An 82-year-old woman with cholangitis and common bile duct (CBD) stones underwent endoscopic retrograde cholangiopancreatography (ERCP). An endoscopic sphincterotomy was carried out using an electrosurgical unit with a standard pull sphincterotome. Multiple stones were removed using an extraction balloon, and subsequently, the patient had no pain or fever and a chest radiograph showed no free air. However, 2 days later the patient complained of abdominal pain. Computed tomography (CT) revealed retroperitoneal air and fluid (• " Fig. 1). Given her age and poor medical condition, the patient was not considered a surgical candidate. ERCP disclosed a perforation in the distal CBD near the ampulla. Multiple plastic stents were inserted (• " Fig. 2) and she was treated with total parenteral nutrition, broad-spectrum antibiotics, and percutaneous catheter drainage from the right pararenal space. The fever subsided and the patient's condition improved, but there was no decrease in the amount of percutaneous catheter drainage (> 150 mL/day). A tubo
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