To boldly drain what others have not drained before

This 26 year old lady had a history of recurrent cholangitis. She had extra hepatic portal venous obstruction with varies at her porta causing compression of the extra hepatic biliary channels. She had previously undergone three ERCPs. The second ERCP showed her dilated left and right biliary systems (A: black arrows) with luminal narrowing of the confluence, CHD & CBD (A: white arrows). Following dilatation with a graduated dilatation catheter, a 10 French plastic stent had been placed in her right system (B: black arrows) but her left system could not be cannulated (B: white arrows). On her 3rd ERCP, the stent had been removed. Now, 4 months later, she presented with cholangitis. Her MRCP images showed the same findings along with stones on the CBD (C: red arrow marks the calculi, black arrows show the narrow CBD, white arrow indicates the narrowing at the hilum and blue arrows show the dilated right and left ductal systems). We booked her for her 4th ERCP. Our guidewire was first manoeuvred into her left system (D: black arrow shows the guidewire and white arrow shows the dilated left system). This was followed by dilatation of the track using a 10 French graduated dilatation catheter (E: white arrows show the dilatation catheter). We then swept the CBD with a biliary balloon (F:black arrows mark the balloon assembly in the CBD) and a  moderate amount of small calculi and sludge was removed (G1: red arrows mark the removed calculi. G2: black arrow shows the "clean sweep" ampulla). We then passed another guidewire in the right system (H: black and white arrows show the two guide wires in the right and left systems, respectively). A 10 French plastic stent of 12 cm length was passed into the right system (I: black arrows mark the stent in the right main duct). A thinner 7 French stent (also of 12 cm length) was then passed into the left system (J: white arrows show the stent in the left main duct while black arrows show the first stent in the right system. K: red arrows show the two stents draining happily in the duodenal lumen).