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).
I am a gastroenterologist. This is a blog of the ERCPs and related endoscopic procedures carried out at my department. Dr Adnan Salim.
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