Finding the middle ground in bile duct injury: the evolving role of biliary rendezvousReferring to Schreuder A et al. p. 577–587
29 May 2018 (online)
Biliary rendezvous is defined as the passage of a guidewire and a grasping device (snare, basket or forceps) from opposing directions of the bile duct, one from an antegrade direction and the other from a retrograde direction, permitting retrieval of the guidewire and, subsequently, access to the previously inaccessible bile duct. Retrograde access for biliary rendezvous is obtained via endoscopic retrograde cholangiopancreatography (ERCP) through the papilla. There are, however, three different approaches to antegrade access for biliary rendezvous: percutaneous, intraoperative or endoscopic, either through the intrahepatic or extrahepatic bile duct, or indirectly through the cystic duct.
Percutaneous rendezvous is occasionally used to facilitate stent insertion in malignant biliary obstruction or to overcome failed cannulation during ERCP for choledocholithiasis. In percutaneous rendezvous, a guidewire is advanced through a percutaneous transhepatic cholangiography (PTC) catheter or an indwelling T-tube into the duodenum. The guidewire is then retrieved through the endoscope and used for retrograde cannulation. Alternatively, retrograde access can be achieved by passing a second guidewire alongside the antegrade wire. In intraoperative rendezvous, a guidewire is passed through the cystic duct into the duodenum during laparoscopic cholecystectomy coupled with intraoperative ERCP for removal of choledocholithiasis. Finally, antegrade access for biliary rendezvous can be achieved endoscopically through pre-existing bilio-enteric anastomoses (surgical  or interventional ) or, more commonly, through de novo endoscopic ultrasound (EUS)-guided puncture of the bile duct. In all of these variations of biliary rendezvous, the meeting between the guidewire and the grasping device takes place within the lumen of the duodenum or the bile duct.
“Treatment of postoperative bile duct injury has gradually shifted away from surgical repair to percutaneous or endoscopic intervention.”
Treatment of postoperative bile duct injury (BDI) has gradually shifted away from surgical repair to percutaneous or endoscopic intervention. Decompression via ERCP has long been established as the treatment of choice for most bile leaks following laparoscopic cholecystectomy . The long-term efficacy of progressive stenting for postoperative biliary strictures remained in question until it was eventually proven . Nonetheless, surgery is still considered mandatory for BDI involving loss of continuity of a major bile duct. Interventional approaches (typically percutaneous drainage) in this setting have an important but only temporizing role until elective surgery can be performed. Anecdotal reports have shown feasibility and proof-of-principle using nonstandard interventional techniques to repair major postoperative bile duct transections or disruptions. Retrograde, antegrade, and combined approaches to recanalize a transected bile duct have been described.
An intriguing novel approach to recanalization of postoperative bile duct transections using PTC combined with ERCP was recently described at two different centers. Fiocca et al. gained access to the subhepatic space from both ends of the transection in 22 patients who had undergone cholecystectomy, manipulating a snare under fluoroscopy to successfully retrieve the wire . In contrast to previous percutaneous rendezvous techniques, in this series the meeting of the guidewire with the snare took place outside the lumen. After rendezvous recanalization of the transection, patients underwent periodic progressive stenting. Donatelli et al. evaluated this novel extraluminal rendezvous technique in 21 patients with bile duct transections following cholecystectomy or hepatectomy . After a mean follow-up after stent removal of 16.6 months, no recurrences occurred among the 12 patients who had completed progressive stenting.
In this issue of Endoscopy, Schreuder et al. report the short- and long-term outcomes of percutaneous rendezvous in 47 consecutive patients who had post laparoscopic cholecystectomy BDI treated at the Academic Medical Center in Amsterdam over a period of 22 years . Patients from a larger cohort of 812 BDI cases were entered into this retrospective study if rendezvous was used for management at this expert referral center. The indication for rendezvous required: a) failed prior ERCP and/or PTC; and b) multidisciplinary team agreement on patient candidacy. Two-thirds of the 47 patients had transections, with nearly all of the remaining patients having major leaks (Amsterdam type D and B lesions , respectively). Primary successful recanalization and stenting was achieved in 44 patients (94 %) by means of extraluminal or intraluminal rendezvous (50 % each), with 18 % procedural morbidity and no mortality. Based largely on physician preference, five of these successfully recanalized patients underwent surgery. The remaining 39 patients underwent periodic progressive stenting for a median of 7 months, with successful stricture remodelling achieved in 31 patients (66 %). After a median follow-up after stent removal of 40 months, there were five stricture recurrences (11 %). Overall, biliary rendezvous was successful in the long-term management of 26 patients (55 %), whereas another 14 patients (30 %) were successfully bridged to surgery. The authors conclude that in experienced hands, rendezvous is safe and should be considered as the next step before moving on to surgery when conventional endoscopic or percutaneous transhepatic interventions fail to restore bile duct continuity in patients with BDI.
This study expands the available evidence on a novel, minimally invasive treatment option for a challenging patient subset in which current practice patterns still dictate surgical reconstruction. The findings of Schreuder et al. are in line with previously published results of two series including heterogeneous bile duct transections and shorter follow-up  . As the authors acknowledge, their treatment protocol for postcholecystectomy BDI evolved during the long study period, moving towards more aggressive stenting. It is interesting to note that the decision to pursue rendezvous over surgical repair in patients with BDI was only taken in 5.8 % of their entire cohort. It is not clear how many of their BDI patients experienced ERCP and/or PTC failure and underwent surgery rather than rendezvous. In the light of these findings, it is reasonable to assume that this number will decrease in future years at tertiary centers where expert percutaneous and endoscopic interventional treatments are available. Once the realization is accepted that interventional repair of complex BDI is feasible, safe, and effective, several questions arise: How reproducible will these challenging combined percutaneous-endoscopic interventions be? Will there be a synergistic effect with emerging technology and procedures, such as digital cholangioscopy  or EUS-guided biliary access  in the setting of BDI, as there already has been in other conditions? How would rendezvous interact with alternative interventional recanalization strategies, such as magnetic compression anastomoses? As evidence gathers to answer these questions properly, a varied choice of reliable interventional options is becoming increasingly available to potentially improve treatment outcomes in patients with more severe BDI.
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