Modified rendezvous technique for biliary cannulation

Solitary Duodenal Ulcer Causing Biliary Obstruction Requiring Rendezvous Procedure in a Pediatric Patient With Eosinophilic Gastroenteritis

Eosinophilic gastroenteritis (EGE) is an uncommon disease characterized by immune cell-mediated inflammation of the gastrointestinal (GI) tract resulting in vague abdominal symptoms, most commonly nausea, vomiting, diarrhea, and abdominal pain. We report the case of a 16-year-old male presenting with a six-week history of progressive pruritus, jaundice, fatigue, abdominal pain, acholic stools, and dark-colored urine. This patient was diagnosed via endoscopy with biliary obstruction caused by a large, solitary, duodenal ulcer secondary to EGE. This is a severe complication of EGE and to our knowledge, this is the first reported case of biliary obstruction caused by a duodenal ulcer in a pediatric patient with EGE. Additionally, we describe the first pediatric combined percutaneous-endoscopic rendezvous technique after failed therapeutic endoscopic retrograde cholangiography (ERCP) to relieve the biliary obstruction.

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in gastrointestinal and biliary diseases

In recent years, a wide range of gastrointestinal endoscopy techniques have been developed, such as endoscopic submucosal dissection (ESD) and endoscopic retrograde cholangiopancreatography (ERCP). Although ESD and ERCP have an important role in gastrointestinal and biliary diseases, each technique has its limitations. Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time. Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area. Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate. The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction, stenosis and bile duct injuries. For patients with simultaneous presence of stones in the gallbladder and the common bile duct, the laparo-endoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP. Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction. The most common used approach to deliver the magnets is by percutaneous-peroral tract. Laparoscopic-assisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.

Usefulness of combined percutaneous-endoscopic rendezvous techniques after failed therapeutic endoscopic retrograde cholangiography in the era of endoscopic ultrasound guided rendezvous

The rendezvous approach is a salvage technique after failure of endoscopic retrograde cholangiography (ERC). In certain circumstances, percutaneous-endoscopic rendezvous (PE-RV) is preferred, and endoscopic ultrasound-guided rendezvous (EUS-RV) is difficult to perform. We aimed to evaluate PE-RV outcomes, describe the PE-RV techniques, and identify potential indications for PE-RV over EUS-RV.Retrospective analysis was conducted of a prospectively designed ERC database between January 2005 and December 2016 at a tertiary referral center including cases where PE-RV was used as a salvage procedure after ERC failure.During the study period, PE-RV was performed in 42 cases after failed therapeutic ERC; 15 had a surgically altered enteric anatomy. The technical success rate of PE-RV was 92.9% (39/42), with a therapeutic success rate of 88.1% (37/42). Potential indications for PE-RV over EUS-RV were identified in 23 cases, and either PE-RV or EUS-RV could have effectively been used in 19 cases. Endoscopic bile duct access was successfully achieved with PE-RV in 39 cases with accessible biliary orifice using one of PE-RV cannulation techniques (classic, n = 11; parallel, n = 19; and adjunctive maneuvers, n = 9).PE-RV uses a unique technology and has clinical indications that distinguish it from EUS-RV. Therefore, PE-RV can still be considered a useful salvage technique for the treatment of biliary obstruction after ERC failure.

Advances in endoscopic management of biliary complications after living donor liver transplantation: Comprehensive review of the literature

Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation (LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.

A new duodenal rendezvous technique for biliary cannulation in patients with T-tube after orthotopic liver transplantation (with video)

BACKGROUND AND AIMS

Because a traditional rendezvous (RV) technique implies stretching of the papilla, possibly leading to post-ERCP pancreatitis, an alternative duodenal RV technique was evaluated. The aim was to assess the effectiveness, safety, and amount of time spent performing duodenal RV versus traditional RV cannulation in orthotopic liver transplantation patients with a T-tube.

METHODS

We retrospectively reviewed data from a prospective ERCP database held by our university hospital. Twenty patients with a T-tube who had undergone ERCP for biliary adverse events after orthotopic liver transplantation were included. The successful cannulation rate, the amount of time spent performing cannulation, the post-ERCP pancreatitis rate, and hyperamylasemia 24 hours after the procedure were recorded.

RESULTS

Successful cannulation was achieved by the duodenal RV technique in 9 of 10 patients (90%), taking 146 seconds (interquartile range 63-341 seconds) with a short learning curve effect. An unsuccessful duodenal RV procedure occurred because of the angulation of the hydrophilic tip of the guidewire while crossing the papilla, thus preventing cannulation. Successful cannulation was achieved by the traditional RV technique in all cases (N = 11), including the failed duodenal RV technique, taking 374 seconds (interquartile range 320-410 seconds) (P < .05 vs duodenal RV). However, no post-ERCP pancreatitis occurred after using the duodenal RV technique compared with 2 episodes of mild pancreatitis after using the traditional RV technique. Twenty-four hours after the procedure, the median amylasemia level was 84 IU/L (interquartile range 49-105 IU/L) and 265 IU/L (interquartile range 73-2945 IU/L) for the duodenal versus traditional RV techniques, respectively (P = not significant).

CONCLUSIONS

In patients with a T-tube after liver transplantation, the duodenal RV technique was not associated with post-ERCP pancreatitis, presumably because of the reduction of stress on the major papilla. Cannulation by using the duodenal RV technique was faster compared with the traditional RV technique. These preliminary data point out the use of the duodenal RV technique as the first option to choose in case of failed cannulation before attempting the traditional RV technique.

Role of endoscopy in the conservative management of biliary complications after deceased donor liver transplantation

The clinical outcome of patients receiving liver transplantation could be significantly affected by biliary complications, including strictures, leaks, stones and bilomas; early diagnosis and treatment of these conditions lead to markedly reduction in morbidity and mortality. Therapeutic gold standard is represented by conservative approaches, both endoscopic and percutaneous, based on the type of biliary reconstruction, the local availability of the procedures and specific expertise. In patients with previous transplantation, the difficult biliary access and the possible presence of concomitant complications (mainly strictures) further restrict the efficacy of the endoscopic and percutaneous treatments; on the other hand, surgery should generally be avoided because of the even increased morbidity and mortality due to technical and clinical issues. Here we review the most common biliary complications occurring after liver transplantation and discuss available treatment options including future perspectives such as endoscopic ultrasound-guided biliary access in patients with Roux-en-Y choledocho-jejunostomy or extracorporeal shock wave lithotripsy for difficult stones.

Drug-induced liver injury in hospitalized patients with notably elevated alanine aminotransferase

AIM: To identify the proportion, causes and the nature of drug-induced liver injury (DILI) in patients with notably elevated alanine aminotransferase (ALT).

METHODS: All the inpatients with ALT levels above 10 times upper limit of normal range (ULN) were retrospectively identified from a computerized clinical laboratory database at our hospital covering a 12-mo period. Relevant clinical information was obtained from medical records. Alternative causes of ALT elevations were examined for each patient, including biliary abnormality, viral hepatitis, hemodynamic injury, malignancy, DILI or undetermined and other causes. All suspected DILI cases were causality assessed using the Council for International Organizations of Medical Sciences scale, and only the cases classified as highly probable, probable, or possible were diagnosed as DILI. Comments related to the diagnosis of DILI in the medical record and in the discharge letter for each case were also examined to evaluate DILI detection by the treating doctors.

RESULTS: A total of 129 cases with ALT > 10 ULN were identified. Hemodynamic injury (n = 46, 35.7%), DILI (n = 25, 19.4%) and malignancy (n = 21, 16.3%) were the top three causes of liver injury. Peak ALT values were lower in DILI patients than in patients with hemodynamic injury (14.5 ± 5.6 ULN vs 32.5 ± 30.7 ULN, P = 0.001). Among DILI patients, one (4%) case was classified as definite, 19 (76%) cases were classified as probable and 5 (20%) as possible according to the CIOMS scale. A hepatocellular pattern was observed in 23 (92%) cases and mixed in 2 (8%). The extent of severity of liver injury was mild in 21 (84%) patients and moderate in 4 (16%). Before discharge, 10 (40%) patients were recovered and the other 15 (60%) were improved. The improved patients tended to have a higher peak ALT (808 ± 348 U/L vs 623 ± 118 U/L, P = 0.016) and shorter treatment duration before discharge (8 ± 6 d vs 28 ± 12 d, P = 0.008) compared with the recovered patients. Twenty-two drugs and 6 herbs were found associated with DILI. Antibacterials were the most common agents causing DILI in 8 (32%) cases, followed by glucocorticoids in 6 (24%) cases. Twenty-four (96%) cases received treatment of DILI with at least one adjunctive drug. Agents for treatment of DILI included anti-inflammatory drugs (e.g., glycyrrhizinate), antioxidants (e.g., glutathione, ademetionine 1,4-butanedisulfonate and tiopronin), polyene phosphatidyl choline and herbal extracts (e.g., protoporphyrin disodium and silymarin). Diagnosis of DILI was not mentioned in the discharge letter in 60% of the cases. Relative to prevalent cases and cases from wards of internal medicine, incident cases and cases from surgical wards had a higher risk of missed diagnosis in discharge letter [odds ratio (OR) 32.7, 95%CI (2.8-374.1), and OR 58.5, 95%CI (4.6-746.6), respectively].

CONCLUSION: DILI is mostly caused by use of antibacterials and glucocorticoids, and constitutes about one fifth of hospitalized patients with ALT > 10 ULN. DILI is underdiagnosed frequently.

Comparative study of rendezvous techniques in post-liver transplant biliary stricture

AIM: To investigate the usefulness of a new rendezvous technique for placing stents using the Kumpe (KMP) catheter in angulated or twisted biliary strictures.

METHODS: The rendezvous technique was performed in patients with a biliary stricture after living donor liver transplantation (LDLT) who required the exchange of percutaneous transhepatic biliary drainage catheters for inside stents. The rendezvous technique was performed using a guidewire in 19 patients (guidewire group) and using a KMP catheter in another 19 (KMP catheter group). We compared the two groups retrospectively.

RESULTS: The baseline characteristics did not differ between the groups. The success rate for placing inside stents was 100% in both groups. A KMP catheter was easier to manipulate than a guidewire. The mean procedure time in the KMP catheter group (1012 s, range: 301-2006 s) was shorter than that in the guidewire group (2037 s, range: 251-6758 s, P = 0.022). The cumulative probabilities corresponding to the procedure time of the two groups were significantly different (P = 0.008). The factors related to procedure time were the rendezvous technique method, the number of inside stents, the operator, and balloon dilation of the stricture (P < 0.05). In a multivariate analysis, the rendezvous technique method was the only significant factor related to procedure time (P = 0.010). The procedural complications observed included one case of mild acute pancreatitis and one case of acute cholangitis in the guidewire group, and two cases of mild acute pancreatitis in the KMP catheter group.

CONCLUSION: The rendezvous technique involving use of the KMP catheter was a fast and safe method for placing inside stents in patients with LDLT biliary stricture that represents a viable alternative to the guidewire rendezvous technique.

Modified rendezvous intrahepatic bile duct cannulation technique to pass a PTBD catheter in ERCP

The rendezvous procedure combines an endoscopic technique with percutaneous transhepatic biliary drainage (PTBD). When a selective common bile duct cannulation fails, PTBD allows successful drainage and retrograde access for subsequent rendezvous techniques. Traditionally, rendezvous procedures such as the PTBD-assisted over-the-wire cannulation method, or the parallel cannulation technique, may be available when a bile duct cannot be selectively cannulated. When selective intrahepatic bile duct (IHD) cannulation fails, this modified rendezvous technique may be a feasible alternative. We report the case of a modified rendezvous technique, in which the guidewire was retrogradely passed into the IHD through the C2 catheter after end-to-end contact between the tips of the sphincterotome and the C2 catheter at the ampulla’s orifice, in a 39-year-old man who had been diagnosed with gallbladder carcinoma with a metastatic right IHD obstruction. Clinically this procedure may be a feasible and timesaving technique.

Parallel cannulation technique at ERCP rendezvous

BACKGROUND

Biliary access at ERCP rendezvous is usually achieved by withdrawing a wire passed antegrade via the accessory channel of the duodenoscope, which is then used for over-the-wire cannulation. The wire is time consuming to maneuver and may be damaged during withdrawal.

OBJECTIVE

Description of a simple technique for cannulation at rendezvous that overcomes these problems.

DESIGN

Observational study.

SETTING

Gastroenterology department of a teaching district general hospital.

PATIENTS

Fourteen consecutive patients undergoing rendezvous after percutaneous transhepatic cholangiography (PTC).

INTERVENTION

A transpapillary drain was placed at PTC in 13 patients. At rendezvous, cannulation alongside the drain was attempted with a sphincterotome cannula. After successful cannulation, the drain was progressively withdrawn, allowing retrograde therapeutic intervention.

RESULTS

In all 13 patients, parallel cannulation was successful, allowing stone removal or biliary stent placement, with cannulation alongside a guidewire in the fourteenth patient. There were no complications except right hypochondrial pain after drain removal.

CONCLUSIONS

Parallel cannulation is straightforward and effective, avoiding the need for guidewire manipulation.

Endoscopic papillotomy, syn. sphincterotomy: results from the past two years

Endoscopic papillotomy, introduced in 1973, is now an established endoscopic procedure for treatment of various diseases of the papilla, bile duct, and pancreas. This article describes the use of this technique, the various instruments that can be employed, the instances in which it is indicated, and its associated complications and risks. Alternative treatments are also summarized.