Second ERCP for post transplant anastomotic biliary stricture (CASE J)

This 56 year old gentleman underwent a living related transplant for liver cirrhosis secondary to Hepatitis C around March 2014. He had his first ERCP in December 2014 (an earlier attempt in October 2014 had been unsuccessful). Contrast injection identified a sharp L-shaped angulation of the left hepatic duct, crossing in front of the right duct (A: white arrows). The right duct was seen behind it (A: black arrow). A 7 French stent of 12cm length was deployed in the left duct after dilating the track with a nominal 7 French graduated dilatation catheter. He again developed burning of the soles of his feet and pruritis along with rising ALP. We decided to remove his stent. On ERCP, it was seen to have migrated inside the CBD (B: Black arrows). We retrieved it using a biliary balloon inflated next to it (C: black arrows show the stent and white arrow marks the balloon adjacent to the stent. D: a single balloon sweep had resulted in some pullout and straightening of the proximal sharply bent portion of the stent-compare with C. E: white arrow shows the retrieved stent). Contrast injection post stent retrieval resulted in clear outlining of the right duct (F: black arrow) however the left L-shaped duct was only marginally outlined (F: white arrow). A balloon assembly was positioned in the right ductal system (G: black arrow) which was then inflated with full obliteration of the waist (H: black arrow). Next we manoeuvred our guidewire into the L-shaped left duct (I: black arrow). Pushing the papillotome over the wire and injection of contrast now outlined the left duct in its sharply bent form (J: black arrows. Compare with A). A 7 French double pigtail stent of 12 cm length was deployed (K: black arrows. Note the marked coil in the proximal portion of the stent. Not quite the desired result but we'll keep an eye on him nevertheless to see how it drains). A collection of contrast was also noted (K: red arrows). This was possibly a result of balloon dilatation of the right system. Admission with antibiotics and an eye on the temperature charts is on the menu.