No one gets left behind-Retained bile duct stone post cholecystectomy

This 32 year old lady had undergone open cholecystectomy at a peripheral centre. Unfortunately, CBD clearance was incomplete and she was referred to us with a large calculus in the left main duct. She was accompanied by a T-tube cholangiogram (A: Red arrow shows the stone and white arrows shows the T-tube). Before going in, we did a repeat cholangiogram via the T-tube and it showed the stone had migrated to the distal CBD (B: Red arrow shows the meniscus sign, indicating the stone). The T-tube was removed and contrast injection following wire cannulation of the CBD showed that the stone had become lodged in a "recess" of sorts (C: Red arrow), made when the CBD was kinked by the pull of the T-tube. Seeing the considerable size of the stone, we decided to do as wide  a papillotomy as possible (D: White arrow). First weapon of choice was our trusty biliary balloon (E: Black arrow shows the inflated balloon proximal to the stone. Red arrow shows the stone itself. White arrow indicates the marked kink that had developed in the CBD once the T-tube was pulled out). The balloon kept slipping by the side of the stone. Next up was the dormia basket (F: White arrow). The basket was manoeuvred past the stone (G1: Black arrows show the open basket and red arrow marks the stone). The "perp" was finally "apprehended (G2: White arrows show the basket and red arrow shows the captured stone). The stone was pulled out (H: Red arrow shows the stone and black arrows indicate the basket wire around it. I: The retrieved stone seen on a gauze-Homo Sapiens forelimb thumb for size comparison. Oversized glove is evident).

The brothers diverticulae

This 35 year old lady had been referred after a history of biliary type pain and an ultrasound which reported gallbladder sludge and a dilated CBD with a distal stricture. The MRCP report confirmed the ultrasound findings of CBD dilatation (A: red arrows) and a distal stricture (A: white arrow). Going in,  we were greeted with two diverticulae (B: red arrows) sitting on top of the papilla (B: white arrow). Contrast injection showed a picture similar to the MRCP of a dilated bile duct (C: red arrows) with distal narrowing (C: white arrow). We did a papillotomy which was limited by the close proximity of the lower edge of the diverticulae (D: red arrow). The CBD was swept with a biliary balloon (E: white arrow). The limited papillotomy necessitated a sphincteroplasty. We used a TTS balloon of 15-18mm expansion range (F1 & F2) and dilated the papilla to 15 mm (G1 & G2 showing the balloon expanding at the papilla) which was maintained for 30 seconds (G3: black arrows mark the balloon. Red arrow shows the waist forming at the papilla). The end result was a wide open papilla (H). 

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 CBD clearance after initial clearing of pancreatic duct

This 18 year old lady underwent ERCP with pancreatic duct clearance a few days ago http://www.ercp365.blogspot.com/2014/03/managing-pancreatitis-with-blocked.html
At that time we hadn't been able to access the CBD. Going in now, the swelling had greatly subsided and we were bale to identify the bile duct clearly (A: black arrow indicates the CBD and white arrow shows the wide open pancreatic duct ). The CBD was cannulated (B: black arrow) followed by contrast injection (C) which outlined a normal calibre CBD with no negative shadows. We decided to do a sphincterotomy (D: white arrow) and swept the CBD with biliary balloon (E: white arrow shows the balloon inflated in the CBD). As suspected, it was a clean sweep and no stones or sludge was extruded.

Tackling a large stone in an old lady

his 80 year old lady had presented with a common bile duct stone (bit unusual in her age group if our past experience was anything to go by). The ampulla was quite swollen (A :white arrow). Contrast injection showed a stone in the upper CBD (B: white arrow). We did a large papillotomy (C: white arrow), keeping in mind the size of the stone. The first attempt at stone extraction was made using a balloon which was maneuvered

across the stone (D: white arrow & E: white arrow shows the balloon inflated behind the stone, marked by the red arrow). The balloon kept slipping past the stone (F: white arrow shows the balloon which has slipped below the stone, marked by the red arrow). We went for the basket next (G: white arrow points to the open basket next to the stone, indicated by red arrow). This was successful and the stone was finally extracted (H1 & H2). Quite large and almost a perfect cylinder (I). Shotgun slugs, anyone?