Tumor of the pancreatic head

This 48 year old patient had a metastatic tumor of the pancreatic head. On physical examination, his gallbladder was palpable and he was jaundiced (Courvoisier 's sign).  His CT film showed the classical "double duct" sign, with dilated pancreatic and biliary ducts within the pancreatic head (A: red arrow points to the bile duct and yellow arrow points to the pancreatic duct. White arrow: gallbladder). He had liver and lung metastases. Going in during ERCP, the area around the papilla was infiltrated and was oozing blood (B1 & B2: red arrows). The cholangiogram showed a grossly dilated CBD (C: green arrow) with distal tapering (C: white arrow). We did a small papillotomy (D: white arrow) and passed a partially covered self expanding metallic stent of 10mm diameter and 60mm length (E: white arrows marking the extent of deployed stent and green arrow marks the "waist" at the affected strictured area. F: green arrow shows the lower end of the deployed stent in the duodenal lumen).