A very large intrahepatic cholangiocarcinoma

This was a 30 year old gentleman who had presented with obstructive jaundice. His CT scan showed a very large mass of approximately 12x11cm occupying most of the left one (A: white arrows) with involvement of the porta hepatis and extensive intra-abdominal lymphadenopathy. On ERCP, contrast injection following placement of guidewire outlined a long stricture involving the region of ductal confluence (B: white arrows) with dilated  left sided ducts proximal to stricture (B: red arrows). Since the right system was not outlined, we left our first guidewire in the left system (C: white arrows) and attempted to pass a second guidewire in the right system (C: black arrows). This was unsuccessful. Luckily, no contrast had gone into the right system. We dilated the structured segment using a graduated 9 French dilatation catheter (D1 & D2: white arrows). A 12 cm long plastic stent of 10 French diameter was then deployed (E1 & E2: black 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).

Self expanding metallic stent placement in a case of cholangiocarcinoma

A 56 year old lady with cholangiocarcinoma deemed inoperable due to metastases. The ampulla was inferior to a diverticulum (A: white arrow shows the diverticulum and green arrow shows the ampulla). Cannulation and contrast injection showed a mid CBD stricture (B: blue arrow). A guidewire was placed across the stricture followed by stent assembly (C: blue arrows). A 10cm long metallic stent of 10mm diameter was placed (D1: blue arrows show the stent on fluoroscopy. D2: blue arrow shows the stent deployed at the ampulla)

Cholangiocarcinoma and cholangitis

A 50 year old lady had developed obstructive jaundice over the past few months and had been admitted with recent onset of fever. She was found to have a mass lesion near the area of confluence. She had no co-morbids. On ERCP, our guidewire couldn't initially go beyond the proximal CHD. The cholangiogram showed the CBD and CHD, along with the sharp cutoff at the proximal CHD (A: white arrow). The cystic duct was also outlined (A: green arrow). The guidewire was finally placed across the strictured part after a few attempts and contrast injection outlined the full biliary tree. The right and left ductal systems were dilated and a stricture was seen just below the confluence (B: white arrow. This would seem to be a Bismuth Type I lesion). After dilatation with a 9 French graduated dilator, we passed a 12 cm long plastic stent of 10 French diameter to drain the biliary system. She will continue to recieve antibiotics and will be placed in our weekly multidisciplinary meeting for review and eventual surgery.

Suspected blockage of metallic stent in a patient with cholangiocarcinoma

This 65 year old patient had two metallic stents placed over the past 18 months. The first was an uncovered stent, followed 8 months later by a partially covered stent placed within the first one. He had now presented with raised bilirubin. The ultrasound scan showed multiple hepatic lesions with query between abscesses and metastatic lesions. The stent seemed patent on direct viewing (A: green arrow). A guidewire was maneuvered across the stent (B: green arrows marking the guidewire and red arrows show the previously placed metallic stent) followed by contrast injection which outlined a patent stent and normal calibre intrahepatic biliary channels (C1 & C2: green arrows). We flushed the stents with saline which removed some debris (D: green arrows show the patent stent and full washout of contrast). Our conclusion was that the raised bilirubin, coupled with patent stents and normal calibre intrahepatic biliary ducts, was attributable to the liver metastatic lesions.

Cholangiocarcinoma below the confluence

This 48 year old gentleman had a cholangiocarcinoma just below the level of confluence. The MRCP showed abrupt cutoff of the common duct just below the hilum (A: green arrow). Contrast injection during ERCP confirmed the MRCP findings of stricture below the confluence, visible just above the endoscope (B: green arrow) and dilated intrahepatic ducts (B: red arrows). We passed a partially covered self expanding metallic stent of 10mm diameter and 80mm length (C: green arrows). The part of the stent crossing the strictured area was apparent (C: red arrow). The covered (D: green arrows) and uncovered (D: red arrows) portions of the stent were visible.