DESCRIPTION OF PROCEDURE: The patient was placed in the supine position and was subsequently intubated by the anesthesiologist. Once this was completed, a side-viewing duodenoscope was advanced to the area of the papilla. The patient was noted to have a previous sphincterotomy. The papilla appeared normal. A short-nose traction sphincterotome was utilized for selective bile duct cannulation. Initially, superficial injection of the pancreatic duct appeared normal. No visualization of the pancreatic tail was made, as vigorous injection of contrast was not performed. Selective bile duct cannulation was then performed. This was performed using the sphincterotome. Initial contrast injection was made with the duodenoscope in the long position. This allowed good visualization of the area of the proximal common bile duct, where a mild stricture was identified on MRCP. Contrast injection revealed what appeared to be a stricture present around the area of previous surgery as noted by multiple clips. Additional contrast injection revealed partial filling of the right main hepatic duct. The patient was purposely kept in the supine position to allow better filling of the right main hepatic duct. Once this was identified, a small sphincterotomy extension was then performed after placement of a Jagwire. The Jagwire was purposely inserted across the right main hepatic duct for later access to that specific duct. No significant filling defects that were compatible with stones were identified. However, with sphincterotomy, some additional sludge was visualized. It was suspected that there may have been some retained contents somewhat more proximally. Therefore, a small basket was utilized and a number of sweeps were made across the common bile duct as well as across the right main hepatic duct. Some additional sludge was removed, though again no stones were identified or withdrawn. Following this, additional clearance of the patient's bile duct as well as the right main hepatic duct was performed using a 9 to 12 mm extraction balloon. The basket was exchanged over a guidewire and the balloon was passed over the guidewire into the bile duct. The balloon was able to traverse the proximal bile duct stricture at 9 mm. There was very mild resistance, although the balloon was able to traverse the affected region. Repeat balloon occlusion cholangiograms appeared to demonstrate effective opening of this area with just the balloon itself. Again, no filling defects were identified. There appeared to be a very short-segment within the right main hepatic duct that appeared mildly strictured. Decision was made to dilate this particular region rather than stenting across it due to the concern that the stent itself may occlude the left main hepatic duct. The extraction balloon was then removed and a cytology brush was passed over the guidewire. Common bile duct brushings were obtained for cytology. Following this, the brush was exchanged in favor of a dilating balloon. An 8 mm dilating balloon was utilized to dilate both the base of the right main hepatic duct, as well as the proximal common bile duct. Following dilation, confirmation of adequate opening was performed utilizing the extraction balloon and a balloon occlusion cholangiogram was again performed. There appeared to be adequate patency in the area of the right main hepatic duct as well as the proximal common bile duct. Following this, a biliary stent was placed up to the level of the bifurcation. Measurement on fluoroscopy estimated the length to traverse the affected area of the proximal common bile duct to about 8 cm. Stents that were manufactured and available for use included 7 cm stents, which were thought to be too short for this use as well as a 10 cm stent. Secondary to this, decision was made to stent the patient using a 10 French 10 cm stent. The stent was successfully placed and deployed. The end of the stent, however, appeared to travel a bit too proximally into the right main hepatic duct and therefore a small snare was utilized to pull the stent a bit more distally back into the area of the hepatic bifurcation. There was very good drainage that was observed. Air and fluid were then aspirated. The scope was withdrawn and the procedure terminated.
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