Endoscopic ultrasonography-guided rendezvous technique (EUS-RV) includes two approaches:
the intrahepatic and extrahepatic bile duct approaches from the stomach and duodenum,
respectively [1]
[2]. However, the technique is impractical when drainage is required for right hepatic
bile duct obstruction. Percutaneous transhepatic biliary drainage has a possible risk
of tumor seeding in a patient with cholangiocarcinoma; therefore, it is not recommended
for surgical candidates [3]
[4]
[5]. We present a case of successful drainage of the obstructed right posterior bile
duct using EUS-RV ([Video 1]).
Video 1 As drainage of the obstructed right posterior bile duct was impossible using endoscopic
retrograde cholangiopancreatography, an endoscopic ultrasonography-guided rendezvous
technique was used successfully.
A 63-year-old woman was admitted with acute cholangitis. Contrast-enhanced computed
tomography revealed Bismuth-Corlette type 4 perihilar cholangiocarcinoma. The surgeons
recommended left trisectionectomy. Drainage for the right posterior bile duct was
required because the posterior segment of the liver was the future remnant lobe. Transpapillary
insertion of the endoscopic nasobiliary drainage tube was attempted. However, this
procedure failed, despite the combination of a hydrophilic guidewire and steerable
or double-lumen catheter, although biliary cannulation was achieved ([Fig. 1]). We exchanged the duodenoscope for a linear EUS scope and inserted it into the
duodenal bulb. The dilated posterior bile duct was then punctured using a 19-gauge
needle ([Fig. 2], [Fig. 3]). A 0.025-inch guidewire was manipulated into the duodenum via the obstruction site
and ampulla. The EUS scope was removed with the guidewire left in place. The duodenoscope
was reinserted where the EUS-placed guidewire passed from the ampulla. The distal
end of the guidewire was grasped with a snare and pulled out through the accessory
channel ([Fig. 4]). A catheter was inserted over the guidewire, and finally, a nasobiliary drainage
tube was placed in the posterior bile duct ([Fig. 5]). No adverse event was encountered, and cholangitis and jaundice subsided.
Fig. 1 Endoscopic retrograde cholangiography demonstrated hilar bile duct obstruction and
dilated anterior bile duct. A hydrophilic guidewire could not be introduced into the
posterior bile duct despite using a steerable catheter and double-lumen catheter.
Fig. 2 Endoscopic ultrasonography scope located at the duodenal bulb showed dilatation of
the posterior bile duct.
Fig. 3 Endoscopic ultrasonography (EUS)-guided cholangiography showed dilatation of the
posterior duct.
Fig. 4 After a guidewire had been passed in an antegrade manner across the obstruction site
and the ampulla into the duodenum, the endoscopic ultrasonography (EUS) scope was
exchanged for a duodenoscope, which was introduced alongside the EUS-placed guidewire.
The guidewire was retrieved through its accessory channel.
Fig. 5 A nasobiliary drainage tube was passed over the guidewire and placed in the posterior
bile duct.
EUS-RV can be useful, especially when drainage for the isolated right hepatic duct
is needed in patients scheduled for surgery.
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
