A modified ‘no contrast, no aspiration’ technique of endoscopic ultrasound-guided rendezvous versus conventional technique to access narrow bile duct in patients with benign biliary obstruction with difficult cannulation: A feasibility assessment study

Aims Endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively new salvage technique for biliary access in cases of failed ERCP. Extra-hepatic approach of EUS-RV can be technically challenging with tapered lower end of common bile duct (CBD), and this situation is commonly encountered in benign biliary diseases. We evaluated a modification of the trans-duodenal technique (no contrast, no aspiration) in benign biliary disease with narrow distal CBD.

Methods Patients with benign biliary disease and tapered lower end CBD (max CBD diameter≤6 mm) fulfilling the ESGE definition of difficult bile duct cannulation (DBC) during ERCP were included. Baseline demographic, clinical, radiology and laboratory details were retrieved. The patients were divided into 2 arms: conventional EUS-RV technique versus the modified technique. EUS-guided puncture of the narrow caliber CBD was done from D1-D2 junction in straight scope position. In the modified method, needle tip inside CBD was ascertained through EUS image alone. Contrast was not injected to prevent cholangitis in case of failed procedure and bile aspiration was not done to prevent collapse of the narrowed CBD. Subsequent steps were similar. Outcome parameters such as technical success, time taken from CBD puncture to wire negotiation across papilla, overall EUS-RV core time, radiation dose and adverse events were noted.

Results A total of 91 patients were evaluated (males 46; 50.5%; mean age 52.7±11.5 vs 50.7±13.6 years; p=0.46) wherein conventional EUS-RV technique was performed in 39 patients and modified technique in 52 cases. Choledocholithiasis was the commonest etiology (51, 56%) with 44% in cholangitis. No intrahepatic bile duct dilatation was noted in 78 (85.7%) cases. Mean total bilirubin levels (2.24±1.54 vs 2.29±1.53 mg/dl; p=0.86) along with the distal CBD diameter (3.56±0.86 vs 3.46±0.95 mm; p=0.61) were similar across both arms [1]. Comparing the outcome parameters between conventional vs modified technique, technical success was similar between the two groups (92.3% vs 94.2%, p=1.00). Subsequent ERCP cannulation was performed along the side of the GW in 89.7% cases. Time taken from puncture of CBD till GW negotiation across papilla (median [IQR] 4.03 [2.5] vs 1.5 [2.45] minutes; p=0.0001) and total core EUS-RV time (median [IQR] 9.2 [3.88] vs 6.8 [5.8] minutes; p=0.003) was significantly shorter in the modified EUS-RV technique. Comparing the safety profile, overall adverse events were similar (15.4% vs 13.5%; p=0.79) with comparable rates of post-ERCP pancreatitis (10.3% vs 7.7%; p=0.669). Overall radiation exposure for EUS-RV procedure was significantly lower in the modified technique (median [IQR] 377 [420] vs 209 [191] mGy; p=0.0001). Radiation exposure for subsequent ERCP procedure and hospital stay were similar in the 2 arms.

Conclusions This modified technique of EUS-RV enables efficient, rapid, and safe biliary access in cases of narrowed CBD without the need for contrast injection or bile aspiration.

Publication History

Article published online:
27 March 2025

• References

• 1 Choudhury A, Samanta J, Muktesh G. et al. Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation: A Randomized Controlled Trial. Ann Intern Med 2024; 177 (10): 1361-1369