Extrinsic biliary compression in a patient with Familial Adenomatous Polyposis

This 35 year old gentleman was a diagnosed case of Familial Adenomatous Polyposis who had developed obstructive jaundice secondary to extrinsic biliary compression. This was evident on MRCP (A: red arrow). This was most likely a lymph node exerting pressure on the bile duct. Contrast injection on ERCP confirmed the MRCP findings (B: red arrow). We dilated the stricture tract with a 10 French dilator (C: black arrows). Further advancement of the dilator revealed a sharp bend (D: white arrow marks the bend. Black arrows delineate the stent). A 12cm long plastic stents of 10 French diameter was placed (E: white arrow shows the "kink" in the stent at the aforementioned bend. Black arrows outline the stent). A snare was used to pull the stent back to straighten it out (F: red arrow shows the snare around the stent. G: black arrows mark the non kinked stent, properly deployed). 

Follow up case of post cholecystectomy biliary leak

This 38 year old lady had previously undergone biliary stunting for a bile leak http://ercp365.blogspot.com/2013/12/and-another-bile-leak-following.html which had occurred following cholecystectomy. We had placed a 10 cm long 10 French plastic stent. We removed the stent (A). The sludge coating prompted us to do a biliary sweep with a stone extraction balloon (B: white arrow shows the papilla with a previous sphincterotomy and the balloon assembly being inserted). The CBD was swept (C: black arrows shows the inflated Ballon in the CBD). Gan occlusion cholangiogram with the balloon inflated at the distal end of the CBD was done (D: black arrow shows the inflated balloon. White arrows delineate the CBD with no leakage). The patient was discharged. 

Major biliary tree disruption post surgery

This 52 year old lady had been referred from another hospital following bile duct injury during open cholecystectomy. She underwent a repeat laparotomy after her gall bladder surgery for the leak. A drain was placed in the sub hepatic space and the patient was subsequently sent to us. Her MRCP wasn't the best of images we had seen, with major motion artifacts (problem with holding her breath, we suppose). A disruption in the bile duct (A: red arrow) and leakage (A: blue arrow) was clear. Contrast injection after CBD cannulation showed the extent of damage, with structures, leaks and what appeared to be an uncommon  anatomical variant of the biliary tree (B: green arrows show the leak. Blue arrow shows a major stricture. Black & white arrows show what appear to be right and left hepatic ducts but without the classical confluence morphology we're used to seeing. Red arrow indicates a 0.035 guidewire which has been placed into the right system). The right system,where we had managed to place the wire, was dilated with a 10 French graduated dilatation catheter (C: black arrows). We then left one wire in the right duct and made multiple attempts to place the second wire into the left duct in order to dilate it (D1 to D4: black arrow shows the first wire in the right system and white arrow shows the second wire as we attempt to place it in the left duct). Alas we were unsuccessful. A decision was made to stent the right duct. A stent assembly was then passed. As we passed the stent over it, the force required to pass the strictured segment (despite dilatation done earlier) caused the stent assembly to warp into the area of leakage (E: white arrows show the stent assembly and black arrow shows the assembly bent into the leak area). A 10 French stent of 12 cm length was then deployed (F1 &  F2: white arrows).