Adenocarcinoma of gallbladder infiltrating into common hepatic duct and right hepatic lobe

A 50 year old lady who had developed jaundice a few weeks earlier. She was a diabetic and hypertensive and also had ischemic heart disease.
The CT scan showed a gallbladder mass infiltrating into the right hepatic lobe and common hepatic duct (A: green arrows & B: red arrows). Cannulation of the CBD was difficult and we kept going into the pancreatic duct. We decided to place a guidewire in the pancreatic duct and keep it there till the CBD was cannulated (C: green arrow). The image shows the papillotome engaging the ampulla with the pancreatic duct guidewire adjacent to it (D: green arrow). This technique helped and the CBD was cannulated (E: red arrow shows the guidewire in the CBD anf green arrow shows the first guidewire in the pancreatic duct). The cholangiogram showed involvement of the common hepatic duct and markedly dilated left ductal system with a poorly outlined right system (F: red arrows & G: green arrows). Only a few peripheral ducts of the right system were seen (G: green arrows). This was in accordance with the CT findings ( A & B). A self expanding metallic stent of 10mm diameter and 100mm length was placed (G: red arrows).