This 45 year old gentleman had suffered from bile duct injury whilst undergoing an open cholecystectomy 10 months ago. The surgeons placed a drain (A: red arrow shows the drain. White arrow shows the large leak-almost looking like the gallbladder in shape. Blue arrow shows the main bile duct). An MRI was done soon after and confirmed the leakage (B: red arrows show the bile leak). He was reffered to our facility and we had placed a 10 French 10cm long plastic stents to bridge the leak. (C: white arrows show the stent) . This was about ten months ago. He was then lost to follow up. He resurfaced at our outpatient out of curiosity asking what was to be done about the Stent we had placed. When questioned as to why he hadn't turned up a month after the procedure, he said he had been told by his physician that his condition has been cured and he needs no more treatment. The moment we went in for ERCP, we were greeted by a normal ampulla with no sign of his placed stent. We thought it had migrated inwards but that wasn't the case as it didn't show up on flouroscopy either. One thing we noted was almost absent bike flow from the ampulla and normal flow from another opening just above it (D: Blue arrow marks the ampulla and white arrow indicates the second opening above it with smeared bile). This second opening was obviously a fistula. Cannulation and contrast injection showed no bile leakage (E: white arrows show the bile duct. Even the fistulous track wasn't outlined). We concluded that the Stent had slipped out and his bole was driving through the fistula. The procedure was ended by a sphincterotomy which was extended to include the fistulous opening above the ampulla (F: white arrow).
