case_images: PMC9035945_01
case_images: Pre-procedure ultrasound scan showing echogenic intraductal material.
case_images: crg-0016-0186-g01.jpg
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case_images: F1
case_images: 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).
case_images: 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.
case_images: crg-0016-0186-g02.jpg
case_images: PMC9035945_01_crg-0016-0186-g02.jpg
case_images: F2
case_images: Although the proximal CBD appeared significantly more dilated, the distal CBD tapered and was less dilated at 12 mm in width (Fig. 2).
case_images: Extracted stone.
case_images: crg-0016-0186-g03.jpg
case_images: PMC9035945_01_crg-0016-0186-g03.jpg
case_images: F3
case_images: 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.
case_images: Stapfer type-1 duodenal perforation.
case_images: crg-0016-0186-g04.jpg
case_images: PMC9035945_01_crg-0016-0186-g04.jpg
case_images: F4
case_images: 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).
case_images: Perforation closed using OTSC.
case_images: crg-0016-0186-g05.jpg
case_images: PMC9035945_01_crg-0016-0186-g05.jpg
case_images: F5
case_images: The perforation defect was entirely suctioned into the cap of the delivery device, and the clip was successfully deployed (Fig. 5).
case_images: Fluoroscopy image post OTSC placement - no contrast leak demonstrated.
case_images: crg-0016-0186-g06.jpg
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case_images: F6
case_images: Subsequent on-table fluoroscopy did not demonstrate any extra-luminal contrast leak (Fig. 6).
case_images: Day-2 CT showing retroperitoneal collection (red arrow) inferior to the OTSC (yellow arrow).
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case_images: PMC9035945_01_crg-0016-0186-g07.jpg
case_images: F7
case_images: 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).
case_images: CT at 4 months showing resolution of collection.
case_images: crg-0016-0186-g08.jpg
case_images: PMC9035945_01_crg-0016-0186-g08.jpg
case_images: F8
case_images: At 4 months, a repeat abdominal CT scan demonstrated that the collection had completely resolved, with the OTSC still in situ (Fig. 8).