EUS guided Rendezvous Technique for Biliary Access after Failed Cannulation

Introduction: Selective cannulation fails in 3% of endoscopic retrograde cholangiography (ERC). EUS guided rendezvous (EUS-RV) can salvage failed cannulation. Aims: To determine the safety and efficacy of EUS-RV in a consecutive series of patients undergoing ERC.

Methods: We identified all patients undergoing EUS-RV from 1/07 to 3/10. EUS-RV was attempted immediately after failed biliary cannulation. We first punctured a dilated intra (IHD) or extra (EHD) bile duct from the stomach and/or the small bowel using a 19G FNA needle under EUS-guidance. We aspirated bile to decompress the biliary tree then performed cholangiography followed by antegrade manipulation of the guidewire into the small bowel. Finally we exchanged the echoendoscope for an appropriate endoscope and cannulated over or adjacent to the guidewire.

Result: 40 patients (2% of all ERC) underwent salvage EUS-RV for obstructive jaundice (28), cholangitis (11), and sphincter of oddi dysfunction (1). Cannulation failed due to cancer infiltration (12), surgically altered UGI and/or biliary anatomy (9), peri-ampullary diverticulum (9), or other technical reasons (10). The bile duct was accessed via EHD (32) and IHD (8) with median duct diameters of 13.5mm 6mm respectively. We punctured the bile duct from the duodenal bulb (16) or the second portion (13), stomach (8) and the jejunum (3). We successfully punctured the bile duct and passed the guidewire in all cases, but could manipulate the guidewire antegrade into the small bowel in only 73% (29/40); success rate for EHD was 81% (25/31) and IHD was 44% (4/9). We failed to pass the biliary strictures with the guidewire in 10 cases and the native ampulla in 1 case. All had endoscopic therapy including stenting (18) and stone extraction after sphincterotomy/balloon dilation (11). Immediate reattempt at ERC in 7 of 11 failed cases was successful in 4 (57%) which were partly attributed to the EUS cholagiogram identifying the biliary orifice within tumor or abnormal anatomy. The remaining 7 had percutaneous drainage (6) or percutaneous rendezvous ERC (1) within 3 days. Complications in 5 of 40 patients (12.5%) included 2 with mild pancreatitis and 1 each with abdominal pain and pneumo- peritoneum treated conservatively. The last patient had unsuccessful EUS-RV followed by immediate repeat ERCP with successful stenting for treatment of obstructive jaundice, but ultimately died from progressive sepsis.

Conclusion: EUS-RV is a safe and effective salvage technique after failed ERC. Immediate reattempt at ERC in patients with failed EUS-RV is also warranted as EUS cholangiogram can facilitate biliary cannulation in some cases. Availability of prompt percutaneous drainage is also important.