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). 

Long CBD stricture secondary to extrinsic compression

This 54 year old lady had a dilated gallbladder compressing the mid CBD upto the confluence (A: MRCP & B: CT scan ; Red arrows showing the dilated gallbladder. Blue arrows show the compression at the confluence and green arrows show dilated intrahepatic channels. C: CT scan; Red arrows marking the gallbladder). Contrast injection on ERCP outlined the narrowing in the CBD (D: black arrows) and dilated intrahepatic ducts. A stent assembly was placed across the affected segment (D). We passed a 15 cm plastic stent of 10 French diameter (E: white arrows show the stent loaded on its assembly. F: Black arrows show the stent passed across the structured segment and into the dilated intrahepatic channels)

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.

Second follow up ERCP for post transplant anastomotic biliary stricture (CASE D)

This 40 year old gentleman had undergone a living donor liver transplant in June 2013 at our centre. He had developed repeated episodes of fever and right hypochondrial pain along with rising bilirubin in December. He was diagnosed with an anastomotic biliary stricture (A: red arrow) . He then traveled abroad and underwent ERCP with placement of a plastic biliary stent of 7 French diameter and 12 cm length. Over the past two weeks, his bilirubin levels had increased and he had been having recurrence of his hypochondrial pain. We suspected a blocked stent. This was confirmed visually and the stent was removed (B1 & B2). Contrast injection outlined the stricture (C: red arrow). A 3cm TTS balloon of 10mm diameter was maneuvered to the stricture (D: black arrows) and inflated (E: white arrow shows the waist of the balloon during inflation). A 12 cm long 10 French plastic stent was placed (F: white arrows).

Managing pancreatitis with a blocked pancreatic duct and ascites

This 18 year girl had developed pancreatitis, most likely biliary in origin and followed by the development of ascites. She was in a a lot of pain and her MRCP showed a significantly dilated pancreatic duct (A: red arrows) with a stone or sludge collection near the terminal end (A: white arrow). The duct was also quite tortuous about a third of the way up (A: blue arrow). Her CT findings also showed the same with a dilated CBD of over 10mm diameter in its terminal portion (B1: black arrow) with an impacted stone/debris collection in its distal end (B2: black arrow). This ERCP was done under propofol sedation due to significant pain reported by the patient. CBD cannulation was quick and contrast injection confirmed the MRCP report with impacted terminal end debris (C: white arrow), dilated pancreatic duct (C: red arrows) and tortuosity (C: blue arrow). We did a pancreatic papillotomy (D1) and the constituency of the impacted material was evident as a white gooey material (D2: white arrow shows debris on the cutting element of papillotome). Further contrast was injected to online the tail region of the pancreatic duct and to rule out any leakage (E)-none was seen.   The papillotomy was extended and further debris was extruded by the extended papillotome (F: white arrow). The pancreatic duct was then swept with balloon (G: white arrow shows the inflated balloon in the pancreatic duct). A large amount of this white gooey debris was removed with repeated balloon sweeps (H1 & H2). Final contrast injection showed a clear pancreatic duct. We decided not to place a stent keeping in mind the large papillotomy done. 

Uncommon biliary tree anatomy

This 54 year old lady had been referred for management of choledocholithiasis prior to undergoing a cholecystectomy. The ultrasound report suggested a single stone in the mid CBD. Initial contrast injection outlined the stone (A: white arrow). Things were about to get interesting, however as further contrast made the picture clearer. We could now see the stone (B: white arrow), the cystic duct (B: blue arrow) and what appeared to be a dividing line right in the middle of the CBD (B: red arrow). And even more contrast finally showed us what we were dealing with: double common bile duct with a common opening with the stone in the left stem (C: white arrow), right and left hepatic ducts draining separately into right and left bile ducts (C: yellow arrows), the cystic duct draining into the right bile duct (C: blue arrow). The arrowheads show black areas which are actually bile ducts viewed head on (C: red arrowhead shows the entrance of the cystic duct into the right bile duct). The stone was removed with an extraction balloon after sphincterotomy (D). The last diagram (E) shows the the modified classification of extrahepatic bile duct duplication as proposed by Choi et al.. Ours seems to be a Va type. The important thing here is the clear communication of this abnormal ductal anatomy to the surgeon who will be doing her cholecystectomy so as to prevent any inadvertent ductal injury and compromised drainage of any of the hepatic lobes.

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

This was a 24 year old gentleman who had undergone a live related liver transplant for Hepatitis B related liver cirrhosis in June 2013. His last ERCP was in December 2013 when 2 biliary plastic stents, both of 10 French diameter, one 10 and the other 12 cm long were placed after balloon stricturoplasty http://ercp365.blogspot.com/2013/12/follow-up-case-of-post-liver-transplant.html. He had now been developing episodes of fever and hypochondrial pain. An ERCP was scheduled and the said stents were seen to be blocked (A1) and removed with a snare (A2). Contrast injection showed the narrowing in the strictured area (B: white arrow). A guidewire (C: red arrow) and 10mm diameter TTS balloon assembly (C: white arrow) were passed across the strictured segment. The balloon was inflated with complete obliteration of waist (D &  E: white arrows). Repeat contrast injection showed significant improvement in the anastomotic stricture site (F: white arrows). This time we decided not to pass any stents. The case will be followed up serial LFTs and ultrasound.