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).

Second follow up ERCP for post transplant anastomotic biliary stricture (CASE D)

This 40 year old gentleman had undergone a living donor liver transplant in June 2013 at our centre. He had developed repeated episodes of fever and right hypochondrial pain along with rising bilirubin in December. He was diagnosed with an anastomotic biliary stricture (A: red arrow) . He then traveled abroad and underwent ERCP with placement of a plastic biliary stent of 7 French diameter and 12 cm length. Over the past two weeks, his bilirubin levels had increased and he had been having recurrence of his hypochondrial pain. We suspected a blocked stent. This was confirmed visually and the stent was removed (B1 & B2). Contrast injection outlined the stricture (C: red arrow). A 3cm TTS balloon of 10mm diameter was maneuvered to the stricture (D: black arrows) and inflated (E: white arrow shows the waist of the balloon during inflation). A 12 cm long 10 French plastic stent was placed (F: white arrows).

Fourth follow up ERCP for a post cholecystectomy CBD stricture

This was the 4th ERCP this lady was undergoing. She had originally been referred for treatment of a post cholecystectomy CBD stricture. Her first ERCP was done in July ( just before I started this blog). She had undergone balloon stricturoplasty followed by plastic stent placement during her second (September) http://ercp365.blogspot.com/2013/09/post-cholecystectomy-cbd-stricture.html and third (December) http://ercp365.blogspot.com/2013/12/follow-up-case-of-post-cholecystectomy.html ERCPs. We removed her previous plastic stent and did a cholangiogram which showed persistence of the stricture (A: white arrow), albeit less than previously. We did a repeat balloon stricturoplasty using a 10mm x 30mm TTS balloon (B: white arrow). Repeat cholangiogram showed widening of the structured segment (C: white arrow). We decided to place two stents again (only one had been placed at her last ERCP). Two guidewires were placed across the selected segment (D: white & red arrows). This was followed by deployment of two plastic stents, each of 10 French diameter and 10cm length (E1 & E2: white & red arrows). She will be reassessed after eight weeks. 

A balloon for every stone

This 50 year old lady had undergone cholecystectomy twenty years earlier. She had now been having recurrent bouts of right hypochondrial pain. An ultrasound scan showed a 12mm stone impacted in the distal CBD. We were greeted by a big fat papilla with the orifice at its lower end (A: white arrow). Multiple attempts to cannulate the CBD were unsuccessful. We decided to do a precut with a needle knife (B). It was a textbook precut and the CBD opening was nicely exposed (C: white arrow shows the CBD opening - somehow appearing suspiciously similar to the Superman insignia). Contrast injection showed two stones, one below the scope and another just above it (D: white arrows). The papillotomy was extended (E) , however the size was insufficient considering the size of the stones. Our next step was to do a sphincteroplasty using an 18mm diameter TTS balloon (F: white arrow shows the waist of the inflated balloon at the ampulla). Following this, two stones were successfully extracted (G1 & G2). A final cholangiogram with an inflated balloon just above the ampulla showed a duct clear of stones (H).

Wrestling with Klastkin

This 85 year old lady presented with obstructive jaundice secondary to a Klastkin tumor. These tumors represent some of our most time consuming cases. On contrast injection, a sharp cutoff was seen at the level of confluence (A: white arrow). We tried to negotiate it with a 0.035 inch guidewire but were unsuccessful. A thinner, 0.025 inch wore was able to cross it (B: white arrow). We then attempted to dilate the track with an 8.5 French dilatation catheter (C: white arrow). Despite significant twisting and turning on our part (some moves would make Christopher Walken proud), the catheter wouldn't go across. We opted for a thinner 7 French dilator which was successfully forced up to level of dilated intrahepatic ducts (D: white arrow). The plan was to dilate the track further using a 10 French TTS balloon (E: white arrow). This however couldn't pass fully beyond the upper end of the stricture and inflation caused to slip backwards repeatedly. Finally, with a thin track that just wouldn't allow anything fatter than 7 French and contrast ominously pooled in the upper system, we passed a 12 cm long plastic stent of 7 French diameter (F1:white arrows). The reward was a gush of our injected contrast (F2: white arrow).

Follow up case of post cholecystectomy biliary stricture

This 40 year old lady had been referred to our centre with a post cholecystectomy biliary stricture five months ago. A single 10 French plastic stent of 12 cm length was placed. She was then reviewed two months later (3 months ago) whereby the single stent was removed and two 10 French plastic stents were passed http://ercp365.blogspot.com/2013/09/post-cholecystectomy-cbd-stricture.html. At that time, the sheath of our guidewire had broken and left in the upper CBD. We had hoped to remove both stents and discharge the patient. On endoscopy, both stents were seen (A: white arrows). One stent was removed with a snare which also resulted in the removal of guidewire sheath left inside three months earlier (B: Red arrow indicates the piece of guidewire sheath. Blue arrow shows the second stent. D: white arrow indicates the piece of guidewire sheath in the intestinal lumen as seen on fluoroscopy. E: The broken sheath after retrieval with forceps). The second stent was also removed using the snare (C: blue arrow). Contrast injection after stent removal showed some persistence of the stricture (F: white arrow) which was dilated with a 10mm diameter TTS balloon (G: white arrow). We then passed a single 12cm long 10 French plastic stent (H: white arrows) and scheduled a repeat appointment after eight weeks.

Follow up case of post liver transplant biliary stricture (CASE B)

This 24 year old patient underwent a living donor liver transplant in June. He developed an anastomotic biliary stricture post surgery, as was evident on the MRCP (A: white arrow). We placed a 10 French plastic biliary stent of 12 cm length in early October (B: white arrows). A repeat follow up ERCP was now done in which the previous stent was removed. Repeat contrast injection showed two strictures, one at the anastomotic site and another higher up involving the right anterior duct (C: white arrows). It was decided to do a balloon stricturoplasty using a TTS balloon of 10mm diameter and 3 cm length. First the lower stricture was dilated (D1: white arrow indicating the balloon waist at the stricture. D2: Fully inflated balloon, with obliteration of waist). This was followed by similar dilatation of the right anterior duct stricture (E: white arrow). We passed two stents, both of 10 French diameter. The first was 12cm long, intended to traverse both the strictures (F1: white arrows). The second was 10cm long and reached just beyond the lower, anastomotic stricture (F2: white arrows).