Endoscopic management of a special case of "stone-basket impaction" during ERCP

A 57-year-old woman suspected of common bile duct stones (CBDSs), who underwent cholecystectomy, choledocholithotomy, and biliary-enteric Roux-en-Y anastomosis for “gallbladder and common bile duct stones” 20 years ago, was referred to our hospital for CBDS extraction ([Video 1]). Preoperative magnetic resonance cholangiopancreatography (MRCP) revealed dilation of the common bile duct and a filling defect in the lower common bile duct ([Fig. 1]). During endoscopic retrograde cholangiopancreatography (ERCP), pus was seen flowing out of the opening of the papilla, and cholangiograms revealed a filling defect in the lower common bile duct and the site of anastomosis, respectively ([Fig. 2]). Anastomotic stenosis was also found, and an extraction basket (FG-22Q-1; Olympus, Tokyo, Japan) was then used for stone removal after endoscopic balloon dilatation of the duodenal papilla ([Fig. 2]). After the CBDS was removed, we continued to attempt to remove the stone at the site of anastomosis. However, the basket was found to be impacted and could not be disengaged ([Fig. 3]). To avoid the potential complications associated with an emergency lithotriptor, a single-balloon enteroscopy was then attempted to further resolve the impaction ([Fig. 4]). However, when the enteroscope reached the biliary-enteric anastomosis, it turned out the filling defect was not a CBDS but a 20-mm mucosal bulge with surface congestion located at the anastomosis ([Fig. 4]). Finally, the basket impaction was retrieved by a foreign body forceps, and the biopsy revealed the mucosal bulge was chronic inflammation.