Post cholecystectomy remnant CBD stones

This 38 year old lady had developed obstructive jaundice a few months after undergoing cholecystectomy. The ultrasound report indicated a single stone in the distal CBD. Her cholangiogram outlined a single large stone seen as a negative shadow just above the scope (A: white arrow). The surgical clips from her cholecystectomy were also visible (A: green arrow). We did a papillotomy and we're doing a routine check of adequacy of the papillotomy by withdrawing a fully open sphincterotome. That apparently was enough to pull the stone out (B: white arrow shows the stone and the sphincterotome in the duodenal lumen). We did a routine sweep of the CBD with an extraction balloon, followed by an occlusion cholangiogram with contrast injection over a fully inflated balloon in the distal CBD (C: white arrow shows the inflated balloon) which showed no negative shadows.

Tumor of the pancreatic head causing obstructive jaundice

A mass of approximately 21cm size in the region of pancreatic head was cashing obstructive symptoms in this 78 year old gentleman. He had also developed fever. His CT scan showed a dilated pancreatic duct (A1: green arrow)  with abrupt obliteration of its lumen (A2: green arrow) with an adjacent mass in the pancreatic head (A2: red arrow). On ERCP, his cholangiogram showed significant intrahepatic biliary dilatation (B: white arrows) with a stricture involving the distal CHD and proximal CBD (B: green arrows). He was in good physical shape and the remaining CT films didn't show any contraindications to resection. We placed a 10cm long plastic stent of 10 French diameter to drain the biliary system and resolve the infection (C: white arrows). He is due to undergo surgery soon after.

Ampullary tumor causing obstructive jaundice

This was a 45 year old lady with an ampullary tumor suggested on he CT scan. The growth was obvious on ERCP (A: green arrow). Contrast injection during ERCP outlined a dilated CBD and intrahepatic biliary channels (B: green arrows) and a stricture in the distal CBD (B: white arrow). A 10 French diameter plastic stent of 10cm length was passed (C: white arrows).

A 40 year old patient with cirrhosis of the liver and biliary stricture

This 40 year old patient had cirrhosis of the liver and a biliary stricture. He had undergone extensive workup for his liver and biliary disease, save for a liver biopsy. His tumor markers were normal, and so was his colonoscopy. He had earlier undergone ERCP with stent placement seven months ago. His latest MRCP showed dilated intrahepatic biliary channels (A & B: green arrows) and a stricture at the level of junction of the common hepatic and cystic ducts (A & B: white arrow). We placed a 10 French plastic stent of 10cm length. He has been admitted for further workup. A liver biopsy is on the cards.

Managing choledocholithiasis and a damaged pancreatic duct in a patient with surgical complications following a history of biliary pancreatitis and pseudocyst formation

This 50 year old patient was himself a physician. He had an episode of biliary pancreatitis which resulted in pseudocyst formation. A percutaneous drainage catheter was placed to drain the cyst during cholecystectomy a few weeks after his pancreatitis had settled. A few days later, significant hemorrhage occurred from the catheter. He underwent repeat surgery during which the affected portion of the pancreas was "packed". He was then referred to our center. His MRCP showed bile duct calculi (A: green arrow) and a disruption in the pancreatic duct continuity (A: white arrows marking the absent portion of the pancreatic duct). Contrast injection on ERCP outlined stones in the mid CBD (B: white arrow). We did a wide papillotomy during which a significant amount of sludge extruded from the CBD (C: green arrows showing sludge around the papilla). The CBD was swept with an extraction balloon (D1: white arrow shows the inflated balloon in the CBD) and a single stone was removed (D2: green arrow shows the stone and red arrow marks the inflated balloon in the duodenal lumen). We then cannulated the pancreatic duct (E: green arrow shows the papilla and the red arrow shows the papillotome engaging the pancreatic duct opening). Initially our guidewire went in along an abnormal path, downwards where the duct disruption began (F1: white arrows show the guidewire in an abnormal position). After repeated attempts, we were able to place the guidewire across the disrupted segment and into the intact distal pancreatic duct (F2:white arrows marking the guidewire). A 10cm long plastic stent of 7 French diameter was placed (G1: white arrows showing the stent placed in the pancreatic duct, bridging the damaged portion. G2: shows the stent draining in the duodenal lumen).

The stone that wouldn't come out

This 28 year old gentleman had what appeared to be "a soft mass with acoustic shadow" in his distal CBD. Contrast injection on ERCP showed a rounded stone in the mid CBD (A: green arrow). After a wide papillotomy, we attempted to extract the stone with an extraction balloon but were unsuccessful. We decided to do a sphincteroplasty with a wire guided balloon (B1 & B2: the balloon specifications and inflation check prior to insertion. C1 to C4: the balloon being placed into the papilla and inflated. C5: green arrows show the extent of dilated balloon on fluoroscopy). Even after sphincteroplasty, the stone could not be removed with the extraction balloon and we could clearly see it stuck in the CBD through the wide papillotomy (D: green arrow). We then decided to use the extraction basket to remove the lodged stone (E: white arrows show the open basket in the CBD). This was rewarded with success and the stone was removed (F: green arrow shows the stone, smeared with blood, lying in the duodenal lumen). 

Multiple CBD stones requiring different removal techniques

This 40 year old lady had a pre ERCP ultrasound which indicated a single 9mm stone in the distal CBD. Going in, we were encountered by a swollen ampulla (A: green arrow), suggesting an impacted stone. Dye injection showed a grossly dilated CBD (B: green arrows) and negative shadows (B :red arrows). The stones could not be removed even after a wide papillotomy. So we went for a sphincteroplasty with an 18mm TTS (through the scope) wire guided balloon (C1 & C2 and D: green arrow showing the inflated balloon at the ampulla). One stone was retrieved (E: green arrow). Repeat cholangiogram showed more stones in the mid CBD (F: green arrow). The remain stones were removed with an extraction basket (G1: green arrow marks the stone and red arrow indicates the basket wires. G2: red arrow marks the stone trapped in the basket wires)

Suspected blockage of metallic stent in a patient with cholangiocarcinoma

This 65 year old patient had two metallic stents placed over the past 18 months. The first was an uncovered stent, followed 8 months later by a partially covered stent placed within the first one. He had now presented with raised bilirubin. The ultrasound scan showed multiple hepatic lesions with query between abscesses and metastatic lesions. The stent seemed patent on direct viewing (A: green arrow). A guidewire was maneuvered across the stent (B: green arrows marking the guidewire and red arrows show the previously placed metallic stent) followed by contrast injection which outlined a patent stent and normal calibre intrahepatic biliary channels (C1 & C2: green arrows). We flushed the stents with saline which removed some debris (D: green arrows show the patent stent and full washout of contrast). Our conclusion was that the raised bilirubin, coupled with patent stents and normal calibre intrahepatic biliary ducts, was attributable to the liver metastatic lesions.

CBD stone removal pre cholecystectomy

A 50 year old lady had come for CBD stone removal before undergoing cholecystectomy. The MRCP showed a stone in the distal CBD (A: green arrow)  and gallbladder calculi (A: red arrow) and a dilated CBD (A: yellow arrow). Contrast injection on ERCP showed the distal CBD stone as in the MRCP and another negative shadow above the ERCP scope (B: green arrows marking the stones and yellow arrow showing a dilated CBD). The distal stone was removed by the papillotome (C: green arrow shows the stone and red arrow marks the papillotome). The CBD was swept with balloon (D: green arrow shows the inflated balloon) and the second stone was also removed (E: green arrows show both the stones in the duodenal lumen).

Iatrogenic CBD injury with bile leakage during cholecystectomy

A 34 year old gentleman had undergone cholecystectomy four weeks earlier. He had suffered an injury to the CBD per op and was referred to us for management. A drain was placed in the sub hepatic space. The bilirubin level in the drain fluid was 53mg/dL. Serum bilirubin was 5mg/dL. The MRCP report showed non visualization of the upper CBD and CHD. A leak was also seen (A: green arrows show the non visualized part of the upper CBD and the CHD while the red arrow marks the leak). CBD cannulation was initially unsuccessful. We were bale to cannulate the pancreatic duct and proceeded to do a transpancreatic papillotomy. That allowed clear visualization and cannulation of the bile duct (B: green arrow shows the guidewire in the CBD and red arrow marks the pancreatic duct opening). Dye injection showed the bile duct (C1 & C2: green arrows), site of leakage (C1 & C2: yellow arrow), the abdominal drain (C1 & C2: red arrows) and the intrahepatic biliary channels proximal to the site of leakage with the guidewir across the leak (C1: white arrows). There was resistance to the papillotome going through the site of leakage and into the right hepatic duct so we dilated the track first (D: green arrows show the dilatation catheter and red arrows show the intrahepatic drain). A 10cm long 10 French plastic stent was placed (E1 & E2: green arrows marking the stent and red arrows show the drainage tube).  

Metastatic ampullary tumor

A 38 year old lady with an ampullary tumor which had metastasized to the liver and duodenum (A: green arrows). On endoscopy, the ampulla was heavily infiltrated (B: green arrow). Cannulation was unexpectedly swift. Dye injection showed a grossly dilated CBD with a distal stricture (C: green arrows showing dilated CBD with red arrow showing the strictured segment). The guidewire was placed across the stricture (D: green arrows) and a self expanding metallic stent of 10mm diameter and 60cm length was placed (E: green arrows showing the stent and red arrow showing constricted part of the stent in the area of the malignant stricture). A gush of pus and bile was seen (F: green arrow) after stent deployment. The patient had developed cholangitis prior to the procedure. Hopefully this stent will help in resolution of the acute condition. 

Gall bladder malignancy

This 70 year old gentleman had a gall bladder mass with involvement of the porta hepatis and duodenum. The ampulla was fairly normal looking when we went in (A:green arrow), though maneuvering into the descending duodenum was a bit tricky. Contrast injection outlined a stricture in the proximal bile duct (B: green arrow) with pre-stenotic dilatation of intrahepatic channels. A self expanding metallic stent assembly was placed across the stricture (C: green arrow) and a 10 cm long stent of 10mm diameter was deployed (D: green arrows and E: green arrow).