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 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 .