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 .

Retrieving a retained stone post cholecystectomy

This 35 year old lady had undergone cholecystectomy at a private facility last month which was complicated by a biliary leak. She was reopened and a T-tube was  placed. A post procedure T-tube cholangiogram showed a calculus in the CBD (A: Red arrow). The T-tube was then removed and she was referred to our centre. An MRCP was done which confirmed the cholangiogram findings of a CBD stone (B: White arrow). Contrast injection on ERCP showed a vague negative shadow in the upper CBD (C: Blue arrow indicates the concerned area while white arrow shows an inflated biliary balloon at the distal CBD). Sphinchteroplasty was planned there wasn't margin for a full blooded sphincterotomy and a 12-15mm TTS balloon rated at 3-8 ATM (D) was used to dilate the ampulla (E: Black arrow shows the inflated balloon). The patient experienced pain despite high dose IV analgesics so we restricted ourselves to 12mm dilatation for 10 seconds (F: Black arrow shows the post sphincteroplasty ampulla). At this point we were skeptical as to whether the stone would be retrieved. Nevertheless a sweep was made and successful stone extraction was done (G1 & G2: Black arrows show the stone being retrieved). An occlusion cholangiogram with an inflated ballon at the ampulla (H: White arrow) showed a clear CBD. 

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Second ERCP for post transplant anastomotic biliary stricture (CASE J)

This 56 year old gentleman underwent a living related transplant for liver cirrhosis secondary to Hepatitis C around March 2014. He had his first ERCP in December 2014 (an earlier attempt in October 2014 had been unsuccessful). Contrast injection identified a sharp L-shaped angulation of the left hepatic duct, crossing in front of the right duct (A: white arrows). The right duct was seen behind it (A: black arrow). A 7 French stent of 12cm length was deployed in the left duct after dilating the track with a nominal 7 French graduated dilatation catheter. He again developed burning of the soles of his feet and pruritis along with rising ALP. We decided to remove his stent. On ERCP, it was seen to have migrated inside the CBD (B: Black arrows). We retrieved it using a biliary balloon inflated next to it (C: black arrows show the stent and white arrow marks the balloon adjacent to the stent. D: a single balloon sweep had resulted in some pullout and straightening of the proximal sharply bent portion of the stent-compare with C. E: white arrow shows the retrieved stent). Contrast injection post stent retrieval resulted in clear outlining of the right duct (F: black arrow) however the left L-shaped duct was only marginally outlined (F: white arrow). A balloon assembly was positioned in the right ductal system (G: black arrow) which was then inflated with full obliteration of the waist (H: black arrow). Next we manoeuvred our guidewire into the L-shaped left duct (I: black arrow). Pushing the papillotome over the wire and injection of contrast now outlined the left duct in its sharply bent form (J: black arrows. Compare with A). A 7 French double pigtail stent of 12 cm length was deployed (K: black arrows. Note the marked coil in the proximal portion of the stent. Not quite the desired result but we'll keep an eye on him nevertheless to see how it drains). A collection of contrast was also noted (K: red arrows). This was possibly a result of balloon dilatation of the right system. Admission with antibiotics and an eye on the temperature charts is on the menu.

First (actually second) ERCP for post liver transplant anastomotic biliary stricture (Case I)

This 25 year old gentleman had undergone a living donor liver transplant at out centre in July 2014 for Budd Chiari syndrome. He presented with jaundice and pruritus six months later in January this year. His MRCP films showed the level of stricture at the anastomotic site (A: red arrow). An attempt at ERCP a month ago was unsuccessful. However as our guidewire went multiple times into the pancreatic duct we placed a plastic stent in the pancreatic duct. A repeat attempt was now made (B: black arrow marks the papillotome and white arrow indicates the previously placed pancreatic stent). Initially we kept going into the pancreatic duct again (C: White arrows mark the guidewire and black arrow shows the stent in the pancreatic duct). We did a papillotomy to get more manoeuvring space for engaging the CBD (D: black arrow) and were rewarded with successful cannulation (E: White arrow shows our wire in the CBD). Contrast injection confirmed the MRCP findings with dilated intrahepatic ducts (F: black arrows) and a tight anastomotic stricture (F: white arrow). A 7 French plastic stent of 15 cm length was placed (G: black arrows). 

Post transplant anastomotic site leakage

Well a refreshing break from all the anastomotic strictures that we had been dealing with earlier!

This 52 year old gentleman had undergone live related transplant in February this year at our centre. He he recently developed right upper quadrant pain. He was a febrile. His labs showed raised ALP and GGT. The ultrasound detected a collection in the sub hepatic area and epigastrium. On MRCP a large collection was seen in at the anastomotic site confirming a leak (A: red arrow shows the leak and white arrow marks the anastomotic site). Contrast injection on ERCP initially showed a sharp cutoff at the site of anastomoses (B: black arrow). Further contrast injection and guide wire progression showed both the leak and the graft biliary channels. Our guide wire kept going into the leak site rather than the channels proximal to the leak (C: white arrow shows the guidewire going into the collection and red arrow indicates our desired guidewire path). Finally we were successful (we got one of our interventional radiologists to manipulate the guidewire rather than our regular assistant. He decided to use his own glide wire for the purpose. These IR guys can work miracles with a wire) and our wire went past the leak and into a graft biliary channel (D: blue arrow shows a significant link in the wire at the leakage site and black arrow shows it in the graft duct). Further manipulation of the wire improved the link (E &F: white arrows. The black arrow in F shows a now smooth wire track on which would ride our stent assembly). A 7 French stent of 12 cm length was deployed (G: black arrows show the stent and blue arrow indicated the level of leak, now properly bridged by the stent). 

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.