Emergency open surgery with a duodenotomy and successful removal of an impacted basket following a complicated endoscopic retrograde cholangiopancreatography procedure: a case report.

BACKGROUND Current management of choledocholithiasis entails the use of endoscopic retrograde cholangiopancreatography (ERCP) and clearance of the common bile duct. A rare complication of this procedure is the impaction of the basket by a large stone, which necessitates lithotripsy. Here we report a case of an impacted basket during ERCP, which was managed by open surgery with a duodenotomy and the manual removal of the basket. CASE PRESENTATION A 79-year-old Caucasian man was admitted to our department with yellowish discoloration of urine, skin and eyes. Abdominal ultrasonography showed a slightly thickened gallbladder, multiple gallbladder stones, dilated intrahepatic bile ducts and extrahepatic bile extending to 1.1 cm. A computed tomography (CT) scan demonstrated a stone in the common bile duct, which caused dilation of the biliary ducts. The patient was diagnosed with obstructive jaundice secondary to choledocholithiasis; and underwent an ERCP, a sphincterotomy and stone extraction. Four days following discharge, the patient was readmitted with jaundice, abdominal pain, vomiting and fever. He was diagnosed with ascending cholangitis and treated initially with antibiotics. A second ERCP revealed a dilated common bile duct and choledocholithiasis. Stone removal with a basket failed, as did mechanical lithotripsy. Finally, the wires of the basket were ruptured and stacked in the common bile duct together with the stone. During exploratory laparotomy, adhesiolysis, a Kocher maneuver of the duodenum and a subtotal cholecystectomy were performed. Choledochotomy did not succeed in removing the impacted wires together with the stone. Therefore, a duodenotomy and an extension of the sphincterotomy were performed, followed by high-pressure lavage of the common bile duct to remove additional small biliary stones. The choledochotomy and duodenotomy were closed by a one-layer suture, and a prophylactic gastroenterostomy was performed to prevent leakage from the common bile duct and the duodenum. The postoperative course was satisfactory. CONCLUSIONS This is the first report in the literature of removal of an impacted Dormia basket through the papilla by performing a duodenotomy and an extension of the sphincterotomy, followed by gastroenterostomy.