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). 

Third (fourth, actually) ERCP for post liver transplant anastomotic biliary stricture (Case J)

This 56 year old gentleman had undergone biliary stenting previously http://ercp365.blogspot.com/2015/04/post-transplant-anastomotic-biliary.html. Following this he developed pruritus and disturbed transaminases and a repeat ERCP with stent removal and extension of sphincterotomy was done last month. The CBD was clean and free of any stones/sludge (A: White arrow). His liver enzymes became disturbed again and he developed pruritus. Contrast injection showed poor filling of the right ductal system (B: White arrow). No attempts at dilatation were made as our papillotome had easily traversed the strictured site and we placed a thicker 10 French stent of 12 cm length (C: White arrows) as opposed to the 7 French stent placed in the ERCP before last (see link above).

Second follow up ERCP for post liver transplant anastomotic biliary structure (Case I)

This 25 year old gentleman had undergone a previous ERCP for an anastomotic biliary stricture. http://ercp365.blogspot.com/2015/04/post-liver-transplant-anastomotic.html. He had developed jaundice with pruritus and fever. His ultrasound showed a blocked stent. On ERCP, the biliary and pancreatic duct stents were visible (A: Black arrow-biliary stent, white arrow-pancreatic stent). Both were removed (B: Black and white stents showing the pancreatic and biliary stents, respectively). Contrast injection identified the site of stricture (C: Black arrow). A 40mm long and 6mm wide (at maximum inflation ) stricture dilatation balloon was positioned across the site (D: Black arrow) and dilated successively above, at and below the site of stricture (E1, E2 & E3: White arrows show the inflated balloon above the stricture site, at the stricture site and below the stricture site, respectively). No stent was passed this time and the patient will be followed up in our outpatient clinic.

Third follow up ERCP for post transplant anastomotic biliary stricture (CASE K)

This 22 year old lady had undergone her second ERCP for an anastomotic biliary stricture less than month earlier http://ercp365.blogspot.com/2015/09/second-follow-up-ercp-for-post-liver.html when we had placed a 7 French 12 cm plastic biliary stent. She had developed cholangitis and pruritus soon after and her ultrasound did not show any pneumobilia. We suspected the sludge ball proximal to the previously deployed stent to be the culprit (Refer to images in the link above). We removed her blocked stent (A). Contrast injection again highlighted the narrowed anastomotic segment (B: Black arrow). A stent assembly was then manoeuvred across this site (C: Black arrow) and a wider 10 French plastic stent of 12 cm length was deployed (D1 & D2: Black arrows).

Second follow up ERCP for post liver transplant anastomotic biliary stricture (Case L)

This 45 year old gentleman was undergoing ERCP for the second time. Earlier  a 7 French 12 cm had been placed in May of this year. He then developed pruritus and a rising alkaline phosphatase. His bilirubin levels remained normal. We removed the previously placed stent which was blocked. Contrast injection showed the strictured segment involving the posterior ductal branch of the graft and native bile duct (A: White arrow). This segment was dilated with a 6mm diameter balloon of 40 mm length. A thicker, 10 French stent of 12 cm length was placed (C: Black arrows).

Second follow up ERCP for post liver transplant anastomotic biliary stricture (Case K)

This 22 year old lady had undergone living donor liver transplant at our centre for hepatitis B related liver disease. She developed an anastomotic stricture shortly after her surgery and underwent an ERCP in April of this year (A 7 French stent of 15 cm length was initially placed after dilatation of stricture with graduated dilatation catheters but she developed GI bleeding the same day. On endoscopy done the next day, the distal end of the stent was seen to erode the opposite duodenal wall and cause ulceration. This was removed and a shorter stent of the same diameter but shorter 12 cm length was placed). Now, she had developed pruritus and fever. Her stent was removed (A). The next image shows her MRCP which was done prior to her first ERCP (B: White arrow shows the anastomotic stricture site and red arrow shows a collection next to the biliary tree). Contrast injection after stent removal showed the narrowed stricture area (C: Black arrow) and what appears to be a sludge ball above the stricture (C: White arrow). A stricture dilatation balloon of 40 mm length and 6 mm diameter was used to dilate the stricture ( D: Black arrow). A stent assembly was placed across the affected area (E: Black arrow) and a 7 French plastic stent of 12 cm length was deployed (F: Black arrows).

Second ERCP for post liver transplant anastomotic biliary structure (Case G)

This 65 year old gentleman last underwent ERCP for his biliary stricture three months earlier http://ercp365.blogspot.co.uk/2015/04/post-liver-transplant-anastomotic_76.html. We had placed a 10 French plastic stent of 12 cm length at that time. He now presented with pruritis, mildly raised bilirubin and markedly raised ALP levels. An ultrasound showed no pneumobilia and prominence of intrahepatic biliary channels. We pulled the old stent (A: White arrow & B) with a snare (A: Black arrow). Contrast injection outlined the stricture site (C: Black arrow). We dilated the track with a graduated dilatation catheter, size 7.5F  to 10 French (D: Black arrow shows the dilation catheter crossing the stricture site) and placed a 12 cm long stent of 10 French size (E:Black arrows), same as last time .

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.

Post liver transplant anastomotic biliary stricture (CASE H)

This 42 year old gentleman had undergone a non related living donor liver transplant at a foreign centre one year ago (March 2014). For the past 6 weeks he had been complaining of pruritus and clay coloured stools. Liver biochemistry revealed rising ALP and bilirubin levels. His MRCP showed a subtle anastomotic stricture (A: red arrow) and prominent intrahepatic biliary channels (A: blue arrows). Contrast injection on ERCP showed the stricture (B: red arrow0 but the guidewire kept going into a sharp bend (B: white arrow) and kept curling up on itself (C: white arrow). We were finally able to get our guidewire across (D: black arrows) whilst avoiding the bend. Our papillotome was then pushed up along a mightily curved path (E: black arrow). The track was first dilated using a 7 French graduated dilatation catheter (F1: black arrows show the catheter while the red arrow indicates the level of stricture). This was followed by a larger 8.5-10 French catheter (F2 & F3: black arrows. Note: Star Wars fans will notice the uncanny resemblance of this catheter's "mouth" to Greedo's). A 7 French stent of 15 cm length was planned to be deployed. This went south as we weren't able to push the stent beyond even the first curve of the hairpin (G: white arrows show the failed stent deployment proximal to the stricture). No fear! We went again with aching muscles and did a repeat dilatation of the track with our  10 French "Greedo" catheter (H: black arrows show the catheter snaking up and red arrow marks the stricture site). A 7 French stent of 12 cm length was deployed. 

Note: This exercise highlights the difficulty while traversing a stricture using  smaller 7 French stent as these are deployed directly over the guidewire without the assembly. No assembly means less stiffness and strength which in turns translates to the stent bending before rather than pushing through an area of resistance.