Third follow-up ERCP for post transplant anastomotic biliary stricture

This 37 year old hospital nurse had undergone living donor liver transplant for Hepatitis C related liver disease. She had developed an anastomotic biliary stricture for which we had done two ERCPs previously, one in September http://ercp365.blogspot.com/2013/09/post-liver-transplant-anastomotic_10.html (single 12 French plastic stent passed) and second in December (Two 10 French plastic stents placed). The latest ultrasound suggested blocked stents. This was confirmed visually (A). Both the stents were removed with snare (B). Contrast injection showed the narrowing in the anastomotic site (C: white arrow). We decided to use a 3cm long, 10mm diameter TTS balloon rated at 90 psi (D) for stricturoplasty. The balloon was inflated in the stricture area (E1 to E3: white arrows). We then swept the CBD with a balloon to clear any sludge. An occlusion cholangiogram showed successful treatment of the stricture (F: white arrow). Although we were thinking pre procedure of placing three stents, the stricturoplasty results made us decide against it. No stents were placed and the patient will now be followed with serial bilirubin levels and ultrasound scans.

Post cholecystectomy CBD stricture

This 40 year old lady had presented with a stricture of the CBD at the level of the cystic duct following a cholecystectomy. We had passed a single plastic stent of 10F diameter two months ago. She currently had normal bilirubin levels. This was a follow up ERCP. We removed the previously placed stent with a snare. Dye injection showed a CBD stricture at the level of cystic duct (A: green arrow). We had planned to place two new 10F x 12 cm plastic stents. The first stent was placed across the stricture (B: green arrow). The guidewire was  then manoeuvred along the first stent (C: green arrow marks the guidewire red arrows mark the first stent). Unfortunately, the sheath on the tip of the guidewire broke off and couldn't be retrieved (D: red arrow). A new guidewire was then passed along the same route and the second stent was placed parallel to the first one ( E1 & E2: green arrows & F).