EUS-guided hybrid rendezvous technique as salvage for standard rendezvous with intra-hepatic bile duct approach

Abstract

EUS-guided rendezvous technique (EUS-RV) is an effective salvage technique for failed biliary cannulation during ERCP. However, it is still difficult to achieve cannulation in some cases, especially using the intrahepatic bile duct (IHBD) approach, which requires complicated guidewire manipulation. EUS-hybrid rendezvous technique (HRV) has been applied as a salvage technique for difficult guidewire placement during EUS-RV with IHBD approach. The aims of this study were to evaluate the efficacy and safety of EUS-HRV using a retrospective study. Database analysis revealed 29 patients who underwent EUS-RV for difficult biliary cannulation. Among them, 8 patients underwent EUS-HRV as a salvage technique for difficult guidewire placement during EUS-RV with the IHBD approach. In EUS-HRV, a 6-French dilator was advanced into the biliary system for better guidewire manipulation. After successful guidewire placement, the EUS scope was exchanged for a duodenoscope, keeping the guidewire and dilator in place. The EUS-placed guidewire was retrieved through the duodenoscope, followed by cannulation over the guidewire. The dilator remained at the fistula until completion of the procedure. The analysis showed that the guidewire placement and the subsequent scope exchange and deep biliary cannulation after the retrieval of the EUS-placed guidewire were successfully conducted for all 8 patients. Mild pancreatitis was recognized as an adverse event in 1 patient. The overall success rate of EUS-RV combined with EUS-HRV was improved up to 90% (26/29). Our results suggested that EUS-HRV can be an effective and safe salvage technique in cases wherein guidewire placement is difficult during EUS-RV with IHBD approach.

A Proposed Algorithm for Endoscopic Ultrasound-Guided Rendezvous Technique in Failed Biliary Cannulation

“…The PEHBD/D1 route was successfully used in all remaining patients but one for whom the LIHBD/S route was used because of an intervening pancreatic cyst. Since the guidewire passage through the distal biliary stricture in the LIHBD/S route was extremely difficult because of the long, winding, and wide bile duct in this case and in previous reports [7,21,22], the PEHBD/D1 route might be better, especially in distal biliary obstruction, than IHBD approaches when the DEHBD/D2 route is impossible or failed. As for hilar biliary obstruction, the puncture of the EHBD was exceedingly challenging because of its extreme thinness due to a lack of the influx of bile juice, so the DEHBD/D2 route was successfully used in only 50% (one of two) of patients, even when using a 22 gauge needle, whereas the RIHBD/D1 route was needed in another patient.…”

“…When the needle direction was not favorable for advancing the guidewire during the puncture, we changed the needle direction to the caudal side by pushing the scope to the cranial side and by using the up-angle of the scope (Figure 9). If advancing the guidewire toward the ampulla was impossible, even when using maneuvers of the scope, we inserted a catheter into the bile duct to assist the guidewire manipulation [5,21]. IHBD approaches were needed in only two patients.…”

Endoscopic ultrasonography-guided hybrid rendezvous technique for pancreatic stenting in a patient with pancreatoduodenectomy

“…This procedure facilitates recognition of the orifice of the pancreatic duct (PD), allows for cannulation of the obstructed PD [1,2], and can be reattempted if the guidewire is dropped. The EUS-guided hybrid rendezvous technique is reported as an advanced technique for biliary drainage [3]. Here, we report that the technique was useful for PD drainage.…”

Haemorrhage from the left gastroepiploic artery: beware of the acute abdomen post endoscopic ultrasound biliary drainage

“…The EUS endoscopy stability varies with position, which can affect guidewire manipulation and prolong procedure time 8 . Furthermore, significant torque may be needed to overcome associated biliary obstruction to allow successful rendezvous with the duodenoscope 9 .…”