PMC9035945_01
Pre-procedure ultrasound scan showing echogenic intraductal material.
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F1
An upper abdominal ultrasound scan revealed dilated intrahepatic bile ducts with intraductal echogenic material present in the intrahepatic ducts and the proximal main bile duct (Fig. 1).
Cholangiogram showing a dilated biliary tree with proximal main duct filling defects. The width of the proximal bile duct stones and the distal CBD are marked.
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F2
Although the proximal CBD appeared significantly more dilated, the distal CBD tapered and was less dilated at 12 mm in width (Fig. 2).
Extracted stone.
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F3
Following wire-guided biliary cannulation and biliary dilatation balloon sphincteroplasty up to 11 mm, balloon sweeps using a 12 mm extraction balloon catheter removed one stone (Fig. 3); removal of the second stone was more difficult, however, was achieved with backward traction on the extraction balloon catheter, and clockwise torque on the duodenoscope.
Stapfer type-1 duodenal perforation.
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F4
At this point, a large iatrogenic perforation of the infero-lateral duodenal wall was recognized, distal to the major papilla, likely as a result of the torquing scope maneuver (Fig. 4).
Perforation closed using OTSC.
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F5
The perforation defect was entirely suctioned into the cap of the delivery device, and the clip was successfully deployed (Fig. 5).
Fluoroscopy image post OTSC placement - no contrast leak demonstrated.
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F6
Subsequent on-table fluoroscopy did not demonstrate any extra-luminal contrast leak (Fig. 6).
Day-2 CT showing retroperitoneal collection (red arrow) inferior to the OTSC (yellow arrow).
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F7
A repeat abdominal CT scan demonstrated a 44 mm x 28 mm x 30 mm gas and fluid containing collection adjacent to the perforation site (Fig. 7).
CT at 4 months showing resolution of collection.
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F8
At 4 months, a repeat abdominal CT scan demonstrated that the collection had completely resolved, with the OTSC still in situ (Fig. 8).