Clearing the pancreatic duct

This 30 year old gentleman had developed biliary pancreatitis. He was treated at another facility a month ago where a papillotomy was done and his CBD was cleared of stones/sludge. A straight 10 French stent of 5 cm length was passed. The pancreatic duct could not be cleared at that time as duct access was unsuccessful. The patient was then referred to us. We were greeted with a post-papillotomy papillary with sign of the previous stent-it must have slipped keeping in mind the papillotomy (perhaps a pigtail stent shoulder been used). We were lucky in gaining rapid pancreatic duct access and congrats injection clearly showed two negative shadows (A: white arrows). The guidewire was then advanced further (B: red arrow) and a balloon assembly was then pushed over it (B: white arrow). The pancreatic duct was the swept with the balloon (C: white arrow shows the inflated balloon in the middle of the pancreatic duct). A lot of small white stones and sludge was removed by multiple balloon sweeps (D1 & D2: red arrows). An occlusion pancreaticogram with the balloon inflated at the distal end of the pancreatic duct (E: white arrow) showed a clear duct with no stones.
We then accessed the CBD (F: blue arrow shows the papillotome in the CBD. White arrow marks the opening of the pancreatic duct in the papilla). Contrast injection outlined a clear bile duct (G: red arrows show the bile duct. White arrows show the contrast in the pancreatic duct). The CBD was swept with balloon.

Techniques to pull an old friend out of trouble

This 34 year old lady had been referred to our centre two years ago with retained CBD stones and bike duct injury following cholecystectomy.  She had a T tube placed. Her old ERCP films showed small stones (A: white arrows) and the T tube (A: red arrows ). The T tube was removed and the CBD was swept with balloon (B:white arrow shows the inflated balloon in the CBD). We placed a 10 French plastic sent of 12 cm length (C: white arrows). She was sent back to her referring centre. We had hoped to see her again after 8 weeks to remove the stent but she was lost to follow up. Fast forward two years and she expectedly developed biliary pain,  jaundice and fever. She went back to her original hospital where a diagnosis of blocked stent and biliary stones was made and she was sent to us. We saw our old stent which had extruded quite a bit forward into he duodenum (D: red arrow) and we couldn't properly place a snare to grab it. Initially we tried to pull it out using an inflated balloon placed adjacent to it in the CBD (E: blue arrow shows the stent and white arrow indicates the balloon adjacent to it). Our next move was to use a large bipod forceps (F1) to grab the stent (F2) and slide it back in the papilla (F3). The stent was now easily grabbed with snare (G: white arrow) and pulled out (H). Repeat contrast injection in the CBD showed a lot of stones (I: black arrows). A papillotomy was done (J). The routine technique if sweeping the lower CBD to gauge adequacy of papillotomy resulted in a lot of sludge being removed (K1 &  K2). The CBD was the swept with balloon (L: black arrow shows the inflated balloon in the upper CBD) which resulted in a lot of stones (M) and sludge (N)  being removed. The final cholangiogram showed a CBD clear of stones (O: red arrows). 

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). 

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.