This 65 year old lady had been admitted with obstructive jaundice and cholangitis secondary to a metastatic peri-ampullary tumor. We encountered a swollen ampulla on duodenal intubation (A). Cannulation and contrast injection outlined a significantly dilated pancreatic duct (B: Black arrows) and what appeared to be the accessory duct (B: White arrow). We did a pancreatic papillotomy (C: White arrow). Further attempts here were unsuccessful and slight scope with-drawl showed an opening at the upper surface of the ampulla seen in image A (D: Black arrow), which was cannulated (E: Black arrow). This was the proper route as evidenced by wire cannulation (F: Black arrows). Contrast injection in this area outlined a dilated proximal bile duct and intrahepatic channels (G: White arrows) with no distal or mid duct delineation. A 10 mm diameter and 8 cm long partially uncovered metallic stent was prepped (I. We used a Micro-Tech stent. These come with an internal stiffening wire with a ring for removal prior to insertion: Red arrow). The stent assembly was placed across the strictured segment unto the dilated duct (J: Black arrows). The stent was then deployed (K1: The stent being deployed. Red arrow marks the gold reference mark which is kept visible just at the edge of field of view. K2: The deployed stent. A gush of contrast and white pus was seen. L1 & L2: White arrows show the fully deployed stent with black arrows indicating the proximal and distal radiographic markers).
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