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).

Second follow up ERCP for post liver transplant anastomotic biliary stricture (Case L)

This 45 year old gentleman was undergoing ERCP for the second time. Earlier  a 7 French 12 cm had been placed in May of this year. He then developed pruritus and a rising alkaline phosphatase. His bilirubin levels remained normal. We removed the previously placed stent which was blocked. Contrast injection showed the strictured segment involving the posterior ductal branch of the graft and native bile duct (A: White arrow). This segment was dilated with a 6mm diameter balloon of 40 mm length. A thicker, 10 French stent of 12 cm length was placed (C: Black arrows).

Second follow up ERCP for post liver transplant anastomotic biliary stricture (Case K)

This 22 year old lady had undergone living donor liver transplant at our centre for hepatitis B related liver disease. She developed an anastomotic stricture shortly after her surgery and underwent an ERCP in April of this year (A 7 French stent of 15 cm length was initially placed after dilatation of stricture with graduated dilatation catheters but she developed GI bleeding the same day. On endoscopy done the next day, the distal end of the stent was seen to erode the opposite duodenal wall and cause ulceration. This was removed and a shorter stent of the same diameter but shorter 12 cm length was placed). Now, she had developed pruritus and fever. Her stent was removed (A). The next image shows her MRCP which was done prior to her first ERCP (B: White arrow shows the anastomotic stricture site and red arrow shows a collection next to the biliary tree). Contrast injection after stent removal showed the narrowed stricture area (C: Black arrow) and what appears to be a sludge ball above the stricture (C: White arrow). A stricture dilatation balloon of 40 mm length and 6 mm diameter was used to dilate the stricture ( D: Black arrow). A stent assembly was placed across the affected area (E: Black arrow) and a 7 French plastic stent of 12 cm length was deployed (F: Black arrows).

Chronic pancreatitis post abdominal trauma leading to pancreatic duct strictures

This patient was a 20 year old gentleman who had suffered blunt abdominal trauma during motorcycle accident. He developed a pancreatic abscess which was managed conservatively. Over the past one year he had repeated episodes of pancreatitis. His MRCP showed two pancreatic duct strictures at the junction of head and body and in the body (A: White arrows). The same were seen during contrast injection during ERCP (B: Black arrows). We did a pancreatic papillotomy (C: Black arrow), following which the pancreatic duct was dilated along its length using an 8mm x 30 mm biliary stricture dilatation balloon (D1 -D3: Black arrows). A stent assembly was then placed into the pancreatic duct (E: Black arrows). A 7 French plastic stent of 10 cm length was then placed (F: Black arrows).

Second ERCP for post liver transplant anastomotic biliary structure (Case G)

This 65 year old gentleman last underwent ERCP for his biliary stricture three months earlier http://ercp365.blogspot.co.uk/2015/04/post-liver-transplant-anastomotic_76.html. We had placed a 10 French plastic stent of 12 cm length at that time. He now presented with pruritis, mildly raised bilirubin and markedly raised ALP levels. An ultrasound showed no pneumobilia and prominence of intrahepatic biliary channels. We pulled the old stent (A: White arrow & B) with a snare (A: Black arrow). Contrast injection outlined the stricture site (C: Black arrow). We dilated the track with a graduated dilatation catheter, size 7.5F  to 10 French (D: Black arrow shows the dilation catheter crossing the stricture site) and placed a 12 cm long stent of 10 French size (E:Black arrows), same as last time .

Retrieving a retained stone post cholecystectomy

This 35 year old lady had undergone cholecystectomy at a private facility last month which was complicated by a biliary leak. She was reopened and a T-tube was  placed. A post procedure T-tube cholangiogram showed a calculus in the CBD (A: Red arrow). The T-tube was then removed and she was referred to our centre. An MRCP was done which confirmed the cholangiogram findings of a CBD stone (B: White arrow). Contrast injection on ERCP showed a vague negative shadow in the upper CBD (C: Blue arrow indicates the concerned area while white arrow shows an inflated biliary balloon at the distal CBD). Sphinchteroplasty was planned there wasn't margin for a full blooded sphincterotomy and a 12-15mm TTS balloon rated at 3-8 ATM (D) was used to dilate the ampulla (E: Black arrow shows the inflated balloon). The patient experienced pain despite high dose IV analgesics so we restricted ourselves to 12mm dilatation for 10 seconds (F: Black arrow shows the post sphincteroplasty ampulla). At this point we were skeptical as to whether the stone would be retrieved. Nevertheless a sweep was made and successful stone extraction was done (G1 & G2: Black arrows show the stone being retrieved). An occlusion cholangiogram with an inflated ballon at the ampulla (H: White arrow) showed a clear CBD. 

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