This 55 year old man was referred for ERCP following laparoscopic cholecystectomy which suggested the possibility of retained common bile duct stones. Because of his size, fluoroscopy could not be used. The ampulla was identified at the base of a diverticulum and was cannulated using a glidewire-papillotome combination. On withdrawal of the glidewire, bile was seen within the lumen of the papillotome, confirming correct diagnosis. A papillotomy was performed. And the DACP scope was advanced into the biliary system without guide wire assistance. Evaluation of the cystic duct revealed no evidence of retained stones in that region. The DACP scope was then repositioned. An examination of the bifurcation was performed. Note the presence of bile in the biliary radicals. The procedure was well tolerated, and the patient was discharged home the following day.
Brenna C. Bounds, M.D., Harvard Medical School, Massachusetts General Hospital