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).