# Rescuing impacted biliary extraction basket using cholangioscopy-directed lithotripsy and a pulley system

## TL;DR

A new endoscopic method using cholangioscopy and a pulley system successfully removes an impacted biliary extraction basket during a complex ERCP procedure.

## Contribution

A novel rescue technique combining cholangioscopy-directed lithotripsy and a pulley system is introduced for impacted biliary baskets.

## Key findings

- Cholangioscopy-directed electrohydraulic lithotripsy effectively fractured the entrapped stone.
- An improvised pulley system using grasping forceps enabled safe basket extraction.
- The patient was discharged within 48 hours without needing surgery.

## Abstract

Impaction of a biliary extraction basket during endoscopic retrograde cholangiopancreatography (ERCP) is a rare but challenging adverse event. We describe a novel endoscopic rescue approach using cholangioscopy-guided lithotripsy and an improvised pulley system to remove an impacted biliary basket after failed transoral mechanical lithotripsy.

A 52-year-old man presented with obstructive jaundice because of a 9-mm common bile duct stone. Initial ERCP with mechanical lithotripsy using an extraction basket resulted in basket impaction. Rescue lithotripsy with a transoral lithotriptor resulted in wires fracturing at the handle. Rescue endoscopic management of the impacted basket was performed at our center. The patient had significant duodenal ulceration due to tension from the exposed basket wires.

Cholangioscopy-directed electrohydraulic lithotripsy was performed to fracture the entrapped stone. An improvised pulley mechanism using grasping forceps as a fulcrum was used to successfully extract the entrapped basket. The patient was discharged within 48 hours without requiring surgical interventions.

Cholangioscopy-guided lithotripsy is effective for releasing impacted baskets from entrapped stones. A pulley technique using grasping forceps can enable safe basket extraction by altering the vector of wire traction. This strategy provides a minimally invasive solution for managing an impacted biliary extraction basket.