Managing a hilar stricture (or trying to, at least)

This 60 year old lady had a hilar cholangiocarcinoma. Significant intrahepatic biliary dilatation was evident on contrast injection (A: Red arrows show dilated intrahepatic ducts and black arrows show the affected narrowed hilar area). We placed one guidewire in the right system (B1: red arrows) and attempted to manoeuvre a second one into the left system (B1: black arrows and B2). This was unsuccessful and it kept going into the right system along with the previous wire. The strictured segment was dilated using an 8.5 French graduated dilatation catheter (C1 & C2: black arrows show the catheter  and red arrows show the second guidewire). The second guidewire was removed and a stent assembly was pushed into the right system (D: black arrows). A 10 French plastic stent of 10 cm length was placed (E: white arrows). The patent was started on antibiotics and she predictably developed fever. However it was short lived and we were able to discharge her home within the week. Retrospectively, what appear to be left sided channels in "A" may well have been right sided channels as well (appearing so due to the patient's position. These suspected left channels are also free of contrast in "C1", so we might not have injected the left system in the first place.

An extraordinarily large duodenal diverticulum

This 70 year old lady had a hilar cholangiocarcinoma. Going in, we were greeted by a cave of a diverticulum (A: blue arrows show the edges of the diverticulum and white arrow points to the duodenal fold with overlying papilla). Finding the papilla within the diverticulum and then cannulating (B: white arrow) it was extremely tricky and required a significant amount of wrist, elbow and torso movements. Contrast injection confirmed the tumor stricture at the area of confluence (C: white arrow. The red arrow points to the anomaly at the lower end of CBD, which was possibly due to the diverticulum). We passed a 10 French plastic stent of 12 cm length (D: white arrows. E: The ampulla "pulled" out of the diverticulum due to the lower end of stent resting on its edge).