrieval.