First ERCP for post liver transplant anastomotic biliary stricture (CASE N)

This 54 year old gentleman had recently undergone living donor liver transplant at our centre. He had presented with fever, chills, pruritus and a raised ALP level. His MRCP showed a short stricture at the anastomotic site (A: white arrow). We were greeted with a bulging ampulla on ERCP (B). Contrast injection highlighted the stricture ( C & D: white arrow). We dilated the track with a 7 French graduated dilatation catheter (D: black arrow) followed by placement of a 7 French plastic stent of 12 cm length (E:black arrows. White arrow shows the upper end of the stent assembly). This was rewarded with a gush (F: white arrow) of white (hence infected) bile.

Duodenal stenting following PTBS for periampullary tumor with gastric outlet obstruction

This 74 year old lady had previously undergone percutaneous transhepatic biliary stenting (PTBS) due to a metastatic periampullary tumor which had also infiltrated into the duodenum (A3 & B: white arrows) causing gastric outlet obstruction (don't forget to check for a succession splash in any patient with jaundice, kids). Once the biliary drainage had been taken care of, we moved to free the route out the stomach. The pyloric opening was narrowed and we dilated it using a TTS balloon (A1 &A2). Following this, we advanced our duodenal stent assembly across the bulb and descending duodenum (B & C1 : black arrows). The stent (20mm x 130mm) was then carefully unsheathed (C1 to C5: white arrows show the stent being deployed. Red arrows shows the "waist" forming right about the middle of the stent at the site of maximal luminal infiltration by the tumor).