Third follow up ERCP for post transplant anastomotic stricture (CASE A)

We last saw this 50 year old gentleman two and a half months earlier when we dilated his anastomotic stricture with a 6mm balloon and placed a 10 French stent http://ercp365.blogspot.com/2014/09/second-follow-up-ercp-for-post-liver.html. His bilirubin levels had started to rise and we expected a blocked stent. His ultrasound confirmed this with no pneumobilia. We removed his previous stent using a snare (A: White arrows mark the wires of the snare around the stent. Blue arrow marks the stent. A guidewire was manoeuvred across the stricture (B: Black arrow shows the level of the stricture on the guidewire). Contrast injection again confirmed the narrowing (C: Black arrows show the narrowing at the anastomotic site). We decided to go for a bigger balloon this time and an 8mm diameter balloon was placed across the stricture (D: White arrows). The balloon was inflated (E: White arrows show the inflated balloon with a "waist" formation at the specific point of concern). Following dilatation, repeat contrast injection showed adequate dilatation (F: Black arrows now show no narrowing).  A stent assembly was then placed (G: White arrows). A 10 French plastic stent of 15 cm length was deployed.

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). 

Blockage of biliary stent placed for post transplant anastomotic stricture

This gentleman had undergone a living donor liver transplant approximately a month ago. A plastic biliary stent had been placed for an anastomotic stricture about three weeks after transplant. This was eight days ago. His total bilirubin level dropped from 15 mg/dL to 10.5 mg/dL in the 72 hours following stent placement. He then experienced fever along with rising bilirubin levels. We expected that the stent was blocked ( we had noted a significant amount of sludge along with bile flowing from the stent the first time we had placed it). Sure enough, we were met with a choked stent on ERCP (A1). We grabbed it with a snare (A2 & A3) and removed it (A4). We then generously flushed the bile duct with saline to wash out all debris (B1). A small papillotomy was also done to assist in drainage of the sludge (B2). Repeat contrast injection was done to check the status of the stricture. Sure enough, the stricture was present just behind the endoscope (C: white arrow). Since it had been only four weeks since the transplant, we avoided balloon dilatation of the strictured area (We had already "stretched" protocol by placing stent larger than 7 French diameter just three weeks after transplant in this patient. We had placed a 10 French stent and vendors that had been blocked). A similar 10 French plastic stent of 10 cm length was placed (D1 &  D2: white arrows). A gush of bile and sludge was seen (E). We're keeping our fingers crossed as there is a probability that this stent might become blocked as well over the next one to two weeks.

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).