Retrieving a retained stone post cholecystectomy

This 35 year old lady had undergone cholecystectomy at a private facility last month which was complicated by a biliary leak. She was reopened and a T-tube was  placed. A post procedure T-tube cholangiogram showed a calculus in the CBD (A: Red arrow). The T-tube was then removed and she was referred to our centre. An MRCP was done which confirmed the cholangiogram findings of a CBD stone (B: White arrow). Contrast injection on ERCP showed a vague negative shadow in the upper CBD (C: Blue arrow indicates the concerned area while white arrow shows an inflated biliary balloon at the distal CBD). Sphinchteroplasty was planned there wasn't margin for a full blooded sphincterotomy and a 12-15mm TTS balloon rated at 3-8 ATM (D) was used to dilate the ampulla (E: Black arrow shows the inflated balloon). The patient experienced pain despite high dose IV analgesics so we restricted ourselves to 12mm dilatation for 10 seconds (F: Black arrow shows the post sphincteroplasty ampulla). At this point we were skeptical as to whether the stone would be retrieved. Nevertheless a sweep was made and successful stone extraction was done (G1 & G2: Black arrows show the stone being retrieved). An occlusion cholangiogram with an inflated ballon at the ampulla (H: White arrow) showed a clear CBD. 

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No one gets left behind-Retained bile duct stone post cholecystectomy

This 32 year old lady had undergone open cholecystectomy at a peripheral centre. Unfortunately, CBD clearance was incomplete and she was referred to us with a large calculus in the left main duct. She was accompanied by a T-tube cholangiogram (A: Red arrow shows the stone and white arrows shows the T-tube). Before going in, we did a repeat cholangiogram via the T-tube and it showed the stone had migrated to the distal CBD (B: Red arrow shows the meniscus sign, indicating the stone). The T-tube was removed and contrast injection following wire cannulation of the CBD showed that the stone had become lodged in a "recess" of sorts (C: Red arrow), made when the CBD was kinked by the pull of the T-tube. Seeing the considerable size of the stone, we decided to do as wide  a papillotomy as possible (D: White arrow). First weapon of choice was our trusty biliary balloon (E: Black arrow shows the inflated balloon proximal to the stone. Red arrow shows the stone itself. White arrow indicates the marked kink that had developed in the CBD once the T-tube was pulled out). The balloon kept slipping by the side of the stone. Next up was the dormia basket (F: White arrow). The basket was manoeuvred past the stone (G1: Black arrows show the open basket and red arrow marks the stone). The "perp" was finally "apprehended (G2: White arrows show the basket and red arrow shows the captured stone). The stone was pulled out (H: Red arrow shows the stone and black arrows indicate the basket wire around it. I: The retrieved stone seen on a gauze-Homo Sapiens forelimb thumb for size comparison. Oversized glove is evident).

Retained CBD stones post cholecystectomy

This lady was referred to us from another hospital. A T tube had been placed following cholecystectomy the post operative ultrasound and T tube cholangiogram suggested that there was a retained stone in the CBD. Contrast injection identified a negative shadow in the upper CBD (A: blue arrow. White arrow marks the T tube). We removed the T tube and performed a balloon sweep which resulted in not one but two stones (B1 & B2: white arrows. The second was a perfectly cut diamond!). An occlusion cholangiogram with contrast injection over a fully inflated balloon (C: white arrow) showed a clear CBD.