A tricky ampullary tumor at the edge of a diverticulum

This 80 year old lady had a metastatic ampullary tumor. We were greeted by an infiltrated ampulla (A: green arrow) lying at the edge of a diverticulum (A: white arrow). This made cannulation extremely tricky. Repeated attempts were rewarded with success. Cannulation showed a significantly dilated CBD (B: white arrow) with distal narrowing (B: red arrow). A stent assembly was placed (C: white arrow) followed by deployment of a 7 cm long self expanding metallic stent (Micro-Tech Nanjing) of 10mm diameter (D: white arrows. E: white arrow shows the distal end of the stent in the duodenum. 

And another bile leak following cholecystectomy

This 38 year old lady had the same problem as the previous case: A cholecystectomy gone wrong. Her MRCP showed a small leak (A: white arrow. Green arrow shows the pancreatic duct). On ERCP, the same leak was outlined on contrast injection (B and C: white arrows).   A 10 cm long plastic stent of 10 French diameter was placed (D: white arrows).

Stenting a biliary leak

A 35 year old lady had been referred to our center after a bile duct injury during cholecystectomy. A drain and been placed in the sub hepatic space. On ERCP, the placed drainage tube (A: blue arrow) was seen just below the level of confluence (A: yellow arrow). The negative shadows seen in the image are actually air bubbles (A: green arrow). Interestingly, the contrast injected didn't show any leakage per se and went straight into the drainage tube instead. We concluded that the tube must be abutting the biliary tree. A 12 cm 10 French plastic stent was placed to bridge the site of leakage (B: blue arrows).

Metastatic ampullary carcinoma

A 55 year old lady had presented with metastatic ampullary tumor causing obstructive jaundice. Endoscopy showed an infiltrated ampulla with a visible bile duct opening (A: white arrow). Ampullary tumors are usually soft and friable and hence offer little hindrance to cannulation. Contrast injection outlined a grossly dilated bile duct (B: white arrows) with a  distal stricture. A 10cm long 10 French plastic stent was placed (C1 & C2: white arrows).

Follow up case of post transplant anastomotic stricture

This patient underwent an ERCP and plastic stent placement following development of an anastomotic stricture after living donor liver transplant. The first ERCP was done three months ago ( two months after transplant) and showed a stricture at the site of anastomosis (A: white arrow). It was dilated with a 7 French dilatation catheter (B: white arrow) followed by a stenting with a 10cm long 10 French plastic stent (C: white arrows). We reviewed the patient again and decided to remove the previously placed stent and see the status of the stricture with a cholangiogram. The old stent was visualized on ERCP (D: white arrows) which was removed. Repeat contrast injection showed narrowing at the anastomostic site (E & F: white arrows). The strictured area was dilated with 8mm x 3cm TTS balloon (G & H: white arrows). Contrast injection now showed successful stricturoplasty (I: white arrows). A 10 French 10cm plastic stent was placed across the anastomotic site (J: white arrows). A second stent assembly was then placed parallel to the first one (K: blue arrow) after which a second 10 French plastic stent of 10cm length was placed (L: white arrows show the two stents placed in parallel). 

Multiple biliary strictures in a patient with lymphoproliferative disorder

This 38 year old patient had extensive abdominal lymphadenopathy with obstructive jaundice. The oncologist had referred him to our institution for biliary stenting. Contrast injection on ERCP showed a dilated biliary tree (A & B: red arrows) with strictures seen in the distal CBD and below the confluence (A & B: blue arrows). A 10cm long 10 French plastic stent was placed (C: blue arrows).

Self expanding metallic stent placement in a case of cholangiocarcinoma

A 56 year old lady with cholangiocarcinoma deemed inoperable due to metastases. The ampulla was inferior to a diverticulum (A: white arrow shows the diverticulum and green arrow shows the ampulla). Cannulation and contrast injection showed a mid CBD stricture (B: blue arrow). A guidewire was placed across the stricture followed by stent assembly (C: blue arrows). A 10cm long metallic stent of 10mm diameter was placed (D1: blue arrows show the stent on fluoroscopy. D2: blue arrow shows the stent deployed at the ampulla)