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).

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. 

Follow up case of post cholecystectomy biliary stricture

This 40 year old lady had been referred to our centre with a post cholecystectomy biliary stricture five months ago. A single 10 French plastic stent of 12 cm length was placed. She was then reviewed two months later (3 months ago) whereby the single stent was removed and two 10 French plastic stents were passed http://ercp365.blogspot.com/2013/09/post-cholecystectomy-cbd-stricture.html. At that time, the sheath of our guidewire had broken and left in the upper CBD. We had hoped to remove both stents and discharge the patient. On endoscopy, both stents were seen (A: white arrows). One stent was removed with a snare which also resulted in the removal of guidewire sheath left inside three months earlier (B: Red arrow indicates the piece of guidewire sheath. Blue arrow shows the second stent. D: white arrow indicates the piece of guidewire sheath in the intestinal lumen as seen on fluoroscopy. E: The broken sheath after retrieval with forceps). The second stent was also removed using the snare (C: blue arrow). Contrast injection after stent removal showed some persistence of the stricture (F: white arrow) which was dilated with a 10mm diameter TTS balloon (G: white arrow). We then passed a single 12cm long 10 French plastic stent (H: white arrows) and scheduled a repeat appointment after eight weeks.

Post cholecystectomy CBD stricture

This 40 year old lady had presented with a stricture of the CBD at the level of the cystic duct following a cholecystectomy. We had passed a single plastic stent of 10F diameter two months ago. She currently had normal bilirubin levels. This was a follow up ERCP. We removed the previously placed stent with a snare. Dye injection showed a CBD stricture at the level of cystic duct (A: green arrow). We had planned to place two new 10F x 12 cm plastic stents. The first stent was placed across the stricture (B: green arrow). The guidewire was  then manoeuvred along the first stent (C: green arrow marks the guidewire red arrows mark the first stent). Unfortunately, the sheath on the tip of the guidewire broke off and couldn't be retrieved (D: red arrow). A new guidewire was then passed along the same route and the second stent was placed parallel to the first one ( E1 & E2: green arrows & F).