Introduction: Selective cannulation fails in approximately 3 % of endoscopic retrograde cholangiography (ERC) procedures. An endoscopic ultrasound-guided rendezvous technique (EUS – RV) may salvage failed cannulation. The aims of the current study were to determine the safety and efficacy of EUS – RV.
Methods: A total of 40 patients underwent salvage EUS – RV. EUS – RV was attempted immediately after failed biliary cannulation. A dilated intra- or extra-hepatic biliary duct (IHBD or EHBD) was punctured from the stomach or the small intestine under EUS guidance followed by cholangiography and antegrade manipulation of the guide wire into the small intestine. Finally, the echoendoscope was exchanged for an appropriate endoscope and biliary cannulation was achieved over or adjacent to the guide wire.
Result: EUS–RV appears safe and effective and may be considered as a primary salvage technique after failed cannulation. Antegrade manipulation of the guide wire into the small intestine was achieved in 29 of 40 patients (73 %; EHBD 25 /31 and IHBD 4/9). The reasons for failure were inability to advance the guide wire through an obstruction or a native ampulla. Re-attempt at ERC immediately after failed EUS – RV was made in seven of the 11 patients, and was successful in four. The remaining seven patients underwent percutaneous drainage within 3 days. Complications occurred in five patients (13 %), including pancreatitis, abdominal pain, pneumoperitoneum, and sepsis/death, which was unlikely to be related to the procedure.
Conclusion: EUS – RV is safe and effective and should be considered as a primary salvage technique after failed cannulation. Immediate re-attempt at ERC after failed EUS – RV is warranted, as EUS-guided cholangiogram can facilitate biliary cannulation in some cases. Finally, prompt alternative biliary drainage should be available.
References
1 Artifon EL, Sakai P, Cunha JE et al. Guide wire cannulation reduces risk of post-ERCP pancreatitis and facilitates bile duct cannulation. Am J Gastroenterol 2007; 102: 2147-2153
2 Bailey AA, Bourke MJ, Williams SJ et al. A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis. Endoscopy 2008; 40: 296-301
3 Lee TH, Park do H, Park JY et al. Can wire-guided cannulation prevent post-ERCP pancreatitis? A prospective randomized trial. . Gastrointest Endosc 2009; 69: 444-449
4 Smith AC, Dowsett JF, Russell RC et al. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet 1994; 344: 1655-1660
6 Beissert M, Wittenberg G, Sandstede J et al. Metallic stents and plastic endoprostheses in percutaneous treatment of biliary obstruction. Z Gastroenterol 2002; 40: 503-510
7 Chang KJ, Albers CG, Erickson RA et al. Endoscopic ultrasound-guided fine needle aspiration of pancreatic carcinoma. Am J Gastroenterol 1994; 89: 263-266
14 Giovannini M, Moutardier V, Pesenti C et al. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy 2001; 33: 898-900
15 Puspok A, Lomoschitz F, Dejaco C et al. Endoscopic ultrasound guided therapy of benign and malignant biliary obstruction: a case series. Am J Gastroenterol 2005; 100: 1743-1747
16 Bories E, Pesenti C, Caillol F et al. Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study. Endoscopy 2007; 39: 287-291
17 Will U, Thieme A, Fueldner F et al. Treatment of biliary obstruction in selected patients by endoscopic ultrasonography (EUS)-guided transluminal biliary drainage. Endoscopy 2007; 39: 292-295
18 Yamao K, Bhatia V, Mizuno N et al. EUS-guided choledochoduodenostomy for palliative biliary drainage in patients with malignant biliary obstruction: results of long-term follow-up. Endoscopy 2008; 40: 340-342
19 Itoi T, Itokawa F, Sofuni A et al. Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2008; 14: 6078-6082
21 Lai R, Freeman ML. Endoscopic ultrasound-guided bile duct access for rendezvous ERCP drainage in the setting of intradiverticular papilla. Endoscopy 2005; 37: 487-489
23 Kahaleh M, Hernandez AJ, Tokar J et al. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc 2006; 64: 52-59
24 Maranki J, Hernandez AJ, Arslan B et al. Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography. Endoscopy 2009; 41: 532-538
25 Kim YS, Gupta K, Mallery S et al. Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series. Endoscopy 2010; 42: 496-502
26 Doctor N, Dick R, Rai R et al. Results of percutaneous plastic stents for malignant distal biliary obstruction following failed endoscopic stent insertion and comparison with current literature on expandable metallic stents. Eur J Gastroenterol Hepatol 1999; 11: 775-780
27 van der Velden JJ, Berger MY, Bonjer HJ et al. Percutaneous treatment of bile duct stones in patients treated unsuccessfully with endoscopic retrograde procedures. Gastrointest Endosc 2000; 51: 418-422
28 Ponchon T, Valette PJ, Bory R et al. Evaluation of a combined percutaneous-endoscopic procedure for the treatment of choledocholithiasis and benign papillary stenosis. Endoscopy 1987; 19: 164-166
29 Dowsett JF, Vaira D, Hatfield AR et al. Endoscopic biliary therapy using the combined percutaneous and endoscopic technique. Gastroenterology 1989; 96: 1180-1186
30 Jacobs M. Endoscopic biliary decompression aided by a different technique of percutaneous transhepatic access. Gastrointest Endosc 1990; 36: 503-505
32 Wayman J, Mansfield JC, Matthewson K et al. Combined percutaneous and endoscopic procedures for bile duct obstruction: simultaneous and delayed techniques compared. Hepatogastroenterology 2003; 50: 915-918
36 Choudari CP, Sherman S, Fogel EL et al. Success of ERCP at a referral center after a previously unsuccessful attempt. Gastrointest Endosc 2000; 52: 478-483