Endoscopic ultrasound-guided rendezvous (EUS-RV) is a rescue technique employed when
biliary access during endoscopic retrograde cholangiopancreatography (ERCP) fails
[1]
[2]
[3]
[4]. However, EUS-RV is challenging due to the bile leakage risk, which can result in
fluid collection between the liver and gastrointestinal tract. We report successful
EUS-RV rescue using a self-expandable metal stent (SEMS) with an ultra-slim delivery
system ([Video 1]).
A covered metal stent with an ultra-slim delivery system is a useful rescue option
after failed endoscopic ultrasound-guided rendezvous, even with fluid accumulation
between the liver and gastrointestinal tract.Video 1
A 69-year-old woman developed obstructive jaundice secondary to pancreatic tail cancer.
Computed tomography revealed hilar biliary obstruction and intrahepatic bile duct
dilation caused by a metastatic tumor. ERCP was initially attempted; however, biliary
cannulation failed, prompting same-session EUS-RV. Duodenal puncture was not feasible
due to a non-dilated extrahepatic bile duct; therefore, a transgastric approach was
adopted. Because the intrahepatic bile duct in segment 2 was less dilated, the dilated
duct in segment 3 was punctured using a 19-gauge needle ([Fig. 1]). A 0.025-inch guidewire was inserted but failed to pass through the hilar biliary
obstruction, even when a hydrophilic guidewire was used owing to the highly angulated
left hepatic duct ([Fig. 2]). A double-guidewire technique using a double-lumen cannula was employed [5]. However, bile leakage occurred during catheter exchange, and fluid collection was
observed between the liver and stomach, complicating the procedure ([Fig. 3]).
Fig. 1 The dilated intrahepatic bile duct in segment 3 was punctured by a 19-gauge needle.
Fig. 2 Cholangiography revealed a highly angulated, left hepatic duct. The extrahepatic bile
duct was not visualized by contrast, making guidewire insertion even more challenging.
Fig. 3 Fluid collection (arrowheads) due to bile leakage was observed between the liver and
the stomach. The arrow indicates the guidewire.
We decided to convert the patient to hepaticogastrostomy. Owing to the anticipated
technical difficulty in inserting a metal stent with a conventional 8-Fr delivery
system without dilation devices such as a cautery dilator or balloon catheter, we
selected a fully covered SEMS with a 5.9-Fr delivery system (8-mm × 12-cm HANAROSTENT;
M.I. Tech, Seoul, Korea). This facilitated smooth stent insertion, and hepaticogastrostomy
was successfully completed ([Fig. 4]). The patient developed peritonitis, which resolved with conservative treatment.
Her total bilirubin levels decreased, and no further biliary drainage was required.
Fig. 4 A covered metal stent with a 5.9-Fr delivery system was easily inserted and placed
between the liver and the stomach.
Endoscopy_UCTN_Code_TTT_1AS_2AH
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
