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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Fifth follow up ERCP for post cholecystectomy biliary stricture.

This was this 40 year old lady's fifth ERCP. Somehow her stricture didn't seem to respond to conventional methods. This time around we removed the two stents that were placed in her last visit http://ercp365.blogspot.com/2014/02/fourth-follow-up-ercp-for-post.html (A). Contrast injection showed the strictured area (B: Red arrow) and dilated biliary channels proximal to the stricture (B: White arrow). A 10 French plastic stent of 12 cm length was placed first (C: White arrows), crossing the affected area (C: Red arrowhead). This was followed by a longer 15 cm plastic stent, also of 10 French diameter (D: Blue arrows. White arrows mark the first stent).

Follow up case of post cholecystectomy biliary leak

This 38 year old lady had previously undergone biliary stunting for a bile leak http://ercp365.blogspot.com/2013/12/and-another-bile-leak-following.html which had occurred following cholecystectomy. We had placed a 10 cm long 10 French plastic stent. We removed the stent (A). The sludge coating prompted us to do a biliary sweep with a stone extraction balloon (B: white arrow shows the papilla with a previous sphincterotomy and the balloon assembly being inserted). The CBD was swept (C: black arrows shows the inflated Ballon in the CBD). Gan occlusion cholangiogram with the balloon inflated at the distal end of the CBD was done (D: black arrow shows the inflated balloon. White arrows delineate the CBD with no leakage). The patient was discharged. 

Fourth follow up ERCP for a post cholecystectomy CBD stricture

This was the 4th ERCP this lady was undergoing. She had originally been referred for treatment of a post cholecystectomy CBD stricture. Her first ERCP was done in July ( just before I started this blog). She had undergone balloon stricturoplasty followed by plastic stent placement during her second (September) http://ercp365.blogspot.com/2013/09/post-cholecystectomy-cbd-stricture.html and third (December) http://ercp365.blogspot.com/2013/12/follow-up-case-of-post-cholecystectomy.html ERCPs. We removed her previous plastic stent and did a cholangiogram which showed persistence of the stricture (A: white arrow), albeit less than previously. We did a repeat balloon stricturoplasty using a 10mm x 30mm TTS balloon (B: white arrow). Repeat cholangiogram showed widening of the structured segment (C: white arrow). We decided to place two stents again (only one had been placed at her last ERCP). Two guidewires were placed across the selected segment (D: white & red arrows). This was followed by deployment of two plastic stents, each of 10 French diameter and 10cm length (E1 & E2: white & red arrows). She will be reassessed after eight weeks. 

Post cholecystectomy bile duct calculi in a 41 year old gentleman

This patient had undergone cholecystectomy three months earlier and was admitted with obstructive jaundice. Ultrasound showed a 4mm calculus into he distal CBD. ERCP outlined what appeared to be stones into he CBD (A:green arrow). After papillotomy, the CBD was swept with extraction balloon. Occlusion cholangiogram (with inflated balloon in the distal CBD and injection of contrast) showed a clear CBD (B).

Bile duct stones in a patient due to undergo cholecystectomy

Our second case of the day. Bile duct stones again. Green arrows show the stones as negative shadows in the cholangiogram (A). We did a papillotomy followed by stolen removal via extraction balloon (D: extracted stones on duodenal lumen). After removal, an occlusion cholangiogram was done with the balloon inflated at the distal end of CBD to show a bile duct clear of stones (C: green arrow). The patient had been sent from the surgical unit and will now undergo a cholecystectomy.