Chronic pancreatitis post abdominal trauma leading to pancreatic duct strictures

This patient was a 20 year old gentleman who had suffered blunt abdominal trauma during motorcycle accident. He developed a pancreatic abscess which was managed conservatively. Over the past one year he had repeated episodes of pancreatitis. His MRCP showed two pancreatic duct strictures at the junction of head and body and in the body (A: White arrows). The same were seen during contrast injection during ERCP (B: Black arrows). We did a pancreatic papillotomy (C: Black arrow), following which the pancreatic duct was dilated along its length using an 8mm x 30 mm biliary stricture dilatation balloon (D1 -D3: Black arrows). A stent assembly was then placed into the pancreatic duct (E: Black arrows). A 7 French plastic stent of 10 cm length was then placed (F: Black arrows).

Second ERCP for post liver transplant anastomotic biliary structure (Case G)

This 65 year old gentleman last underwent ERCP for his biliary stricture three months earlier http://ercp365.blogspot.co.uk/2015/04/post-liver-transplant-anastomotic_76.html. We had placed a 10 French plastic stent of 12 cm length at that time. He now presented with pruritis, mildly raised bilirubin and markedly raised ALP levels. An ultrasound showed no pneumobilia and prominence of intrahepatic biliary channels. We pulled the old stent (A: White arrow & B) with a snare (A: Black arrow). Contrast injection outlined the stricture site (C: Black arrow). We dilated the track with a graduated dilatation catheter, size 7.5F  to 10 French (D: Black arrow shows the dilation catheter crossing the stricture site) and placed a 12 cm long stent of 10 French size (E:Black arrows), same as last time .

Post liver transplant anastomotic biliary stricture (CASE H)

This 42 year old gentleman had undergone a non related living donor liver transplant at a foreign centre one year ago (March 2014). For the past 6 weeks he had been complaining of pruritus and clay coloured stools. Liver biochemistry revealed rising ALP and bilirubin levels. His MRCP showed a subtle anastomotic stricture (A: red arrow) and prominent intrahepatic biliary channels (A: blue arrows). Contrast injection on ERCP showed the stricture (B: red arrow0 but the guidewire kept going into a sharp bend (B: white arrow) and kept curling up on itself (C: white arrow). We were finally able to get our guidewire across (D: black arrows) whilst avoiding the bend. Our papillotome was then pushed up along a mightily curved path (E: black arrow). The track was first dilated using a 7 French graduated dilatation catheter (F1: black arrows show the catheter while the red arrow indicates the level of stricture). This was followed by a larger 8.5-10 French catheter (F2 & F3: black arrows. Note: Star Wars fans will notice the uncanny resemblance of this catheter's "mouth" to Greedo's). A 7 French stent of 15 cm length was planned to be deployed. This went south as we weren't able to push the stent beyond even the first curve of the hairpin (G: white arrows show the failed stent deployment proximal to the stricture). No fear! We went again with aching muscles and did a repeat dilatation of the track with our  10 French "Greedo" catheter (H: black arrows show the catheter snaking up and red arrow marks the stricture site). A 7 French stent of 12 cm length was deployed. 

Note: This exercise highlights the difficulty while traversing a stricture using  smaller 7 French stent as these are deployed directly over the guidewire without the assembly. No assembly means less stiffness and strength which in turns translates to the stent bending before rather than pushing through an area of resistance.

Post liver transplant anastomotic biliary stricture (CASE G)

This 65 year old gentleman had undergone living donor liver transplant two years ago. He had recently developed pruritus. His MRCP showed dilated intrahepatic biliary channels proximal to the strictured anastomotic site (A: red arrows show the dilated intrahepatic bile ducts and white arrows indicates the narrowed anastomotic segment). Due injection confirmed the MRCP findings (B: black arrow marks the stricture site). The stricture was dilated using a 7-8.5-10 French graduated dilatation catheter (C:black arrows show the catheter traversing the stricture). A stent assembly was then passed ahead. We had to do a bit of pulling and straightening (D1, D2 & D3: red arrows mark the stent assembly and the black arrow shows the kink that we had to "iron out". The white arrow in D3 shows the stent going up a straight assembly). A 10 French plastic stent of 12 cm length was deployed (E & F: white arrows show the deployed stent). 

 

Fifth ERCP for post transplant anastomotic biliary stricture (CASE A)

This gentleman had come after about four months after his last ERCP http://www.ercp365.blogspot.com/2015/02/fourth-follow-up-ercp-for-post-lover.html?m=1. We had placed a single plastic stent at that time. His labs showed a normal bilirubin but  constantly rising ALP and GGT. His ultrasound showed no pneumobilia with the proximal tip of the stent slightly distal to the anastomotic site. We removed his stent and manoeuvred the guidewire across the stricture (A: Black arrow shows the guidewire curling back across the site of the stricture. B: The wire finally across the strictured segment, indicated by the black arrow. Contrast injection shows dilated ducts in the implanted liver indicated by white arrows) . A pneumatic balloon rated to 8 atm/10 mm was used. It was placed across the stricture (D: black arrows show the balloon assembly and blue arrows show its proximal and distal radio opaque markers). The balloon was then inflated (E: black arrows mark the fully inflated balloon with an obliterated "waist"). Repeat contrast injection showed a fully dilated stricture (F: blue arrows). No stent was placed this time and the patient was discharged. We expect to see him in the OPD with a fresh ultrasound and LFTs in a few weeks. 

 

First ERCP for anastomotic biliary stricture following liver transplantation (CASE E)

This gentleman had recently undergone a live related liver transplant. His bilirubin levels started to rise along with his alkaline phosphatase. An anastomotic stricture was suspected and confirmed on MRCP (A: red arrow shows the strictured area along the left maim duct). A guidewire was passed into the left system (B: black arrows mark the guidewire in the left ductal system). A TTS stricture dilatation balloon was manoeuvred across the affected segment and inflated to 9mm (C: black arrows indicate the balloon in the stricture site. The balloon isn't clearly visible because we haven't mixed any contrast with the saline). Repeat contrast injection some improvement in ductal filling (D). We then placed a plastic stent of 10 French diameter and 12 cm length (E: black arrows mark the deployed stent). 

Fourth follow-up ERCP for post lover transplant anastomotic stricture (CASE A)

This 50 year old gentleman had come for his 4th follow up procedure after developing jaundice and recurrent fever. We removed his old plastic sent placed during his previous (3rd) ERCP http://ercp365.blogspot.com/2014/09/third-follow-up-ercp-for-post.html using a snare. Contrast injection outlined the anastomotic stricture (A: black arrow). We dilated the stricture using a TTS balloon inflated to 8mm (B: white arrows show the balloon assembly in place at the stricture site with the balloon inflated). A 10 French plastic stent of 12 cm length was placed. 

Fourth follow-up ERCP for post transplant biliary stricture (CASE B)

This 24 year old gentleman was undergoing his fourth ERCP this patient was undergoing for his anastomotic stricture. No stent was placed at his last visit http://ercp365.blogspot.com/2014/03/third-follow-up-ercp-for-post.html but this time around he was developing fever and slight rise in his bilirubin levels. His ampulla showed adequate outflow of bile (A: Black arrow). Initially our guidewire passed only up to just below the anastomotic site and contrast outlined a normal calibre lower CBD (B: Black arrows indicate the native bile duct). Finally our guidewire crossed the stricture site and the graft ducts were also outlined (C: White arrows show the stricture. Blue arrow shows the guidewire which isn't yet going straight up as we would like. Red arrow shows the dilated ducts in the graft). With repeated efforts we were able to get the wire go up in a direct line (D: Black arrows show the native bile duct, of normal calibre. White arrows show the structured anastomotic site. Blue arrow shows the tip of the guidewire). We dilated the stricture with a 10 French graduated dilatation catheter (E: White arrows mark the catheter). A stent assembly was then placed across the stricture and a 10 French plastic stent of 12 cm length ( F: White arrows show the stent assembly and black arrows indicate the stent passing over the assembly) was passed (G: Black arrows mark the deployed stent).