Second (actually 3rd) ERCP for post transplant biliary leak

This 60 year old gentleman had earlier undergone ERCP and stenting for an anastomotic biliary leakage a few months earlier http://ercp365.blogspot.com/2015/09/first-ercp-for-post-transplant.html?m=1. A 7 French 12 cm plastic stent was placed across the site of leakage and later removed. His bilirubin levels had showed a mild rise over the past few months and ultrasound showed a small collection in the subhepatic space (indicating a persistent leak). We decided to intervene. Initially our guidewire couldn't cross the site of leak and contrast showed a sharp cutoff. We switched from an 0.035 inch to an 0.025 inch wire and were successful in crossing the structure site (A: black arrow). Further contrast injection showed leakage (B: Red arrow) and outlined the proximal bile ducts (B: White arrow indicates he proximal ducts and black arrow shows the site of ductal anastomosis/narrowing/leakage ). Since our papillotome had to be forced across the leak site, we decided to dilate it with dilatation catheters (C1 & C2: Dialatation being done with 5-6-7 French and 8-9-10 French graduated catheters, respectively ). A stent assembly was then passed into one of the proximal ducts (D: Black arrow) and a 10 French plastic stent of 12 cm length was passed (E: Black arrows). 

First ERCP for post liver transplant anastomotic biliary stricture (CASE N)

This 54 year old gentleman had recently undergone living donor liver transplant at our centre. He had presented with fever, chills, pruritus and a raised ALP level. His MRCP showed a short stricture at the anastomotic site (A: white arrow). We were greeted with a bulging ampulla on ERCP (B). Contrast injection highlighted the stricture ( C & D: white arrow). We dilated the track with a 7 French graduated dilatation catheter (D: black arrow) followed by placement of a 7 French plastic stent of 12 cm length (E:black arrows. White arrow shows the upper end of the stent assembly). This was rewarded with a gush (F: white arrow) of white (hence infected) bile.

Duodenal stenting following PTBS for periampullary tumor with gastric outlet obstruction

This 74 year old lady had previously undergone percutaneous transhepatic biliary stenting (PTBS) due to a metastatic periampullary tumor which had also infiltrated into the duodenum (A3 & B: white arrows) causing gastric outlet obstruction (don't forget to check for a succession splash in any patient with jaundice, kids). Once the biliary drainage had been taken care of, we moved to free the route out the stomach. The pyloric opening was narrowed and we dilated it using a TTS balloon (A1 &A2). Following this, we advanced our duodenal stent assembly across the bulb and descending duodenum (B & C1 : black arrows). The stent (20mm x 130mm) was then carefully unsheathed (C1 to C5: white arrows show the stent being deployed. Red arrows shows the "waist" forming right about the middle of the stent at the site of maximal luminal infiltration by the tumor).