Percutaneous endoscopic removal of an impacted cystic duct stone

immediately removed. The catheter's proximal end was sited at the bifurcation of the common hepatic duct and the distal end protruded 1.5 cm into the duodenal lumen. Within 3 months her bilirubin level was normal with an AST of 49 units/liter, alkaline phosphatase of 168 units/ liter, and her ascites had disappeared. Because the patient remained remarkably well for over 3 years, only ultrasonic examinations were done, which showed dilation of the choledochus with an echogenic focus within it and hepatosplenomegaly. An upper gastrointestinal endoscopy in mid-1989 did not reveal any further variceal development, but the stent was not seen in the duodenum. At ERCP, a loop of broken stent was present in a moderately dilated choledochus with surrounding sludge. These were removed with a Dormia basket and stone extractor balloon. At the end of the procedure, the duct was seen to be cleared of all sludge, except for a tiny piece of stent which was not removable. Within 2 hours the patient had rigors and by the next day her serum bilirubin level had risen to 10 mg/dl. On antibiotic therapy the ascending cholangitis settled rapidly and a plain abdominal film 3 days later showed that the piece of stent had passed. When last seen 24 months after the ERCP, the patient had remained in a satisfactory condition and her liver function studies have all returned to normal. The common complications of blockage of a stent with subsequent cholangitis occurs in the majority of patients within 1 to 12 months (mean, 5 months).5 Less common complications include dislodgment of the stent, migration of the stent into the biliary tree,6 and injury to the common bile duct or the duodenal mucosa by the stent. As far as we could ascertain there are no cases reported of an endoprosthetic biliary stent that had broken within the choledochus. As far as we are aware no damage occurred to the stent during insertion. The stent was made of polyethylene and we can only presume that the long period that the stent was left in situ led to its disintegration. The above case demonstrates this rare complication which in this patient was asymptomatic. We have, however, subsequently treated a second patient in whom a long-standing stent had been inserted by the percutaneous transhepatic route for a benign post-operative biliary stricture. He presented with ascending cholangitis and jaundice. At ERCP a stent fractured into two pieces was found in the choledochus and removed along with stones and sludge, using a Dormia basket. To avoid this complication stents should probably be replaced at yearly intervals or earlier. If stents remain in place for longer than a year, an abdominal x-ray should be taken every six months to detect this potential complication as soon as possible. B. Novis, MB I. Pomeranz, MD Gastroenterology Institute

R. Zissin, MD

V. Rathaus, MD Radiology Institute Meir Hospital Kfar Saba, Israel Tel-Aviv University Sack~rSchoolofMedicme

Tel-Aviv, Israel

VOLUME 37, NO.5, 1991

REFERENCES 1. Huibregtse K, Tytgat GNJ. Palliative treatment of obstructive

jaundice by transpapillary introduction of large bone bile duct endoprosthesis. Gut 1982;23:371-5. 2. Siegel JH, Yato RP. Biliary endoprostheses for the management of retained common bile duct stones. Am J Gastroenterol 1984;79:50-4.

3. Cotton PB, Forbes A, Leung JWC, Dineen L. Endoscopic stenting for long-term treatment of large bile duct stones: 2- to 5-year follow-up. Gastrointest Endosc 1987;33:411-2. 4. Johnson GK, Geenen JE, Venu RP, Hogan WJ. Endoscopic treatment of biliary duct strictures in sclerosing cholangitis. Follow-up assessment of a new therapeutic approach. Gastrointest Endosc 1987;33:9-12. 5. Huibregtse K. Late complications. Endoscopic biliary and pancreatic drainage. Stuttgart: Georg Thieme Verlag, 1988. 6. Monroe PS. Therapeutic endoscopy of the biliary tract. Gastrointest Endosc 1987;33:331.

Percutaneous endoscopic removal of an impacted cystic duct stone To the Editor: Percutaneous cholecystoscopic lithotripsy is a minimally invasive procedure for the treatment of gallstones. Under endoscopic control the stones are fragmented by ultrasonic shockwaves and removed by suction. A prerequisite for percutaneous cholecystoscopic lithotripy has been a functioning gallbladder and exclusion of cystic duct obstruction by a stone. However, we used a similar percutaneous method and instruments to remove a stone from the cystic duct. The procedure was performed in a single stage and proved to be both safe and effective. A 78-year-old woman was admitted in October 1989 with a I-day history of severe upper abdominal pain, fever, and chills without signs of peritoneal irritation. Laboratory studies showed elevated bilirubin, alkaline phosphatase, and transaminases. Endoscopic retrograde cholangiography revealed the presence of multiple stones in the common bile duct without visualization of the gallbladder. Following endoscopic sphincterotomy, balloon extraction of the stones was performed. Because of advanced age and high cardiovascular risk, we decided to perform percutaneous lithotripsy of residual gallbladder stones. Under ultrasonographic control, a puncture was made subcostally and a needle passed into the gallbladder. After aspiration of bile the tract was dilated to 28 F. An Anplatz catheter was inserted over the largest dilator functioning as a temporary fistula to the gallbladder. Lithotripsy was performed using an ultrasound lithotriptor (Storz), which was passed through a rigid nephroscope (Storz). Control intraoperative x-ray after stone removal showed the persistence of a stone (2 cm in diameter) in the cystic duct. Contrast was flushed forcefully into the gallbladder, but the impacted stone did not move at all, although the common bile duct could be visualized. Using a flexible pediatric endoscope (Olympus P2), we were able to enter the cystic duct and to visualize the stone. A polypectomy snare was used to grasp the stone, and on withdrawing the endoscope, the stone fell into the gallbladder and was disintegrated with the lithotriptor. Four days after the procedure, the patient was discharged and followup at 3 months showed a patient free of symptoms. Per-oral 583

cholecystography at that time showed a functioning gallbladder without stones. With ultrasound guidance, percutaneous drainage and lithotripsy of gallbladder stones has become routine on our service. The technique has been used by other authors as well.1-4 Since 1987 we have performed percutaneous extraction of gallbladder stones in 86 cases. Indications were patients who refused cholecystectomy and patients with high surgical risk. We use the subcostal approach for the placement of the guidewire because of better visibility and working conditions compared with the transhepatic route. Furthermore, hepatic bleeding is avoided. 5, 6 We think that percutaneous cholecystoscopic lithotripsy is a valuable alternative in treating gallbladder stones in selected cases. In addition, the case presented proves that stones in the cystic duct are not a contraindication to this technique. It opens up a new era in treating cholecysto- and cystic duct lithiasis using non-operative procedures.

nally over the wire to push the mushroom end of the gastrostomy tube over the wire and into the mouth where the mushroom end was grasped and removed. After removal of the mushroom end of the PEG, the bougie was pulled out, along with the wire, externally through the abdominal wall. Even trying to remove the mushroom end of the PEG over the wire with a snare can cause difficulty. Pfeil et aU described one case in which resistance at the cricopharyngeal region prohibited removal. We had a similar experience and thus elected to use the bougie technique. Proper orientation of the mushroom end of the PEG is mandatory in order for it to be removed through the mouth. The orientation can be maintained over a wire, but sliding the mushroom end out the gastrointestinal tract over the wire requires a bougie. It is also emphasized that our patients all had mature tracts. Elliott Schuman, MD Peter E. Balsam, MD Parrish Medical Center Titusville, Florida

B. Vermeersch, MD P. Steyaert, MD P. Hoste, MD Departments of Gastroenterology and Urology Elisabeth's Hospital Sijsele, Belgium

1.

2. 3. 4. 5. 6.

REFERENCES Kellett MJ, Wickham JEA, Russell RCG. Percutaneous cholecystolithotomy. Br Med J 1988;296:453-5. Inui K, Nakazawa S, Naito Y, et al. Nonsurgical treatment of cholecystolithiasis with percutaneous transhepatic cholecystoscopy. Am J GastroenteroI1988;83:1124-7. Wenk H, Thomas St, Schmeller N, et al. Percutaneous transhepatic cholecysto-lithotripsy (PTCL). Endoscopy 1989;21: 221-2. Inui, K, Nakae Y, Nakamura J, et al. Percutaneous transhepatic cholecystoscopy (PTCCS). Gastroenterol Endosc 1983;25:51520. Saver RW, Hawkins JF, Soong J. Percutaneous cholecystostomy. Am J Radiol 1982;138:1133-6. Dunham F, Marliere P, Mortier C. Ultrasound-percutaneous and transhepatic cholecystostomy: a complementary procedure to therapeutic endoscopy. Endoscopy 1985;17:153-6.

REFERENCE 1. Pfeil S, Blades E, Yang P. Complications of percutaneous

endoscopic gastrostomy removal. Gastrointest Endosc 1990; 36:316.

Unusual complication of naso-enteric feeding tube To the Editor: We recently encountered a complication of a small caliber feeding tube that we feel is unique. The pleuropulmonary complications of small bore polyurethane naso-enteric feeding tubes are known. MeWey et al. 1 described a complication of perforation of the esophagus at the gastroesophageal junction with entry of the catheter into the peritoneum.

A simple method for PEG tube removal To the Editor: In reviewing the literature on PEG removal, I could only find a Letter to the Editor in your journal by Pfeil et al. 1 We wish to describe our simple technique for PEG removal, which we have used successfully in three cases. Our first patient was a 70-year-old woman with oropharyngeal dysphagia who had a PEG (Ross Laboratories, Columbus, Ohio) inserted. Some 7 months after PEG insertion, after physical therapy, her ability to swallow was regained and a request was made for PEG removal. A PEG kit wire was passed from the external PEG into the stomach. An Olympus XQ10 endoscope was then passed in the stomach and the wire was grasped with a snare. The PEG was then cut at the external skin line, and the wire was brought out the mouth. After this, the endoscope was re-inserted and with the gentle tension, after straightening out the wire, a 24 French Savary bougie was passed exter584

Figure 1. Chest x-ray after ENtube"" placement demonstrating apparent proper position. GASTROINTESTINAL ENDOSCOPY