deja53
Networker
EXTENT OF EXAM: second portion of duodenum
Findings: EGD: Normal esophagus, stomach, duodenum. No stent
seen exiting the ampulla. EUS: Linear EUS performed via
esophagus, stomach, duodenum. There is a hyperechoic metal bile
duct stent with acoustic shadowing seen within the CBD. The
common hepatic duct proximal to the CBD stent is normal in
appearance without stones. No gallbladder seen. Homogeneous
pancreas without masses. PD is normal in course and caliber
measuring 1-2 mm in the body of the pancreas. Few 4-6 mm
well-defined, triangular lymph nodes which are mostly hypoechoic
with hyperechoic center. Normal left lobe of liver. Normal
peripancreatic vessels including celiac axis. Normal left
adrenal gland, left kidney spleen. ERCP: TJF scope was used.
Ampulla with signs of previous sphincterotomy but no stent seen
exiting the ampulla. Stent is also visualized on fluoroscopy
and had clearly migrated proximally into the bile duct.
Selective bile duct cannulation easily achieved using balloon
tipped catheter loaded with 0.025 in guidewire. Bile aspirated.
Balloon sweep performed using 11.5 mm balloon to try to move
metal bile duct stent more distally but the balloon removed
moderate amount of stone debris from the stent/bile duct without
moving the bile duct stent. Then, we dilated the ampulla/distal
bile duct using TTS CRE balloon to maximum of 10 mm to help
facilitate stent removal. Following dilation of distal bile
duct/ampulla, the dilation balloon was inflated within the metal
stent and this allowed the metal stent to be moved distally such
that the distal aspect of the stent was now visible outside the
ampulla. The dilation balloon was deflated and removed. Then,
the metal stent was grasped using rat tooth forceps and removed
from the mouth. The scope was reintroduced and selective bile
duct cannulation achieved again using balloon tipped catheter.
Multiple balloon sweeps performed using 8.5 and 11.5 mm balloons
with removal of small amount of stone debris. Occlusion
cholangiogram showed CBD measuring 7-8 mm without any evidence
of leak, stricture or filling defect. Contrast drained very
well. Multiple balloon sweeps performed to clear any residual
contrast. Excellent drainage of bile and contract at the end of
the case. Pancreatic duct intentionally not cannulated and
pancreatogram intentionally not performed. I personally
interpeted all fluoroscopic imaging of bile duct as described
above.
Endoscopic Diagnosis: 1) Proximally migrated fully covered
metal bile duct stent (seen on EUS). 2) ERCP with bile
duct/ampulla balloon dilation, stone debris removal, metal bile
duct stent removal. Cholangiogram shows no further bile duct
stricture, leak or bile duct stones.
Findings: EGD: Normal esophagus, stomach, duodenum. No stent
seen exiting the ampulla. EUS: Linear EUS performed via
esophagus, stomach, duodenum. There is a hyperechoic metal bile
duct stent with acoustic shadowing seen within the CBD. The
common hepatic duct proximal to the CBD stent is normal in
appearance without stones. No gallbladder seen. Homogeneous
pancreas without masses. PD is normal in course and caliber
measuring 1-2 mm in the body of the pancreas. Few 4-6 mm
well-defined, triangular lymph nodes which are mostly hypoechoic
with hyperechoic center. Normal left lobe of liver. Normal
peripancreatic vessels including celiac axis. Normal left
adrenal gland, left kidney spleen. ERCP: TJF scope was used.
Ampulla with signs of previous sphincterotomy but no stent seen
exiting the ampulla. Stent is also visualized on fluoroscopy
and had clearly migrated proximally into the bile duct.
Selective bile duct cannulation easily achieved using balloon
tipped catheter loaded with 0.025 in guidewire. Bile aspirated.
Balloon sweep performed using 11.5 mm balloon to try to move
metal bile duct stent more distally but the balloon removed
moderate amount of stone debris from the stent/bile duct without
moving the bile duct stent. Then, we dilated the ampulla/distal
bile duct using TTS CRE balloon to maximum of 10 mm to help
facilitate stent removal. Following dilation of distal bile
duct/ampulla, the dilation balloon was inflated within the metal
stent and this allowed the metal stent to be moved distally such
that the distal aspect of the stent was now visible outside the
ampulla. The dilation balloon was deflated and removed. Then,
the metal stent was grasped using rat tooth forceps and removed
from the mouth. The scope was reintroduced and selective bile
duct cannulation achieved again using balloon tipped catheter.
Multiple balloon sweeps performed using 8.5 and 11.5 mm balloons
with removal of small amount of stone debris. Occlusion
cholangiogram showed CBD measuring 7-8 mm without any evidence
of leak, stricture or filling defect. Contrast drained very
well. Multiple balloon sweeps performed to clear any residual
contrast. Excellent drainage of bile and contract at the end of
the case. Pancreatic duct intentionally not cannulated and
pancreatogram intentionally not performed. I personally
interpeted all fluoroscopic imaging of bile duct as described
above.
Endoscopic Diagnosis: 1) Proximally migrated fully covered
metal bile duct stent (seen on EUS). 2) ERCP with bile
duct/ampulla balloon dilation, stone debris removal, metal bile
duct stent removal. Cholangiogram shows no further bile duct
stricture, leak or bile duct stones.