This was the 3rd ERCP that this 54 year old gentleman underwent. His last procedure was in February when two plastic stentswere placed after stricturoplasty http://ercp365.blogspot.com/2014/02/follow-up-ercp-of-post-liver-transplant.html?m=0. His ALP levels had started to rise and the ultrasound scan suggested blocked scents. We retrieved the two stents (A: white arrows show the stents and red arrow shows the snare around them. B: the retrieved stents). Contrast injection initially showed a cutoff at the proximal level of the native duct (C: white arrow) but further contrast outlined the implant's ductal system (D: white arrows show the site if anastomosis and the segmental branches). We decided to use a TTS balloon (E) to dilate the stricture again. The guidewire could only be maneuvered into one of the segmental branches (F: white arrow) and despite repeated attempts, even with a thinner 0.018 inch glide wire, we couldn't enter into the remaining two branches (F: red arrows). This segmental branch's combined Union with the confluence area, along with the main anastomotic site were then dilated (G: white arrow shows the contrast filled balloon). Repeat dye injection showed considerable improvement in the anastomotic site (H: white arrow. Red arrow shows one of the branches with a narrow Union that we couldn't enter) so we decided not to put any stents this time. This patient had a biliary cast last time so we decided to sweep the bike duct with a stone extraction balloon (I: white arrow shows the balloon assembly in position. J: black arrows show the inflated balloon being pulled downward). There were no casts this time and the sweep was clean. The patient would be followed up with ultrasound and LFTs.
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