Second (actually 3rd) ERCP for post transplant biliary leak

This 60 year old gentleman had earlier undergone ERCP and stenting for an anastomotic biliary leakage a few months earlier http://ercp365.blogspot.com/2015/09/first-ercp-for-post-transplant.html?m=1. A 7 French 12 cm plastic stent was placed across the site of leakage and later removed. His bilirubin levels had showed a mild rise over the past few months and ultrasound showed a small collection in the subhepatic space (indicating a persistent leak). We decided to intervene. Initially our guidewire couldn't cross the site of leak and contrast showed a sharp cutoff. We switched from an 0.035 inch to an 0.025 inch wire and were successful in crossing the structure site (A: black arrow). Further contrast injection showed leakage (B: Red arrow) and outlined the proximal bile ducts (B: White arrow indicates he proximal ducts and black arrow shows the site of ductal anastomosis/narrowing/leakage ). Since our papillotome had to be forced across the leak site, we decided to dilate it with dilatation catheters (C1 & C2: Dialatation being done with 5-6-7 French and 8-9-10 French graduated catheters, respectively ). A stent assembly was then passed into one of the proximal ducts (D: Black arrow) and a 10 French plastic stent of 12 cm length was passed (E: Black arrows). 

First ERCP for post liver transplant anastomotic biliary stricture (CASE N)

This 54 year old gentleman had recently undergone living donor liver transplant at our centre. He had presented with fever, chills, pruritus and a raised ALP level. His MRCP showed a short stricture at the anastomotic site (A: white arrow). We were greeted with a bulging ampulla on ERCP (B). Contrast injection highlighted the stricture ( C & D: white arrow). We dilated the track with a 7 French graduated dilatation catheter (D: black arrow) followed by placement of a 7 French plastic stent of 12 cm length (E:black arrows. White arrow shows the upper end of the stent assembly). This was rewarded with a gush (F: white arrow) of white (hence infected) bile.

Duodenal stenting following PTBS for periampullary tumor with gastric outlet obstruction

This 74 year old lady had previously undergone percutaneous transhepatic biliary stenting (PTBS) due to a metastatic periampullary tumor which had also infiltrated into the duodenum (A3 & B: white arrows) causing gastric outlet obstruction (don't forget to check for a succession splash in any patient with jaundice, kids). Once the biliary drainage had been taken care of, we moved to free the route out the stomach. The pyloric opening was narrowed and we dilated it using a TTS balloon (A1 &A2). Following this, we advanced our duodenal stent assembly across the bulb and descending duodenum (B & C1 : black arrows). The stent (20mm x 130mm) was then carefully unsheathed (C1 to C5: white arrows show the stent being deployed. Red arrows shows the "waist" forming right about the middle of the stent at the site of maximal luminal infiltration by the tumor).

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).

First ERCP for post transplant anastomotic stricture (CASE M)

This 60 year old gentleman had undergone live related liver transplant a couple of months ago. He had developed anastomotic stricture along with a large collection that was also contributing to obstruction by extrinsic compression upon the biliary confluence and proximal CBD (A: MRCP images. White arrows show the dilated intrahepatic biliary channels and red arrow shows the collection in the sub-hepatic space). A drain was placed to treat the collection. We initially attempted an ERCP but getting across the stricture was unsuccessful due to the combined effect of a tight stricture and extrinsic compression. Since the patient was showing signs of cholangitis, quick drainage was mandatory. We asked the interventional radiologist to place a percutaneous transhepatic biliary drainage (PTBD) catheter over a guidewire. We would then utilise the guidewire to do a railroad endoscopic biliary stenting. On ERCP, the guidewire was grabbed with a snare and the wire was pulled through the channel of the scope. Contrast injection outlined the biliary tree and stricture (B: White arrow shows the PTBD catheter. Red arrow shows the abdominal catheter used to drain the collection also seen in A. Blue arrow shows the guidewire which has now been pulled into the scope. Black arrow shows the dilated intrahepatic duct in the graft). A stent assembly was then placed over the guidewire (C: Black arrows). A 7 French diameter stent of 12 cm length was then deployed (D1 & D2: Black arrows mark the deployed stent. Blue are shows the PTBD catheter. Red arrow marks the abdominal drain in the subhepatic space. White arrow shows the injected contrast which has decreased in size after stent placement-compare D1 with D2).