Modified Rendezvous Technique for Bilateral Biliary Drainage Through a Jejunal Interponat of the Common Bile Duct with Anastomotic Strictures

The proximal common bile duct was accidentally removed during laparoscopic cholecystectomy in a 43-year-old man. Biliary drainage was successfully re-established in our clinic by the formation of a jejunal interponat, but the patient’s cholestasis relapsed, due to delayed biliary drainage and moderate stenosis of both jejunal anastomoses (Figure [1] a). Attempts to manage this by crossing of the interponat to the opposite opening with a guide-wire during endoscopic retrograde cholangiography or percutaneous trans-hepatic cholangiography failed.

A rendezvous maneuver was then performed. First, a guide-wire was advanced into the interponat via percutaneous trans-hepatic cholangiography, where it was grasped with a Dormia basket and was used to guide an 8.5-Fr pushing catheter (PC 8.5; Wilson-Cook, Winston-Salem, North Carolina, USA) through the endoscope to the proximal anastomosis. A second guide-wire was then inserted through this catheter into the left intrahepatic bile duct (Figure [1] b). With two guide-wires in place, an 8.5-Fr, 15-cm endoprosthesis was advanced, after dilation, into each hepatic lobe. Finally, a third transpapillary, 8.5-Fr, 9-cm endoprosthesis was placed into the jejunal interponat (Figure [1] c). The patient’s cholestasis resolved and 6 months later no significant strictures were detected, and all the endoprostheses were removed. The patient has been asymptomatic for 4 years.

Figure 1 Modified rendezvous technique for bilateral biliary drainage in a patient with a jejunal interponat of the common bile duct and anastomotic strictures. a Percutaneous trans-hepatic cholangiography showing the jejunal interponat with moderate stenosis of the hepato-jejunal anastomosis (black arrow) and of the jejuno-biliary anastomosis (white arrow). b The percutaneously introduced wire (white arrow) has been grasped with a Dormia basket in the jejunal interponat and pulled through the endoscope. Using an 8.5-Fr pushing catheter placed over the first wire through the endoscope, a second wire (black arrow) was placed in the left intrahepatic bile duct. c The final result, showing two 8.5-Fr, 15-cm endoprostheses, one in the left intrahepatic bile duct and one in the right intrahepatic bile duct, and an 8.5-Fr, 9-cm endoprosthesis in the jejunal interponat.

In this case, a rendezvous maneuver [1] was combined with a double-wire technique using a pushing catheter for the insertion of a second guide-wire through a biliary jejunal interponat into the left lobe of the liver. Bilateral hepatic drainage was thus ensured without the need for a second percutaneous puncture, and dilation of the strictures with placement of endoprostheses resulted in sustained remission of the patient’s cholestasis, even after removal of the stents.

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Reference

• 1 Sommer A, Burlefinger R, Bayerdorffer E. et al . Internal biliary drainage in the ”rendezvous” procedure. Combined transhepatic endoscopic retrograde methods.  Dtsch Med Wochenschr. 1987;  112 747-775