New wire-guided basket for intrahepatic stone extraction
A Chan, S Chung
New wire-guided basket for intrahepatic stone extraction Angus C. W. Chan, MBChB, FRCS (Edin), S. C. Sydney Chung, MD, FRCS (Edin), FRCP (Edin)
Background: Endoscopic extraction of intrahepatic ductal stones with conventional stone retrieval baskets sometimes is difficult when the stones are deep in the segmental ducts or in a tortuous duct. We evaluated the use of a new wire-guided basket for endoscopic bile duct stone extraction. Methods: The new wire-guided basket has a separate lumen for the guidewire on one side of the catheter. It is rail-loaded and advanced over a guidewire into the desired segmental duct. After they are engaged, the stones are dragged into the duodenum and the guidewire is left in the segmental duct. The basket then can be reinserted into that particular ductal segment over the wire for further stone extraction. Results: The basket was used to treat three patients.Two patients had multiple intrahepatic stones. Repeated passage of the basket back to the desired location was accomplished without difficulty. All stones were removed successfully. Conclusion: The new wire-guided basket is a useful device for removing intrahepatic stones, particularly from patients with multiple ductal stones.
Intrahepatic stones are a frequent occurrence in East Asia.1 In Hong Kong, recurrent pyogenic cholangitis2,3 is prevalent. Clearance of intrahepatic Received June 6, 1998. For revision January 6, 1999. Accepted March 11, 1999. From the Endoscopy Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China. Reprint requests: S. C. Sydney Chung MD, FRCS (Edin), Department of Surgery, Prince of Wales Hospital, Shatin, NT, Hong Kong, China. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/69/98452 VOLUME 50, NO. 3, 1999
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B Figure 1. A, Memory II basket with guidewire exiting the smaller lumen. B, Open Memory II basket with guidewire in place.
stones by means of ERCP has been less than satisfactory because of the presence of intrahepatic strictures and stones in multiple segments.4 Technical difficulties often are encountered while a stone retrieval basket is negotiated into the desired intrahepatic segment. Multiple passes often are needed to clear multiple intrahepatic stones. To allow easy passage of the basket into the desired segment, a wireguided Dormia basket would be helpful. A new wireguided basket (Memory II double-lumen basket; Wilson-Cook Medical, Inc., Winston-Salem, N.C.) has become available. We report on our initial experience with the use of this new wire-guided basket to treat three patients. PATIENTS AND METHODS The Memory II wire-guided basket consists of a catheter sheath that has two parallel lumens (Fig. 1). The GASTROINTESTINAL ENDOSCOPY
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A Chan, S Chung
New wire-guided basket for intrahepatic stone extraction
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Figure 2. A, Right intrahepatic ductal stricture (arrow) with multiple stones proximally. B, Balloon dilatation of the stricture with guidewire left inside the segment. C, Wire-guided basket placed into the segment over the guidewire.
Figure 3. Black pigment stones were extracted from the segment with the guidewire left inside the segment (arrow). smaller lumen at the side allows passage of a standard 0.035-inch guidewire (Tracer Hybrid; Wilson Cook, or Zebra; Microvasive–Boston Scientific Corp., Natick, Mass.). The basket can be opened without interference from the guidewire, stones can be engaged without removing the guidewire, and the guidewire can be left in place during stone removal. Repeated passage into the same duct segment thus can be achieved. Use of this wire-guided basket was evaluated in the care of three patients.
RESULTS Case 1 A 53 year-old-man was admitted with acute right upper quadrant pain, fever, and jaundice. 402
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US showed stones in the right hepatic duct. Emergency ERCP confirmed similar findings, and a nasobiliary drain was inserted into the right intrahepatic duct for temporary drainage. ERCP was performed 72 hours later with the intention of extracting the stones. A short-segment stricture was demonstrated at the confluence of right segmental ducts, and multiple stones were present proximally (Fig. 2A). A guidewire was directed to the desired segment (Fig. 2B). The stricture was dilated with an 8 mm by 3 cm Rigidflex balloon catheter (Microvasive). After dilation, the guidewire was left in position. The wire-guided basket was advanced to the segment over the guidewire, and stones were extracted (Figs. 2C and 3). The guidewire was left in the ductal segment to allow multiple passes of the basket into the segment. Ductal clearance was confirmed on the occlusion cholangiogram. Case 2 A 55-year-old woman was found to have a persistently elevated plasma alkaline phosphatase level. US showed multiple stones in the extrahepatic bile ducts and intrahepatic ducts. ERCP confirmed the presence of multiple 1.5 cm diameter stones in the extrahepatic duct and left main duct. The stones in the left main duct were impacted at the confluence and it was not possible to pass a conventional basket beyond. A guidewire was negotiated beyond the stone, and the wire-guided basket was slid over the guidewire into the segment (Fig. 4A and B). The stone was successfully engaged and removed (Fig. 4C and D). The rest of the left ductal stones were similarly extracted, and the guidewire was kept in the segment during the process. VOLUME 50, NO. 3, 1999
New wire-guided basket for intrahepatic stone extraction
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A Chan, S Chung
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Figure 4. A, Left main intrahepatic duct stone (arrow) with guidewire placed into the segment. B, Wire-guided basket placed into the segment over the guidewire. C, Left main intrahepatic duct stone engaged with the wire-guided basket (arrow). D, Stone being removed (arrow) with the guidewire left in the intrahepatic duct.
Case 3 A 10 year-old-girl reported acute right upper quadrant pain. This was associated with elevated liver enzyme levels. US showed a distended gallbladder with an echogenic focus in the distal common bile duct. ERCP was performed under sedation. Two 0.5-cm diameter stones were found in the common duct. Because of the young age of the patient, balloon dilatation of the papilla was performed with a 6 mm by 2 cm Rigidflex (Microvasive) balloon catheter in an attempt to conserve sphincter function. To facilitate stone extraction, the guidewire was left in place, and the wire-guided basket was used without difficulty to extract the stones (Fig. 5). DISCUSSION Endoscopic clearance of stones from extrahepatic ducts is successful in 80% to 90% of cases.5,6 However, extraction of intrahepatic stones is a chalVOLUME 50, NO. 3, 1999
lenge even for experienced biliary endoscopists. In an earlier study our overall clearance rate was only 26%4 because of the presence of strictures and the fact that the stones were deep in the segmental ducts. Passage of a basket into the desired segment is usually by trial and error. If multiple passes are needed to extract the stones, the procedure becomes prolonged and tedious. A wire-guided basket would be particularly helpful because multiple passes into the same segment could be achieved by leaving the guidewire in the same segmental duct until all stones are cleared. Guidewires are more easily manipulated into the intrahepatic ducts than are stone retrieval baskets. The concept of the wire-guided basket is that of a Dormia basket catheter that can be guided over a wire. The earlier prototype (Olympus Optical, Ltd., Tokyo, Japan) has a central lumen at the tip of the GASTROINTESTINAL ENDOSCOPY
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A Chan, S Chung
New wire-guided basket for intrahepatic stone extraction
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Figure 5. A, Small common duct stone at distal end (arrow). B, Balloon dilation of the papilla with guidewire in place. C, Wire-guided basket placed over the guidewire for stone extraction.
basket for the guidewire to pass through. When the basket is opened, the guidewire occupies the center of the basket and therefore has the potential to interfere with stone entrapment. The guidewire must be removed before stones can be engaged. For patients with multiple stones, the wire must be reinserted repeatedly. With the new Memory II wireguided basket, the guidewire exits at the side of the basket, and stones can be engaged without removing it. Repeated passage of the basket into the same segment is easily accomplished. The only disadvantage of using this new basket is the inability to crush the stone mechanically. For patients with larger intrahepatic stones or stones proximal to a stricture, use of the wire-guided basket may risk entrapment and stone impaction because the stone cannot be fragmented after engagement. A wire-guided mechanical lithotriptor basket would be the obvious next generation of basket for development.
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In conclusion, the new double lumen wire-guided basket was particularly helpful in extracting multiple intrahepatic stones. We believe the overall success rate in clearing intrahepatic stones would be improved with use of this new device. REFERENCES 1. Nakayama F, Soloway RD, Nakama T, Miyazaki K, Ichimiya H, Sheen PC, et al. Hepatolithiasis in East Asia: retrospective study. Dig Dis Sci 1986;31:21-6. 2. Cook J, Hou PC, Ho HC, McFadzean AJS. Recurrent pyogenic cholangitis. Br J Surg 1954;42:188-203. 3. Li AKC, Chung SCS, Leung JWC, Mok SD. Recurrent pyogenic cholangitis: an update. Trop Gastroenterol 1985;6:119-31. 4. Leung JWC, Venezuela RR, Banez VP, Chung SCS, Lau JWY, Li AKC. Endoscopic management of intrahepatic stones [abstract]. Gastrointest Endosc 1991;37:256. 5. Siegel JH. Endoscopic papillotomy in the treatment of biliary tract disease: 258 procedures and results. Dig Dis Sci 1981; 26:1057-64. 6. Chung SCS, Leung JWC, Leong HT, Li AKC. Mechanical lithotripsy of large common bile duct stones using a basket. Br J Surg 1991;78:1448-50.
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