A blocked stent within a blocked stent

This 78 year old gentleman had undergone ERCP for a Klastkin tumor three months ago. The procedure was unsuccessful and he was then referred for a PTBS (percutaneous transhepatic biliary stenting) following which a self expanding metallic stent was placed. Two months later, his stent was blocked and he underwent an ERCP in which a double pigtail 10 French diameter stent of 10 cm length was placed within the metallic stent (A: white arrows show the extent of the metallic stent and black arrows indicate the curved ends of the plastic stent within it ). This plastic stent lasted for over a month before being blocked (B: white arrow marks the blocked metal stent and blue arrows indicate the curled distal end of the plastic stent). The plastic stent was retrieved with a snare (C). Contrast injection outlined the intraheptic channels and the guidewire was advanced beyond the stent (D: white arrow shows the extent of the metallic PTBS stent and black arrow shows the guidewire beyond its upper end ). On retrieval, the sheath of the guidewire tip was broken and left inside (E: black arrow). The next image shows a more clear outlining of the left ductal system (F: white arrows). The metal stent and biliary tree was flushed with saline and an 11 cm straight plastic stent of 10 French diameter was placed (G: white arrows show the metal stent and black arrows show the new plastic stent protruding at both ends. H: the new plastic stent within the metal stent as seen in the duodenum).

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 ERCP of a post liver transplant biliary stricture (CASE C)

This 54 year old gentleman had earlier undergone ERCP and stricture dilatation followed by plastic stent placement in December last year http://ercp365.blogspot.com/2013/12/post-liver-transplant-anastomotic.html. He had a 12 cm long 10 French plastic stent in situ. His bilirubin levels were rising and the ultrasound scan showed no pneumobilia. We found the stent to be blocked and removed it. A sweep of the bile duct with balloon extruded a large cast (A: white arrow). Following a clean sweep of the CBD (B), we placed a guidewire in the right anterior duct (C1 & C2: white arrow) and a second guidewire in one of the segment VIII ducts (C2: blue arrow). This was followed by TTS balloon dilatation with an 8mm diameter balloon of the segment VIII duct (D: white arrows) and of the site of anastomosis of anterior and segment VIII ducts with the main bile duct (E: white arrows). We then passed two plastic stents, both of 10 French diameter.  The shorter, 12 cm stent was placed in the right anterior duct (F: black arrows). The longer, 15 cm stent was placed in the one of the segment VIII branches (F: white arrows). 

Stage IV esophageal cancer with bronchoesophageal fistula

This 65 year old gentleman had been referred for palliative therapy for a stage IV esophageal cancer with a bronchoesophageal fistula communicating with the right main bronchus (CT chest.  A1: white arrow shows the extensive local invasion and white arrow in A2 shows the fistulous communication between esophagus and right bronchus). His barium studies didn't show any holdup of contrast but the irregular outline of the mucosa was evident (B1 & B2). On endoscopy, the lesion started at 23cm from incisors (C). The fistula opening was seen clearly (D: black arrow). The lesion continued till the  35cm mark (E) after which the lumen seemed disease free (F). Keep in in mid the 12cm long affected area, we decided to place a 14 cm long partially covered stent of 20mm diameter. This stent has a 1 cm uncovered segment at each end (G: Stent assembly partially deployed for demonstration - white arrow shows the sheath, black arrow shows the coated/covered segment of the stent and blue arrow shows the uncovered distal segment). After passing a guidewire, markers were stuck to the patient's body under fluoroscopic guidance to mark the extent of lesion (H: white arrows show the markers stuck on the patient's skin). The stent assembly was then placed in the correct position (I: white arrows) and deployed (J: white arrows show the lower end of stent being deployed and expanding. K: white arrows mark the fully deployed stent and black arrows indicate the skin markers). Repeat endoscopy after stent deployment showed that the upper end of the stent was barely above the upper margin of the tumor (L: white arrows). We decided to use a forceps to grasp the thread at the upper end to pull the stent slightly upward for a better clearer margin (M: white arrow). The stent was now in a better position to our satisfaction with a larger clear zone above the tumor (N: black arrows show the clear zone).

Diverticula Galore!

This 84 year old lady had been admitted with cholangitis. Her ultrasound scan indicated a dilated CBD with a distal stricture. Her CA 19-9 level was also normal. The MRCP film confirmed the ultrasound findings of a dilated CBD with a distal narrowing (A: white arrow). Starting our ERCP, we were greeted with a duodenum full of diverticulae. Fortunately, the papilla was not at the bottom of one of these (B: white arrows indicating two adjacent diverticulae, with food residue in the left one. Blue arrow indicating the papilla. Black arrow indicating the duodenal lumen). Thankfully it didn't take too long to cannulate the papilla (C). Contrast injection showed the same findings as the MRCP (D) and we suspect that the lower narrowing in the CBD could be attributed to the diverticulae. We passed a 10 French 7cm long plastic stent (E1 & E2: white arrows).

A balloon for every stone

This 50 year old lady had undergone cholecystectomy twenty years earlier. She had now been having recurrent bouts of right hypochondrial pain. An ultrasound scan showed a 12mm stone impacted in the distal CBD. We were greeted by a big fat papilla with the orifice at its lower end (A: white arrow). Multiple attempts to cannulate the CBD were unsuccessful. We decided to do a precut with a needle knife (B). It was a textbook precut and the CBD opening was nicely exposed (C: white arrow shows the CBD opening - somehow appearing suspiciously similar to the Superman insignia). Contrast injection showed two stones, one below the scope and another just above it (D: white arrows). The papillotomy was extended (E) , however the size was insufficient considering the size of the stones. Our next step was to do a sphincteroplasty using an 18mm diameter TTS balloon (F: white arrow shows the waist of the inflated balloon at the ampulla). Following this, two stones were successfully extracted (G1 & G2). A final cholangiogram with an inflated balloon just above the ampulla showed a duct clear of stones (H).