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case_images: (a) Large stones at the common bile duct (13 mm) and cystic duct (16 and 18 mm). (b) The posterior wall of the intrapancreatic bile duct was only partially surrounded by the pancreatic parenchyma.
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case_images: CT and magnetic resonance cholangiopancreatography showed a distal bile duct diameter of 16 mm, and the dorsal portion of the intrapancreatic bile duct was only partially surrounded by the pancreatic parenchyma (Figure 1).
case_images: (a) Endoscopic retrograde cholangiopancreatography demonstrated a stone above a tapered distal duct. (b) Beginning of dilation with the balloon waist. (c) Full dilation was performed up to 18 mm.
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case_images: Thereafter, we continued dilating the balloon and observed the disappearance of the balloon waist at maximal pressure (8 atm, 18 mm), and the balloon deflated immediately (Figure 2).
case_images: (a) Endoscopic view after endoscopic papillary large balloon dilatation showed injuries to the bile duct and hepatoduodenal mesentery from the posterior wall of the bile duct. (b, c) Computed tomography after endoscopic retrograde cholangiopancreatography showed perforation and accumulation of contrast medium at the posterior wall of the descending region of the duodenum, and free air from around the duodenum to the right retroperitoneum.
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case_images: The endoscopic view of the biliary orifice after EPLBD showed bile duct injuries and hepatoduodenal mesentery from the posterior wall of the bile duct (Figure 3a). CT after ERCP revealed perforation and accumulation of contrast medium at the posterior wall of the descending region of the duodenum and free air from around the duodenum to the right retroperitoneum (Figure 3b,c).
case_images: (a) Computed tomography the day after endoscopic retrograde cholangiopancreatography showed inflammatory spread to the anterior pararenal space due to pancreatitis. (b) Cholangiography from the endoscopic nasal biliary drainage tube showed a small amount of contrast medium surrounding the papilla as shown using the arrow, but no leakage into the abdominal cavity.
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case_images: C-reactive protein concentration of 17.2 mg/dL, and pancreatic amylase activity of 137 U/L. CT revealed inflammation spread to the anterior pararenal space due to mild pancreatitis (Figure 4a). Cholangiography of the ENBD tube did not demonstrate leakage of the contrast medium into the peritoneal cavity, and the ENBD tube was removed on the eighth day (Figure 4b).