title: Transnasal extraction of residual biliary stones by Seldinger technique and nasobiliary drain.
abstract: BACKGROUND
  Complete endoscopic clearance of bile duct stones is unsuccessful in up to 30% of patients at the first attempt, necessitating further endoscopic procedures. A novel transnasal approach for extraction of these residual stones using Seldinger technique and a nasobiliary drain was evaluated.
  
  
  METHODS
  Twenty-one patients with residual biliary stones after ERCP underwent transnasal extraction under fluoroscopy without sedation. A 0.035-inch guidewire was inserted though the previously placed nasobiliary drain into the intrahepatic ducts. The nasobiliary drain was removed, leaving the guidewire in place. A double-lumen extraction balloon was inserted over the guidewire. Multiple withdrawal maneuvers of the inflated balloon were performed to clear the bile duct.
  
  
  RESULTS
  Residual stones were present in the extrahepatic and intrahepatic ducts in, respectively, 18 and 3 patients. The mean largest stone diameter was 5.9 mm (range, 3-12 mm). Seventeen patients had a single stone. Complete duct clearance was achieved in 17 patients (81%). The procedure was unsuccessful because of guidewire dislodgement in 3 patients and inability to pass the guidewire through the nasobiliary drain in 1 patient. There was no procedure-related complication.
  
  
  CONCLUSIONS
  Transnasal extraction of residual biliary stones after ERCP with the Seldinger technique is safe and feasible with reasonable success and can avoid the inconvenience and cost of a repeat ERCP.
authors.affiliation: Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, A. Gemelli University Hospital, Rome, Italy.
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Mutignani
authors.forename: Saumil K
authors.initials: SK
authors.lastname: Shah
authors.forename: Francesca
authors.initials: F
authors.lastname: Foschia
authors.forename: Monica
authors.initials: M
authors.lastname: Pandolfi
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Perri
authors.forename: Guido
authors.initials: G
authors.lastname: Costamagna
mesh_terms: D001649:Bile Duct Diseases / Q000000981:diagnostic imaging / Q000628:therapy*; D002404:Catheterization / Q000295:instrumentation / Q000379:methods*; D002758:Cholangiography; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002769:Cholelithiasis / Q000000981:diagnostic imaging / Q000628:therapy*; D004322:Drainage; D005471:Fluoroscopy; D006801:Humans; D009666:Nose; D017211:Treatment Failure