Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series

Abstract

Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66 +/- 18.2 years; malignant = 10, benign = 5). Mean diameter of measured bile ducts was 14.3 +/- 5.17 mm (range 4-23 mm). The reasons for initial ERCP failure were tumor infiltration or edema (n = 9), intradiverticular papilla (n = 2), pre-existing duodenal stent (n = 1), and anatomic anomalies (n = 3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100 %), with drainage being successful in 12 / 15 (80 %). Failures occurred in three patients due to inability to traverse the biliary stricture (n = 2) or dissection of a choledochocele with the guide wire (n = 1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.

Endoscopic Ultrasound in Pancreatic Cancer: The New Perspective

“…One approach is transduodenal in combination with ERCP (rendez-vous technique), with reported technical success rates of 75-100% [159,160]. EUS-guided choledochoduodenostomy with transluminal stenting is successful in 75-88% of cases [161][162][163][164], while the transgastric approach has a success rate of 65-100% [165][166][167].…”

Endoscopic ultrasound guided biliary drainage

“…In six reports [9,11,12,17,23,26] on EUS-guided rendezvous technique describing a total of 45 patients, the overall success rate was 80% (36/45). The complication rate was 4% (2/45), including pneumoperitoneum and bile leakage.…”

“…Recently endoscopic ultrasonography-guided biliary drainage has been reported as an alternative technique by many researchers . Endoscopic ultrasonography-guided biliary drainage (EUS-BD) using either direct access or a rendezvous technique has attracted attention as an alternative procedure to PTBD, with a technical success between 75%-100% and with low complication rate [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] . Indeed another important advantage of EUS-BD compared with external PTBD is better quality of life due to the internal placement of the stent: this is undoubtedly a desirable goal; moreover, if allowed by local facilities, EUS-BD performed in the same session of the failed ERCP, in the same room and under the same sedation, could have many advantages for the patient and could be a rational approach also from the cost standpoint.…”

The Society for Gastrointestinal Intervention. Are We, as an Organization of Disparate Disciplines, Cooperative or Competitive?

“…access to the gall bladder and bile duct to allow acute decompression, usually into the duodenum. 23,24 Additional studies have reported a variety of endoscopic techniques to create a permanent cholecystoduodenal fistula thereby opening up the gall bladder to non-surgical therapy, particularly in the surgically unfit patient and …”

“…Likewise, EUS-assisted access to the biliary tree may make PTBD unnecessary in some tertiary referral centers but data requiring comparable safety and cost are recommended before a major shift in practice pattens can be recommended. 23,24 Additional and commonplace interdisciplinary procedures occur in the setting of iatrogenic biliary injury and leak. In this setting, it may be inadequate to place a biliary stent to facilitate drainage and close a leak.…”