Retained CBD stones post cholecystectomy

This lady was referred to us from another hospital. A T tube had been placed following cholecystectomy the post operative ultrasound and T tube cholangiogram suggested that there was a retained stone in the CBD. Contrast injection identified a negative shadow in the upper CBD (A: blue arrow. White arrow marks the T tube). We removed the T tube and performed a balloon sweep which resulted in not one but two stones (B1 & B2: white arrows. The second was a perfectly cut diamond!). An occlusion cholangiogram with contrast injection over a fully inflated balloon (C: white arrow) showed a clear CBD.

An extraordinarily large duodenal diverticulum

This 70 year old lady had a hilar cholangiocarcinoma. Going in, we were greeted by a cave of a diverticulum (A: blue arrows show the edges of the diverticulum and white arrow points to the duodenal fold with overlying papilla). Finding the papilla within the diverticulum and then cannulating (B: white arrow) it was extremely tricky and required a significant amount of wrist, elbow and torso movements. Contrast injection confirmed the tumor stricture at the area of confluence (C: white arrow. The red arrow points to the anomaly at the lower end of CBD, which was possibly due to the diverticulum). We passed a 10 French plastic stent of 12 cm length (D: white arrows. E: The ampulla "pulled" out of the diverticulum due to the lower end of stent resting on its edge). 

Tackling a large stone in an old lady

his 80 year old lady had presented with a common bile duct stone (bit unusual in her age group if our past experience was anything to go by). The ampulla was quite swollen (A :white arrow). Contrast injection showed a stone in the upper CBD (B: white arrow). We did a large papillotomy (C: white arrow), keeping in mind the size of the stone. The first attempt at stone extraction was made using a balloon which was maneuvered

across the stone (D: white arrow & E: white arrow shows the balloon inflated behind the stone, marked by the red arrow). The balloon kept slipping past the stone (F: white arrow shows the balloon which has slipped below the stone, marked by the red arrow). We went for the basket next (G: white arrow points to the open basket next to the stone, indicated by red arrow). This was successful and the stone was finally extracted (H1 & H2). Quite large and almost a perfect cylinder (I). Shotgun slugs, anyone?

Gastric outlet obstruction secondary to duodenal ulcer induced stricture

This patient was a 65 year old lady who had developed duodenal luminal stenosis after healing of a large duodenal ulcer. On endoscopy, the duodenal lumen was reduced to a pinhole just beyond the bulb (A: white arrow). We were using an Olympus dual channel scope. We decided to use a straight ERCP cannula to try and go through the stricture (B) but even that couldn't go through. We were however able to get a guidewire across the stricture after engaging it with the cannula (C: white arrows). This was followed by dilatation of the strictured track with graduated dilatation catheters (D1, D2 & D3: white arrows). A stent assembly was then placed across the stricture (E: white arrows) and an uncovered self expanding metallic stent of 20mm diameter and 130mm length was deployed (F1 & F2: white arrows. Red arrows show the "waist" of the stent due to the strictured area. G1, G2 & G3: the stent going through expansion).

Bile duct injury and calculi post cholecystectomy

This 35 year old lady had undergone a laparosocpic cholecystectomy at another hospital three months ago. She had been re-admitted with an acute abdomen and the surgeons reported a rent in the CBD and placed a T-tube. She was then referred to us for CBD stenting. Her T-tube cholangiogram showed leakage of contrast (A: white arrow) and what appeared to be a stone (A: red arrow). Contrast injection on ERCP confirmed the cholangiogram findings and showed both the leak and the stone (B: white and red arrows respectively). Curiously, the T-tube was not outlined and we Suspected that it may have gotten dislodged. We did a wide papillotomy (C) and swept the CBD with a stone extraction balloon (D) which yielded a stone (E: white arrow). An occlusion cholangiogram an inflated balloon (F: white arrow) showed a clear CBD. We ended the procedure by placing a 12 cm long single pigtail stent of 10 French diameter (G: white arrows). Single pigtail stent being necessary to anchor the stent inside the CBD keeping in mind the wide papillotomy that had been done. 

Metastatic gallbladder cancer infiltrating into liver

This 85 year old gentleman had obstructive jaundice due to a locally infiltrative, metastatic gallbladder tumor. This case was difficult from the word go. We had to dilate the pharyngo-esophageal area with a 45 French dilator as the ERCP scope wouldn't go across. We saw extensive esophageal candidiasis. Maneuvering the scope across the pylorus was extremely difficult as well. However, once in, cannulation was achieved swiftly. Contrast injection showed a long stricture due to the tumor (A: white arrows). After placing a stent assembly across the strictured segment (B: white arrows), a self expanding metallic stent of 10mm diameter and 80mm length was deployed (C1 & C2: white arrows).

A very long biliary stricture secondary to cholangiocarcinoma

This 54 year old gentleman had obstructive jaundice due to a metastatic cholangiocarcinoma and was due to undergo placement of a self expanding metallic stent. Going in, we were welcomed by a worm at the junction of bulb and descending duodenum (A: white arrow). Contrast injection showed a sharp cutoff above the mid CBD (B: white arrow). The guidewire was placed across the strictured segment after some maneuvering and contrast injection showed the extent of the stricture (C: white arrows) and dilated intrahepatic ducts. The stent assembly was then positioned across the tumor area (D: white arrows). A 10 mm wide 10 cm long uncovered self expanding metallic stent was deployed (E: white arrows).