Managing a hilar stricture (or trying to, at least)

This 60 year old lady had a hilar cholangiocarcinoma. Significant intrahepatic biliary dilatation was evident on contrast injection (A: Red arrows show dilated intrahepatic ducts and black arrows show the affected narrowed hilar area). We placed one guidewire in the right system (B1: red arrows) and attempted to manoeuvre a second one into the left system (B1: black arrows and B2). This was unsuccessful and it kept going into the right system along with the previous wire. The strictured segment was dilated using an 8.5 French graduated dilatation catheter (C1 & C2: black arrows show the catheter  and red arrows show the second guidewire). The second guidewire was removed and a stent assembly was pushed into the right system (D: black arrows). A 10 French plastic stent of 10 cm length was placed (E: white arrows). The patent was started on antibiotics and she predictably developed fever. However it was short lived and we were able to discharge her home within the week. Retrospectively, what appear to be left sided channels in "A" may well have been right sided channels as well (appearing so due to the patient's position. These suspected left channels are also free of contrast in "C1", so we might not have injected the left system in the first place.

A very large intrahepatic cholangiocarcinoma

This was a 30 year old gentleman who had presented with obstructive jaundice. His CT scan showed a very large mass of approximately 12x11cm occupying most of the left one (A: white arrows) with involvement of the porta hepatis and extensive intra-abdominal lymphadenopathy. On ERCP, contrast injection following placement of guidewire outlined a long stricture involving the region of ductal confluence (B: white arrows) with dilated  left sided ducts proximal to stricture (B: red arrows). Since the right system was not outlined, we left our first guidewire in the left system (C: white arrows) and attempted to pass a second guidewire in the right system (C: black arrows). This was unsuccessful. Luckily, no contrast had gone into the right system. We dilated the structured segment using a graduated 9 French dilatation catheter (D1 & D2: white arrows). A 12 cm long plastic stent of 10 French diameter was then deployed (E1 & E2: black arrows )

Stenting a malignant duodenal stricture

This 70 year old gentleman had previously undergone placement of a metallic biliary stent last year for an ampullary tumor. He was subsequently lost to follow up and had only now presented with gastric outlet obstructive symptoms. A swallowed contrast study (A) clearly showed the problem. The previously placed stent was outlined (A: white arrows) along with the intrahepatic biliary channel (A: green arrows). The stricture was also seen as a thin structured segment in the second part of the duodenum (A: red arrow). On endoscopy, the affected area was seen with almost complete luminal obstruction (B: white arrow). We placed a biliary cannulation catheter across the stricture followed by contrast injection which outlined the extent of the stricture (C: red arrowheads) and the unaffected bowel segment beyond the stricture (C: blue arrow). The biliary stent was also seen (C: white arrowheads). A guidewire was then placed across the stricture (D: white arrows) followed by a stent assembly (E: black arrows). A 12 cm long stent of 20 mm diameter was then deployed (F1 & F2 : black arrows show the stent assembly. White arrowheads show the deployed portion of the stent . Red arrowheads show the distal  and middle radiographic markers of the stent. F3: Fully deployed stent. Stent outlined with white arrowheads. Red arrowheads showing the radiographic stent markers. Blue arrow showing the previously injected contrast in the lumen of the distal portion of the stent. G1 & G2: The stent as seen by the endoscope: white arrows. Compare with B).