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).
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