Stenting a metastatic ampullary tumor

A 52 year old gentleman with metastatic ampullary tumor. His CT scan showed a grossly dilated CBD (A: white arrow). Ampullary infiltration was evident on ERCP (B: white arrow). Contrast injection outlined a markedly dilated CBD (C: white arrow). A 10cm long plastic stent of 10 French diameter was deployed (D1, D2 & D3: white arrows).

Bike leak following laparosocpic cholecystectomy

This 54 year old gentleman had been referred to our unit with bile leak following a laparosocpic cholecystectomy. His MRCP showed the leak and collection (A: white arrow). Contrast injection on ERCP confirmed the MRCP report and the leakage was clearly seen (B1 & B2: white arrows). A 10cm long 10 French plastic stent was passed to bridge the leak (C: white arrows show the stent. Red arrow marks the leaked contrast).

Blockage of biliary stent placed for post transplant anastomotic stricture

This gentleman had undergone a living donor liver transplant approximately a month ago. A plastic biliary stent had been placed for an anastomotic stricture about three weeks after transplant. This was eight days ago. His total bilirubin level dropped from 15 mg/dL to 10.5 mg/dL in the 72 hours following stent placement. He then experienced fever along with rising bilirubin levels. We expected that the stent was blocked ( we had noted a significant amount of sludge along with bile flowing from the stent the first time we had placed it). Sure enough, we were met with a choked stent on ERCP (A1). We grabbed it with a snare (A2 & A3) and removed it (A4). We then generously flushed the bile duct with saline to wash out all debris (B1). A small papillotomy was also done to assist in drainage of the sludge (B2). Repeat contrast injection was done to check the status of the stricture. Sure enough, the stricture was present just behind the endoscope (C: white arrow). Since it had been only four weeks since the transplant, we avoided balloon dilatation of the strictured area (We had already "stretched" protocol by placing stent larger than 7 French diameter just three weeks after transplant in this patient. We had placed a 10 French stent and vendors that had been blocked). A similar 10 French plastic stent of 10 cm length was placed (D1 &  D2: white arrows). A gush of bile and sludge was seen (E). We're keeping our fingers crossed as there is a probability that this stent might become blocked as well over the next one to two weeks.

Wrestling with Klastkin

This 85 year old lady presented with obstructive jaundice secondary to a Klastkin tumor. These tumors represent some of our most time consuming cases. On contrast injection, a sharp cutoff was seen at the level of confluence (A: white arrow). We tried to negotiate it with a 0.035 inch guidewire but were unsuccessful. A thinner, 0.025 inch wore was able to cross it (B: white arrow). We then attempted to dilate the track with an 8.5 French dilatation catheter (C: white arrow). Despite significant twisting and turning on our part (some moves would make Christopher Walken proud), the catheter wouldn't go across. We opted for a thinner 7 French dilator which was successfully forced up to level of dilated intrahepatic ducts (D: white arrow). The plan was to dilate the track further using a 10 French TTS balloon (E: white arrow). This however couldn't pass fully beyond the upper end of the stricture and inflation caused to slip backwards repeatedly. Finally, with a thin track that just wouldn't allow anything fatter than 7 French and contrast ominously pooled in the upper system, we passed a 12 cm long plastic stent of 7 French diameter (F1:white arrows). The reward was a gush of our injected contrast (F2: white arrow).

Stone extraction impeded by infra-diverticular ampulla and narrow CBD

This 72 year old lady had been referred for a stone extraction. Our typical biliary stone patients are usually much younger females. Going in, we were greeted by an infra-diverticular ampulla (A: white arrow). The ampulla was at the edge of the diverticulum. Such ampullas are difficult to cannulate and have a tendency to keep sliding over the edge of the diverticulum. Once cannulation was achieved, contrast injection showed a large stone in a very prominent CHD (B: white arrow) and a prominent CBD (B: blue arrow) with a tapered lower end. The position of the ampulla restricted the extent of our papillotomy (C: white arrow). One can easily end with an intestinal perforation if too "courageous" with papillae that lie on the borders of diverticuli. Keeping in mind the size of the stone, the patient's age, the narrowed lower CBD and limited papillotomy, we decided to pass a plastic stent of 10 French diameter and 12 cm length (D: white arrows).

One for the Stonehenge: An unusually large CBD stone

This 35 year old lady was one of our staple cases: CBD clearance before undergoing cholecystectomy. The ultrasound report mentioned multiple CBD stones. Contrast injection on ERCP seemed to confirm the ultrasound report with a long line of negative shadows in the CBD (A: white arrow). Once we had done a papillotomy and proceeded to retrieve some of the stones with extraction balloon, we realized that we were dealing with one very large stone. It just kept coming and coming (B & C: white arrows. Blue arrow indicated the balloon). All that was left was a very wide open papilla (D: white arrow) and further balloon sweeps were clean. The calculus filled the duodenal lumen (E: white arrows). Reminds me of the menhirs from the quarry of a certain indomitable Gaul.

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.

Follow up case of post liver transplant biliary stricture (CASE B)

This 24 year old patient underwent a living donor liver transplant in June. He developed an anastomotic biliary stricture post surgery, as was evident on the MRCP (A: white arrow). We placed a 10 French plastic biliary stent of 12 cm length in early October (B: white arrows). A repeat follow up ERCP was now done in which the previous stent was removed. Repeat contrast injection showed two strictures, one at the anastomotic site and another higher up involving the right anterior duct (C: white arrows). It was decided to do a balloon stricturoplasty using a TTS balloon of 10mm diameter and 3 cm length. First the lower stricture was dilated (D1: white arrow indicating the balloon waist at the stricture. D2: Fully inflated balloon, with obliteration of waist). This was followed by similar dilatation of the right anterior duct stricture (E: white arrow). We passed two stents, both of 10 French diameter. The first was 12cm long, intended to traverse both the strictures (F1: white arrows). The second was 10cm long and reached just beyond the lower, anastomotic stricture (F2: white arrows).

Anastomotic biliary stricture developing 3 weeks after living donor liver transplantation

A 54 year old gentleman with liver cirrhosis secondary to Hepatitis C. He received a right lobe graft from his nephew. This stricture was noted three weeks post transplant. The stricture was evident ton cholangiogram during ERCP (A: white arrow). A 12cm plastic stent of 10 French diameter was placed (B &  C: white arrows). There was a lot of sludge coming out of the stent and we suspect that the stent may get blocked sooner rather than later.

Post liver transplant anastomotic biliary stricture (CASE C)

This 54 year old gentleman underwent a living donor liver transplant (his son was the donor) in January (10 months ago) at our centre. Early post transplant MRCP films showed narrowing at the anastomotic site but since his Labs were normal, we decided to monitor him. His latest MRCP, done a month ago, showed the stricture (A: white arrow) and that, along with rising bilirubin levels, prompted us TO intervene. Contrast injection on ERCP outlined the pancreatic duct (B: white arrow) and the strictured anastomotic site (C & D: white arrows). Three ducts, the right anterior, right posterior and segment VIII ducts had been anastomosed to the native duct. We were able to pass a guidewire, followed by a dilatation catheter in the right posterior duct (E: white arrow). We the dilated the right posterior and segment VIII anastomoses with a TTS wire guided balloon (F & G, respectively: white arrows). We ended the procedure with a 12 cm 10 French plastic stent placement in the right posterior duct (H: white arrows).

And another unresectable ampullary tumor

This 55 year old lady had a plastic stent placed for an unresectable ampullary tumor a month back. It had gotten blocked with debris and she had developed cholangitis. We decided to remove the plastic stent and place a metallic stent. A significantly dilated CBD was seen on ERCP (A: white arrow). A partially covered self expanding metallic stent (Wallstent. Boston Scientific) of 6 cm length and 10mm diameter was deployed (B & C: white arrows. D1 & D2 show the duodenal end of the deployed stent).