The rendezvous technique for the treatment of choledocholithiasis

Endoscopic ultrasound-rendezvous versus percutaneous-endoscopic rendezvous endoscopic retrograde cholangiopancreatography for bile duct access: Systematic review and meta-analysis

OBJECTIVES

Endoscopic ultrasound (EUS) or percutaneous-assisted antegrade guidewire insertion can be used to achieve biliary access when standard endoscopic retrograde cholangiopancreatography (ERCP) fails. We conducted a systematic review and meta-analysis to evaluate and compare the effectiveness and safety of EUS-assisted rendezvous (EUS-RV) and percutaneous rendezvous (PERC-RV) ERCP.

METHODS

We searched multiple databases from inception to September 2022 to identify studies reporting on EUS-RV and PERC-RV in failed ERCP. A random-effects model was used to summarize the pooled rates of technical success and adverse events with 95% confidence interval (CI).

RESULTS

In total, 524 patients (19 studies) and 591 patients (12 studies) were managed by EUS-RV and PERC-RV, respectively. The pooled technical successes were 88.7% (95% CI 84.6-92.8%, I2  = 70.5%) for EUS-RV and 94.1% (95% CI 91.1-97.1%, I2  = 59.2%) for PERC-RV (P = 0.088). The technical success rates of EUS-RV and PERC-RV were comparable in subgroups of benign diseases (89.2% vs. 95.8%, P = 0.068), malignant diseases (90.3% vs. 95.5%, P = 0.193), and normal anatomy (90.7% vs. 95.9%, P = 0.240). However, patients with surgically altered anatomy had poorer technical success after EUS-RV than after PERC-RV (58.7% vs. 93.1%, P = 0.036). The pooled rates of overall adverse events were 9.8% for EUS-RV and 13.4% for PERC-RV (P = 0.686).

CONCLUSIONS

Both EUS-RV and PERC-RV have exhibited high technical success rates. When standard ERCP fails, EUS-RV and PERC-RV are comparably effective rescue techniques if adequate expertise and facilities are feasible. However, in patients with surgically altered anatomy, PERC-RV might be the preferred choice over EUS-RV because of its higher technical success rate.

Effectiveness and Safety of EUS Rendezvous After Failed Biliary Cannulation With ERCP: A Systematic Review and Proportion Meta-analysis

BACKGROUND

Endoscopic ultrasound-guided rendezvous (EUS-RV) endoscopic retrograde cholangiopancreatography (ERCP) is an alternative to interventional radiology-guided rendezvous ERCP in patients who failed biliary cannulation with conventional ERCP. However, there is significant variation in reported rates of success and adverse events associated with EUS-RV-assisted ERCP. We performed a systematic review and a proportion meta-analysis to reliably assess the effectiveness and safety of the EUS-RV-assisted ERCP.

MATERIALS AND METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through August 2020) to identify studies reporting EUS-RV-assisted ERCP in patients who failed biliary cannulation with conventional ERCP techniques. Using the random-effects model described by DerSimonian and Laird, we calculated the pooled rates of technical success, clinical success, and adverse events of EUS-RV-assisted ERCP.

RESULTS

Twelve studies reporting a total of 342 patients were included in the meta-analysis. The pooled rate of technical success (12 studies reporting a total of 342 patients) was 86.1% [95% confidence interval (CI): 78.4-91.3]. The pooled rate of clinical success (4 studies reporting a total of 94 patients) was 80.8% (95% CI: 64.1-90.8). The pooled rate of overall adverse events (12 studies; 42 events in 342 patients) was 14% (95% CI: 10.5-18.4). Low to moderate heterogeneity was noted in the analyses.

CONCLUSIONS

EUS-RV-assisted ERCP appears to be effective and safe in patients who failed biliary cannulation with conventional ERCP. Given the risk of adverse events, it should be performed in centers with expertise in therapeutic endoscopic ultrasound.

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

ACR Appropriateness Criteria® Radiologic Management of Biliary Obstruction

Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Safety and efficacy of percutaneous transhepatic-endoscopic rendezvous procedure in a single session

PURPOSE

To demonstrate the feasibility and safety of PTE-RV performed in a single session.

MATERIALS AND METHODS

This is a retrospective review of a prospective database on ERCP between January 2014 and December 2018. PTE-RV was performed in case of second ERCP failure. Technical success was defined as the establishment of an intestinal access to the biliary tract using a PTE-RV procedure allowing an immediate internal biliary drainage. Safety endpoints included intra-operative complications, morbidity and mortality occurring within 30 days after the procedure.

RESULTS

Eighty-four patients (44 M/40F) with a median age of 69 years (range 40-91 years) underwent combined PTE-RV. The PTE-RVs were successfully performed in the same session in 80 subjects, resulting in an overall technical success rate of 95.2%. Adverse events were observed in 19% (16/84) of cases. The mortality rate within 30 days after the procedure was 9.5%.

CONCLUSION

Percutaneous transhepatic-endoscopic rendezvous technique is feasible in a single session with acceptable level of risk. A randomized trial is required to compare EUBD and PTE-RV.

Comparison Between Endoscopic Biliary Stenting Combined with Balloon Dilation and Balloon Dilation Alone for the Treatment of Benign Hepaticojejunostomy Anastomotic Stricture

BACKGROUND

Hepaticojejunostomy anastomotic stricture (HJAS) is an important complication of biliary reconstructive surgery but has no standard treatment. We aimed to evaluate the outcomes of endoscopic treatment for benign HJAS and identify the risk factors for its recurrence.

METHODS

This study retrospectively analyzed 176 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for HJAS between April 2008 and March 2016. The outcome of endoscopic biliary stenting combined with balloon dilation (EBS group) and balloon dilation alone (balloon group) was evaluated.

RESULTS

The scope was successfully inserted into the HJ site in 93.8% patients (165/176), and 139 patients underwent endoscopic treatment after HJAS was confirmed. Successful biliary drainage was achieved in 137 patients by using ERCP and rendezvous procedures. Among these, 103 patients were included in balloon group and 34 patients were in EBS group. HJAS was resolved in 132 patients; five died from recurrence of primary disease. The 1 (3)-year bile duct patency rates in the balloon and EBS groups were 62.5% (46.6%) and 89.4% (84.7%), respectively (p = 0.015). Univariate analysis showed that balloon dilation (p = 0.009) and early HJAS formation (time from surgery to ERCP < 1 year) (p = 0.02) were risk factors for HJAS recurrence. In the multivariate analysis, balloon dilatation was identified as independent risk factors for HJAS recurrence.

CONCLUSIONS

Balloon dilation without stent deployment and early HJAS formation are risk factors for HJAS recurrence after endoscopic treatment. Stent deployment might be recommended for definite resolution of HJAS.

Endoscopic Biliary Intervention Using Traction Devices for Periampullary Diverticulum

We describe the case a 92-year-old woman who was admitted to our hospital with choledocholithiasis and periampullary diverticulum (PAD). Due to PAD, clear visualization of the ampulla of Vater could not be obtained. Although selective bile duct cannulation was difficult, a 7-Fr plastic stent was placed during the first session. Fifteen days later, endoscopic retrograde cholangiopancreatography was retried using traction devices, and the papilla became visible. Endoscopic sphincterotomy and stone extraction were performed without any complications. The application of traction devices in endoscopic submucosal dissection may be a promising technique in cases in which endoscopic biliary intervention is difficult due to PAD.

Endoscopic ultrasound-guided rendezvous in benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire

Background and study aims  The aim of this study was to assess the efficacy and safety of endoscopic ultrasound-guided rendezvous (EUS-RV) for benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire. Patients and methods  Patients who underwent EUS-RV after failed biliary or pancreatic cannulation for benign disorder were candidates for this study. For EUS-RV, a 22-gauge needle and a 0.018-inch guidewire were used. Inclusion criteria were unsuccessful biliary or pancreatic cannulation for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with benign biliary or pancreatic obstruction. Exclusion criteria included malignant biliary or pancreatic obstruction, inaccessible papilla due to surgically altered upper gastrointestinal anatomy or duodenal stricture, and previous sphincterotomy and/or biliary stent placement. The primary outcome was the technical success rate of biliary or pancreatic cannulation, and the secondary outcome was the rate of adverse events. Results  Thirty-one patients were evaluated. The overall technical success rate was 80.6 % (81.5 % in biliary and 75 % in pancreatic cases). Adverse events (AEs) were identified in 12.9 % of patients, including one with biliary peritonitis, one with abdominal pain and one with severe pancreatitis plus pneumomediastinum. Only one of the AEs (3.3 %) was directly related to the rendezvous procedure. Conclusions  EUS-RV may be a safe and feasible salvage method for unsuccessful cannulation for benign disorders. Use of a 22-gauge needle with a 0.018-inch guidewire may be the first option for benign pathology.

Percutaneous-transhepatic-endoscopic rendezvous procedures are effective and safe in patients with refractory bile duct obstruction

Background

Percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RVs) are rescue approaches used to facilitate biliary drainage.

Objective

The objective of this article is to evaluate the safety and the technical success of PTE-RVs in comparison with those of percutaneous transhepatic cholangiographies (PTCs).

Methods

Percutaneous procedures performed over a 10-year period were retrospectively analyzed in a single-center cohort. Examinations were performed because of a previous or expected failure of standard endoscopic methods including endoscopic retrograde cholangiography (ERC) or balloon-assisted ERC to achieve biliary access.

Results

In total, 553 percutaneous procedures including 163 PTE-RVs and 390 PTCs were performed. Overall, 71.3% of the patients suffered from malignant disease with pancreas-carcinoma (32.8%) and cholangio-carcinoma (19.0%) as the most frequent, while 28.7% of the patients suffered from benign disease. Many patients had a postoperative change in bowel anatomy (50.8%).PTC had a higher technical success rate (89.7%); however, the technical success rate of PTE-RVs was still high (80.4%; p < 0.003). Overall complications occurred in 23.5% of all procedures. Significantly fewer complications occurred after performing PTE-RVs than after PTCs (16.6% vs 26.4%; p = 0.037).

Conclusion

Beside a high technical efficacy of PTE-RVs, significantly fewer complications occur following PTE-RVs than following PTCs; thus, PTE-RV should be preferred over PTC alone in selected patients.

Successful biliary cannulation by the rendezvous technique via percutaneous transhepatic gallbladder drainage: A report of two cases

Reports of the rendezvous technique via percutaneous transhepatic gallbladder drainage are very rare because of difficulties with insertion of the guidewire from the gallbladder into the common bile duct. In particular, our report includes a case with distal common bile duct stricture. To our knowledge, such a case has never been previously reported.

Analysis of Wire-Guided Hemostasis Introducer for Percutaneous Therapy of Bile Duct Stones

BACKGROUND

Bile duct stones (BDS) are usually removed via endoscopic retrograde cholangiopancreatography (ERCP) or, if ERCP remains unsuccessful, percutaneous transhepatic cholangiodrainage (PTCD). However, PTCD provides limited access to large BDSs. We analyzed a modified approach of PTCD for percutaneous therapy of BDS.

METHODS

We used a modified approach of PTCD with a 13-french (Fr) hemostasis introducer for transhepatic access to BDS. Short-wired balloon or basket catheter were applied for safe removal of BDS. Patient characteristics, effectiveness, and complications were analyzed.

RESULTS

We identified 11 patients who underwent PTCD with hemostasis introducer. BDSs were either pushed forward to the duodenum (36%) or both partly pushed and extracted via hemostasis introducer (64%). In some cases, mechanical lithotripsy was necessary (45%). Complete removal of BDS was initially achieved in 36% of patients, 45% received additional PTCD, and in 19% stent implantation was performed. Finally, all BDSs could be removed. Laboratory analysis revealed significant reduction of alkaline phosphatase (p = 0.03) and C reactive protein (p = 0.03). Complications occurred only in 1 patient with post-interventional cholangitis.

CONCLUSION

Our study showed feasibility and safety of a modified PTCD with hemostasis introducer. In addition, protection of liver tissue from sharp-edged catheters and stones was achieved. Therefore, our modification revealed an innovational approach for transhepatic removal of BDS.

Papillary Cannulation Facilitated by Submucosal Saline Injection into an Intradiverticular Papilla

Endoscopic retrograde cholangiopancreatography (ERCP) of the intradiverticular papilla with its invisible orifice remains challenging. Several techniques have been introduced to evert the papillary opening to facilitate cannulation. A 79-year-old woman with bile duct stones underwent ERCP, which revealed that the papilla was located inside a large diverticulum and tended to rotate inward with a trial of papillary cannulation. Submucosal papillary injection of 3 cc of normal saline was performed at 3 and 9 o’clock. Eversion and fixation of a papilla in the diverticulum with this technique allowed selective cannulation of the biliary tree. Stones were retrieved after endoscopic papillary balloon dilation without complications. She had an uneventful post-procedural course. Our findings suggest that submucosal saline injection technique is safe and effective for selective cannulation and can be recommended when cannulation is very difficult because of an intradiverticular papilla.

Cannulation in patients with large periampullary diverticulum using SpyBite miniforceps

Introduction

Cannulation is difficult in patients with periampullary diverticulum (PAD). The described success rate varies from 61% to 95.4%.

Material and methods

Four cases with PAD in which, despite repeated attempts, we were unable to locate the papilla and cannulate. To overcome this difficulty, we used SpyBite forceps (Boston Scientific) to pull out the papillary orifice and then perform the cannulation using a sphincterotome introduced through the same working channel.

Results

This method reduced the time required for cannulation. In all four of our cases, we had 100% success in cannulation.

Conclusions

Use of SpyBite miniforceps in difficult cannulations in patients with PAD is useful and has an excellent success rate.

Endoscopic Ultrasound-guided Rendezvous Technique after Failed Endoscopic Retrograde Cholangiopancreatography: Which Approach Route Is the Best?

Objective The endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a salvage method for failed selective biliary cannulation. Three puncture routes have been reported, with many comparisons between the intra-hepatic and extra-hepatic biliary ducts. We used the trans-esophagus (TE) and trans-jejunum (TJ) routes. In the present study, the utility of EUS-RV for biliary access was evaluated, focusing on the approach routes. Methods and Patients In 39 patients, 42 puncture routes were evaluated in detail. EUS-RV was performed between January 2010 and December 2014. The patients were prospectively enrolled, and their clinical data were retrospectively collected. Results The patients' median age was 71 (range 29-84) years. The indications for endoscopic retrograde cholangiopancreatography (ERCP) were malignant biliary obstruction in 24 patients and benign biliary disease in 15. The technical success rate was 78.6% (33/42) and was similar among approach routes (p=0.377). The overall complication rate was 16.7% (7/42) and was similar among approach routes (p=0.489). However, mediastinal emphysema occurred in 2 TE route EUS-RV patients. No EUS-RV-related deaths occurred. Conclusion EUS-RV proved reliable after failed ERCP. The selection of the appropriate route based on the patient's condition is crucial.

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.

The rendezvous technique involving insertion of a guidewire in a percutaneous transhepatic gallbladder drainage tube for biliary access in a case of difficult biliary cannulation

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic method and treatment approach for biliary diseases. However, biliary cannulation can be difficult in some cases. We performed ERCP in a 97-year-old woman with abdominal pain resulting from acute cholangitis caused by choledocholithiasis and observed difficult biliary cannulation. Eventually, the patient was successfully treated with the rendezvous technique. We could not cannulate the biliary duct during ERCP twice. Therefore, we placed a percutaneous transhepatic gallbladder drainage (PTGBD) tube without intrahepatic dilation. The rendezvous technique was performed using the PTGBD tube. The patient did not experience pancreatitis or perforation.

Outcomes of management for biliary stricture after living donor liver transplantation with hepaticojejunostomy using short-type double-balloon enteroscopy

BACKGROUND AND AIMS

To evaluate the outcomes of management for biliary stricture (BS) after living donor liver transplantation (LDLT) using short-type double-balloon enteroscopy.

METHODS

This study retrospectively evaluated 20 patients who underwent endoscopic retrograde cholangiography using short-type double-balloon enteroscopy (sDB-ERC) upon suspicion of BS after LDLT with hepaticojejunal (HJ) reconstruction at Okayama University Hospital.

RESULTS

Scope insertion to the HJ site and sDB-ERC succeeded in 85 % (17/20) and 82.4 % (14/17) of patients, respectively. Of 14 patients who required treatment for BS, 11 were successfully treated using sDB-ERC, and 3 were successfully treated using sDB-ERC and rendezvous procedures. Adverse events occurred in 2.9 % of all sessions (2/68). After resolution of BS, 7 patients (50 %) experienced a recurrence. Of these, 6 (85.7 %) were treated with only balloon dilation, and 1 (14.3 %) was treated with both balloon dilation and stent deployment (P = 0.029).

CONCLUSIONS

sDB-ERC is a useful procedure for diagnosis and treatment for BS after LDLT with HJ reconstruction. Balloon dilation combined with stent deployment might be recommended for definite resolution of BS.

Endoscopic ultrasonography-guided rendezvous technique

Endoscopic retrograde cholangiopancreatography (ERCP) requires deep biliary cannulation. When deep biliary cannulation is failed, the endoscopic ultrasonography rendezvous technique (EUS-RV) is a useful salvage method. From the previous 15 articles that included 382 EUS-RV cases, the overall success rate of EUS-RV is 81 % with a complication rate of 10 %. In EUS-RV, the bile duct is punctured under EUS guidance and a guidewire is advanced into the duodenum via the papilla. The EUS scope is then switched to a duodenoscope and inserted into the bile duct over the guidewire exiting the papilla, or the guidewire is grasped with forceps and passed through the working channel; the catheter can then be inserted through the papilla over the wire. There are three puncture routes for EUS-RV: transgastric puncture of the intrahepatic bile duct (IHBD), transduodenal puncture of the extrahepatic bile duct (EHBD) via the proximal duodenum (D1), and transduodenal puncture of the EHBD via the second portion of the duodenum (D2). The puncture route for each patient should be selected based on the patient condition. GW selection for EUS-RV is critical, a hydrophilic GW is useful for this procedure. Although EUS-RV is now performed relatively routinely in a few high-volume centers, procedure standardization and the development of exclusive devices for EUS-RV are still underway. The development of exclusive devices for EUS-RV and prospective comparative studies with other salvage methods are needed to truly evaluate the procedure's usefulness and safety.

Current situation of endoscopic biliary cannulation and salvage techniques for difficult cases: Current strategies in Japan

In the pancreatobiliary session at Endoscopic Forum Japan (EFJ) 2015, current trends of routine biliary cannulation techniques and salvage techniques for difficult biliary cannulation cases were discussed. Endoscopists from nine Japanese high-volume centers along with two overseas centers participated in the questionnaires and discussion. It was concluded that, currently, in Western countries, the wire-guided cannulation (WGC) technique is favored during initial cannulation attempts. However, the conventional technique using an endoscopic retrograde cholangiopancreatography catheter with contrast medium injection is still used as first choice at most Japanese high-volume centers. The WGC technique is used as the second choice at some institutions only. After failed biliary cannulation attempts, the initial salvage option preferred in most centers includes pancreatic guidewire placement, followed by precut techniques as the second salvage choice. Among several precut techniques, the free-hand needle knife sphincterotomy with cutting upwards from the pancreatic duct is most popular. Endoscopic ultrasonography-guided rendezvous technique is also carried out as a final salvage option at select institutions.

Endoscopic retrograde cholangiopancreatography in periampullary diverticulum: The challenge of cannulation

Periampullary diverticulum (PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD is usually asymptomatic and discovered incidentally during endoscopic retrograde cholangiopancreatography (ERCP), it is associated with different pathological conditions such as common bile duct obstruction, pancreatitis, perforation, bleeding, and rarely carcinoma. ERCP has a low rate of success in patients with PAD, suggesting that this condition may complicate the technical application of the ERCP procedure. Moreover, cannulation of PAD can be challenging, time consuming, and require the higher level of skill of more experienced endoscopists. A large portion of the failures of cannulation in patients with PAD can be attributed to inability of the endoscopist to detect the papilla. In cases where the papilla is identified but does not point in a suitable direction for cannulation, different techniques have been described. Endoscopists must be aware of papilla identification in the presence of PAD and of different cannulation techniques, including their technical feasibility and safety, to allow for an informed decision and ensure the best outcome. Herein, we review the literature on this practical topic and propose an algorithm to increase the success rate of biliary cannulation.

Biliary drainage: role of EUS guidance

BACKGROUND AND AIMS

EUS-guided biliary drainage is a technique being increasingly used when ERCP fails, and it has been the focus of multiple studies and investment in recent years. However, the proportion of cases for which it is really indicated has not been established. The aim of this study is to determine how often EUS-guided biliary drainage is needed in a tertiary-care level therapeutic endoscopy unit.

METHODS

This is a prospective cohort study at a single tertiary-care center with a high volume of therapeutic endoscopy. A thousand consecutive ERCPs performed from November 1, 2013 to September 12, 2014 were screened, and those with previous biliary intervention were excluded (n = 476). EUS-guided biliary drainage was performed in suitable patients with failed ERCP and malignant biliary obstruction. The main outcome measures were the rates of ERCP failure and EUS-guided biliary drainage.

RESULTS

A total of 524 native papilla ERCPs were performed (41.2% male; median age 60 years, range 6-97 years; 9.4% outside failed ERCP; 1.9% surgically altered anatomy). The ampulla was reached in 518 (98.9%) and not reached in 6 (1.1%) because of surgically altered anatomy (n = 2), malignant duodenal stenosis (n = 3), or both (n = 1). The overall ERCP failure rate was 1.7% (9/524). Cannulation was successful in 99.4% (515/518) and unsuccessful in 0.6% (3/518) of cases in which the ampulla was reached. EUS-guided biliary drainage was indicated in 0.6% (3/524) of all referred native papilla ERCPs, or 33% (3/9) of those patients with failed ERCP; EUS-biliary drainage was successful in all cases.

CONCLUSIONS

In a tertiary-care center, use of advanced ERCP techniques results in a high technical success rate. EUS-guided biliary drainage was required in only 0.6% of native papilla ERCPs, and although a number of excellent indications exist, it should not replace good ERCP technique.

Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients

BACKGROUND/AIMS

Choledocholithiasis is a common complication of cholecystolithiasis, occurring in 15-20% of patients who have gallbladder stones. Endoscopic retrograde cholangio-pancreatography is the standard treatment. When this is not possible or not feasible, percutaneous transhepatic stone removal is an alternative treatment. In this retrospective study, we analyze 110 patients who were treated with percutaneous transhepatic removal of Common Bile Duct (CBD) stones.

PATIENTS AND METHODS

Between March 1998 and September 2013 110 patients (61 men, 49 women; aged 14-96, mean age 69.7 years) with confirmed bile duct stones were included. PTC was done using ultrasound and fluoroscopy. Balloon dilatation of the papilla was done with 8-12 mm balloons. If stone size exceeded 10 mm, mechanical lithotripsy was performed. Stones were then removed by percutaneous extraction or evacuation into the duodenum.

RESULTS

In 104 patients (104/110; 94.5%) total stone clearance of the CBD was achieved. A total of 12 complications occurred (10.9%), graded with the Clavien-Dindo scale as IVa, IVb, and V, respectively; hypoxia requiring resuscitation, sepsis and death due to ongoing cholangiosepsis (n = 1, 4, 1). Minor complications I, II, and IIIa included: small liver abscess, pleural empyema, transient hemobilia and mild fever (n = 1, 1, 2, 2).

CONCLUSION

Percutaneous removal of CBD stones is an effective alternative treatment, when endoscopic treatment is contra-indicated, fails or is not feasible. It is effective, has a low complication rate and using deep sedation potentially requires only a very limited number of treatment sessions.

Endoscopic ultrasound guided biliary and pancreatic duct interventions

When endoscopic retrograde cholangio-pancreatography fails to decompress the pancreatic or biliary system, alternative interventions are required. In this situation, endosonography guided cholangio-pancreatography (ESCP), percutaneous radiological therapy or surgery can be considered. Small case series reporting the initial experience with ESCP have been superseded by comprehensive reports of large cohorts. Although these reports are predominantly retrospective, they demonstrate that endoscopic ultrasound (EUS) guided biliary and pancreatic interventions are associated with high levels of technical and clinical success. The procedural complication rates are lower than those seen with percutaneous therapy or surgery. This article describes and discusses data published in the last five years relating to EUS-guided biliary and pancreatic intervention.

Combined interventional radiology followed by endoscopic therapy as a single procedure for patients with failed initial endoscopic biliary access

BACKGROUND

Percutaneous transhepatic cholangiography (PTC) assisted endoscopic retrograde cholangiopancreatography (ERCP) usually requires two separate sessions. There are no reports to support performing the procedures in a single session.

AIM

The purpose of this study was to assess the feasibility and safety of the ERCP rendezvous technique via PTC in a single session for patients with initially failed endoscopic biliary intervention.

METHOD

We conducted a retrospective cohort study in a high volume tertiary referral center. A single experienced endoscopist and two interventional radiologists performed all the procedures. Patient demographics and all the related clinical data from January 2009 to July 2011 were obtained from hospital records. Outcome measures were the overall success rates of completion of the combined PTC and ERCP sessions for biliary drainage. Procedure-related complications (bleeding, perforation, hemobilia, bile leak, pancreatitis or cholangitis) were also assessed.

RESULT

Twenty-three patients (14 men) with a median age of 68 years (range 47-89 years) underwent 26 combined PTC-ERCP as a single procedure. PTC and ERCP were both performed within 6 h of failed ERCP in 19 cases (73 %) and the others within 72 h. A total of 91 % of patients had underlying gastrointestinal metastatic cancers, and a surgically altered pancreaticobiliary system was found in 26 % of patients. Percutaneous biliary access was obtained via PTC in all procedures and successful rendezvous therapy was performed in 23 cases (88 %), which include biliary stone removal with a balloon catheter (n = 7) and biliary prostheses (n = 19). The median procedure length for successful PTC-ERCP rendezvous was 60 min (range 14-147 min). With the mean follow-up of 202 days (range 8-833 days), three immediate procedural complications [asymptomatic pneumoperitoneum (n = 2) and post biliary sphincterotomy bleeding (n = 1)] and two delayed complications (a hemorrhagic shock from a damaged branch of hepatic artery and a biloma with secondary infection) occurred, and there was no procedure-associated mortality.

CONCLUSION

This is the first report assessing the feasibility and safety of a combined procedure of ERCP and PTC in a single session. In experienced hands, the combined approach in a single session is appropriate in selected patients with an acceptable risk.

Interventional endoscopic ultrasonography: an overview of safety and complications

BACKGROUND

In recent years, endoscopic ultrasonography (EUS)-guided techniques have been developed as alternatives to surgical, radiologic, or conventional endoscopic approaches for the treatment or palliation of several digestive diseases. The use of EUS guidance allows the therapeutic area to be targeting more precisely, with a possible clinical benefit and less morbidity. Nevertheless, the risks persist and must be taken into consideration. This review gives an overview of the complications observed with the most established procedures of therapeutic EUS.

METHODS

The PubMed and Embase databases were used to search English language articles on interventional EUS. The studies considered for inclusion were those reporting on complications of EUS-guided celiac plexus block (EUS-CPB), EUS-guided celiac plexus neurolysis (EUS-CPN), drainage of fluid pancreatic and pelvic collections, and EUS-guided biliary and pancreatic drainage (EUS-BD and EUS-PD). Variations in methodology and design in most studies made a thorough statistical analysis difficult. Instead, a frequency analysis of complications and a critical discussion were performed.

RESULTS

Although EUS-guided celiac plexus injection causes mainly mild and transient complications, growing experience shows that EUS-CPN is not as benign a procedure as previously thought. Most of the major complications have been observed in patients with chronic pancreatitis. The findings show that EUS-guided drainage of fluid collections is a safe procedure. Complications occur more often after the drainage of pancreatic abscesses and necrosis. Although the heterogeneity of studies dealing with pancreatobiliary drainage makes the evaluation of risks after these procedures difficult, complications after EUS-BD and EUS-PD are relatively frequent and can be severe. The technical complexity and the lack of specifically designed devices may account for their complication rates.

CONCLUSIONS

Clinicians can consider EUS-guided celiac injection and EUS-guided drainage of fluid collections to be safe alternatives to surgical and radiologic interventions. Well-designed prospective trials are needed to assess the risks of EUS-BD and EUS-PD accurately before they are broadly advocated after a failed endoscopic retrograde cholangiopancreatography (ERCP).

Percutaneous transgallbladder rendezvous for enteroscopic management of choledocholithiasis in patients with surgically altered anatomy

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy (SAA) is generally challenging despite the use of enteroscopy. After failed biliary cannulation, rendezvous technique (RV) can be an option to assist the biliary access. However, proper needle puncture of biliary ducts, which is critical in the RV procedure, can be difficult because of insufficient biliary dilation. By contrast, the gallbladder can be punctured as a possible access route for RV.

AIM

To evaluate the feasibility and safety of percutaneous transgallbladder (PTGB)-RV in patients with SAA.

PATIENTS AND METHODS

Six patients who underwent PTGB-RV were included. PTGB drainage was performed in cases without sufficient biliary duct dilation. A guidewire was inserted through the PTGB route with antegrade passage through the cystic duct, common bile duct and duodenal papilla. An enteroscope was inserted up to the papilla, at the guidewire exit site. The guidewire was pulled out through the accessory channel followed by biliary cannulation over the guidewire and endoscopic papillary balloon dilation (EPBD) for stone removal.

RESULTS

Six patients with SAA (Roux-en-Y in 4 and Billroth-II in 2) underwent PTGB-RV for removal of bile duct stones. In all patients, a guidewire was successfully inserted into the duodenum followed by insertion of the enteroscope and biliary cannulation. EPBD was then performed, but subsequent stone removal failed in 1 patient. Stone removal was successful in 5 patients without complication, except 1 case of mild pancreatitis.

CONCLUSION

PTGB-RV seems to be a feasible and relatively safe salvage technique in patients with SAA.

Difficult biliary access for ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically-demanding procedure. The ability to selectively cannulate the bile duct and pancreatic duct (PD) quickly and atraumatically is the key to successful therapeutic ERCP, and to minimizing post-ERCP complications, especially pancreatitis (PEP). Prophylactic stenting of the PD has significantly reduced the risk of severe PEP. Difficult ERCP access refers to the length of time and number of attempts it takes to achieve deep cannulation of the desired duct. If biliary access cannot be achieved quickly, PD stenting over a guide wire is recommended, which facilitates further attempts to enter the bile duct. Familiarity with guide wires and needle knife papillotomy technique are necessary to achieve close to 100 % biliary cannulation. Anatomic abnormalities, from gastric outlet strictures, periampullary diverticula, and ampullary masses to surgical rearrangement of the upper GI tract, contribute to the difficulty of performing ERCP. Adjunctive techniques to overcome these problems include percutaneous transhepatic biliary access and endoscopic ultrasound (EUS)-guided puncture of the bile duct through the stomach or duodenal wall. Therapeutic EUS is emerging as a major tool in the management of pancreatic and biliary disease, and will likely replace many therapeutic ERCP techniques in the next decade.

Clinical utility of an endoscopic ultrasound-guided rendezvous technique via various approach routes

BACKGROUND

The endoscopic ultrasound-guided rendezvous techniques (EUS-rendezvous) provide reliable biliary access after failed endoscopic retrograde cholangiopancreatography (ERCP) cannulation. We evaluated the clinical utility of an EUS-rendezvous technique using various approach routes.

METHODS

Patients undergoing EUS-rendezvous for biliary access after failed bile duct cannulation in ERCP were included. EUS-rendezvous was performed via three approach routes depending on the patient's condition: transgastric, transduodenal in a short endoscopic position, or transduodenal in a long endoscopic position. The main outcomes were the technical success rates. Secondary outcomes were procedure time and complications.

RESULTS

Fourteen patients (median age, 77 years) underwent EUS-rendezvous for biliary access resulting from failed biliary cannulation. The reasons for biliary drainage were malignant biliary obstruction in five patients and choledocholithiasis in nine. Transgastric, transduodenal in a short position, and transduodenal in a long position EUS-rendezvous was performed in five, five, and four patients, respectively. Bile duct puncture occurred in the left intrahepatic duct in four patients, right hepatic duct in one, middle common bile duct in four, and lower common bile duct in five. The technical success rate was 100 %. In four patients, the approach route was modified from transduodenal in a short position to transduodenal in a long position or transgastric route. The median procedure time was 81 min. One case each of biliary peritonitis and pancreatitis occurred and were managed conservatively.

CONCLUSIONS

EUS-rendezvous provided safe and reliable transpapillary bile duct access after failed ERCP cannulation. The selection of the appropriate approach routes, depending on patient condition, is critical.

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.

Outcome of repeat ERCP after initial failed use of a needle knife for biliary access

INTRODUCTION

A needle knife is often used to gain bile duct access when standard techniques have failed. If unsuccessful, the next step may involve either radiological- or endoscopic ultrasound-guided biliary access. However, repeat endoscopic retrograde cholangiopancreatography (ERCP) may be an option if the patient's clinical condition permits.

AIM

To determine the success of repeat ERCP after failed use of a needle knife to gain biliary access.

METHODS

Retrospective analysis of all patients who underwent initial unsuccessful biliary cannulation after use of a needle knife between 2007 and 2010.

RESULTS

Seventy five patients were identified. Of these, 51 (68%) underwent repeat ERCP, and biliary cannulation was successful in 38 (75%). The median time to repeat ERCP was 7.7 days (range 1-28 days). Complications developed in two (4%) patients. These included one case each of wire-guided perforation and mild pancreatitis, both of which were resolved by conservative management.

CONCLUSIONS

Repeat ERCP within a few days after failed use of a needle knife for biliary access is associated with acceptable success and acceptable incidence of complications, and therefore obviates the need for alternative approaches for biliary access for most patients.

The Use of a Hemostasis Introducer for Percutaneous Extraction of Bile Duct Stones

Background

Choledocholithiasis is defined as presence of at least one gallstone in the bile duct. Those bile duct stones (BDS) usually are extracted by ERCP. In case the bile duct is not accessible endoscopically (e.g. after major abdominal surgery), PTCD has to be performed. Extraction of the stones via PTCD has several risks as are hemorrhage, pancreatitis and injuries of the liver tissue.

Methods

We here report about our experience with a significant modification of this technique by use of a 13-french hemostasis introducer as a sheath to track the transhepatic access to the bile ducts in order to reduce time and risk.

Results

Three patients were treated by use of the reported modification. In all cases, the stones were successfully removable without complications.

Conclusion

We demonstrate that the use of a hemostasis introducer for percutaneous extraction of common bile duct stones seems to be promising in terms of shortening hospital stay and increasing patient safety.

EUS-guided biliary rendezvous using a short hydrophilic guidewire

BACKGROUND AND STUDY AIMS: EUS-guided rendezvous technique for biliary access requires expert manipulation of the guidewire across the downstream stricture or papilla. Published literature reports usage of the long-wire system to prevent loss of wire during scope exchange. We studied the efficacy of using a short hydrophilic guidewire in EUS-guided rendezvous. PATIENTS AND METHODS: This is a retrospective study conducted in a tertiary care referral centre. 15 patients underwent EUS-guided biliary rendezvous with short wire. EUS-guided transduodenal/transgastric puncture of the biliary system was performed, followed by anterograde placement of a hydrophilic short-wire (260 cm) across the downstream stricture and/or papilla. Retrograde access was then achieved by retrieving the trans-papillary wire, followed by standard ERCP intervention. Main outcome measurements were rates of procedural success and complications. RESULTS: EUS-guided biliary rendezvous was successful in 14 patients (93.3%). Failure was seen in one patient due to a tight malignant biliary stricture. One patient had peri-choledochal bile tracking which did not require any specific treatment. CONCLUSIONS: Short-wire system in EUS-guided biliary rendezvous is highly effective and safe. It is a useful salvage procedure for biliary cannulation in patients with accessible papilla.

EUS-guided biliary rendezvous using a short hydrophilic guidewire

BACKGROUND AND STUDY AIMS: EUS-guided rendezvous technique for biliary access requires expert manipulation of the guidewire across the downstream stricture or papilla. Published literature reports usage of the long-wire system to prevent loss of wire during scope exchange. We studied the efficacy of using a short hydrophilic guidewire in EUS-guided rendezvous. PATIENTS AND METHODS: This is a retrospective study conducted in a tertiary care referral centre. 15 patients underwent EUS-guided biliary rendezvous with short wire. EUS-guided transduodenal/transgastric puncture of the biliary system was performed, followed by anterograde placement of a hydrophilic short-wire (260 cm) across the downstream stricture and/or papilla. Retrograde access was then achieved by retrieving the trans-papillary wire, followed by standard ERCP intervention. Main outcome measurements were rates of procedural success and complications. RESULTS: EUS-guided biliary rendezvous was successful in 14 patients (93.3%). Failure was seen in one patient due to a tight malignant biliary stricture. One patient had peri-choledochal bile tracking which did not require any specific treatment. CONCLUSIONS: Short-wire system in EUS-guided biliary rendezvous is highly effective and safe. It is a useful salvage procedure for biliary cannulation in patients with accessible papilla.

Self-expandable metal stents for malignant distal biliary strictures

Obstructive jaundice can result from benign or malignant etiologies. The common benign conditions include primary sclerosing cholangitis, chronic pancreatitis, and gallstones. Malignant biliary obstruction can be caused by direct tumor infiltration, extrinsic compression by enlarged lymph nodes or malignant lesions, adjacent inflammation, desmoplastic reaction from a tumor, or a combination of these factors. Malignant diseases causing biliary obstruction include pancreatic cancer, ampullary cancer, cholangiocarcinoma, and metastatic diseases. This article focuses on malignant distal biliary obstruction and its management.

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.

Endoscopic ultrasound-guided cholangiopancreatography and rendezvous techniques

Endoscopic ultrasound-guided cholangiopancreatography (EUCP) has become an alternative to percutaneous drainage or surgery in patients with obstructive jaundice or pancreatic obstruction after failed conventional ERCP. The different techniques of biliary and pancreatic drainage are described and the literature is reviewed. Due to the technical complexity associated with this procedure, it should be reserved for endoscopists at tertiary care centers with advanced training in both EUS and ERCP.

Usefulness of the rendezvous technique for biliary stricture after adult right-lobe living-donor liver transplantation with duct-to-duct anastomosis

BACKGROUND/AIMS

Replacement of a percutaneous transhepatic biliary drainage (PTBD) catheter with inside stents using endoscopic retrograde cholangiography is difficult in patients with angulated or twisted biliary anastomotic stricture after living donor liver transplantation (LDLT). We evaluated the usefulness and safety of the rendezvous technique for the management of biliary stricture after LDLT.

METHODS

Twenty patients with PTBD because of biliary stricture after LDLT with duct-to-duct anastomosis underwent the placement of inside stents using the rendezvous technique.

RESULTS

Inside stents were successfully placed in the 20 patients using the rendezvous technique. The median procedure time was 29.6 (range, 7.5-71.8) minutes. The number of inside stents placed was one in 12 patients and two in eight patients. One mild acute pancreatitis and one acute cholangitis occurred, which improved within a few days. Inside stent related sludge or stone was identified in 12 patients during follow-up. Thirteen patients achieved stent-free status for a median of 281 (range, 70-1,351) days after removal of the inside stents.

CONCLUSIONS

The rendezvous technique is a useful and safe method for the replacement of PTBD catheter with inside stent in patients with biliary stricture after LDLT with duct-to-duct anastomosis. The rendezvous technique could be recommended to patients with angulated or twisted strictures.

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis

BACKGROUND

Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV).

METHODS

A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options.

RESULTS

Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors' comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems.

CONCLUSIONS

There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Single-operator EUS-guided cholangiopancreatography for difficult pancreaticobiliary access (with video)

BACKGROUND

When conventional ERCP methods fail because of periampullary or ductal obstruction, EUS-guided cholangiopancreatography (EUS-CP) may aid in pancreaticobiliary access.

OBJECTIVE

To report our experience when using single-operator EUS-CP.

SETTING

An academic tertiary-referral center.

METHODS

Consecutive patients undergoing EUS-CP were prospectively identified. These patients had undergone failed attempt(s) at therapeutic ERCP. A data sheet was used to record indications, reasons for failed ERCP, EUS-CP visualization of the duct of interest, transpapillary or transenteric intervention, clinical follow-up, and complications.

MAIN OUTCOME MEASUREMENTS

Technical success was decompression of the duct of interest. Clinical success was resolution of jaundice or a > or = 50% reduction in pain or narcotics, as applicable.

RESULTS

Between February 2003 and June 2007, EUS-CP was attempted in 20 patients (11 men, 9 women; mean [SD] age 58 +/- 14.9 years). Indications included jaundice (n = 8), biliary stones (n = 3), chronic pancreatitis (n = 6), acute pancreatitis (n = 2), and papillary stenosis (n = 1). Reasons for failed ERCP included periampullary mass (n = 8), intradiverticular papillae (n = 4), and pancreatic duct (PD) stricture (n = 7) or stone (n = 1). Technical success was achieved in 18 of 20 patients (90%). Biliary decompression was obtained in 11 of 12 patients (92%) (7 transpapillary and 4 transenteric-transcholedochal). Pancreatic decompression was obtained in 7 of 8 patients (88%) (3 transpapillary, 4 transgastric). On follow-up, clinical improvement was noted in 15 of 20 patients (70%). For treatment of pain associated with chronic pancreatitis, pain scores decreased by a mean of 1.75 (P = .18). Complications (in 2 of 20 [10%]) included perforation (n = 1) and respiratory failure (n = 1).

LIMITATIONS

A single-center nonrandomized observational study with a small patient population.

CONCLUSIONS

At our academic referral center, single-operator EUS-CP provided decompression of obstructed ducts and may be performed after a failed attempt at conventional ERCP during the same endoscopic session.

Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction

Biliary strictures after living donor liver transplantation (LDLT) with duct-to-duct (D-D) reconstruction are associated with postoperative morbidity and mortality. The aims of this study were to evaluate the long-term outcomes of endoscopic deployment of plastic stents, and to investigate factors associated with the stent deployment failure. Between April 2001 and May 2007, 96 patients received LDLT with D-D reconstruction at Okayama University Hospital. Among them, 41 patients (43%) had anastomotic biliary strictures, and all were referred first for endoscopic retrograde cholangiography (ERC). When deployment was unsuccessful, a percutaneous transhepatic procedure was employed. Successful stent deployment was achieved in 35 out of total 41 patients (85%) by both procedures. Among the 35 patients, 28 had their stents removed as a result of strictures resolution. Eight patients underwent ERC and repeated stent deployment as a result of recurrence of the strictures. Finally, 21 out of 41 (51%) patients with biliary stricture were completely treated by endoscopic therapy during the observation period (median 873 days: range 77-2060). By multivariate analysis, biliary leakage was associated with stent deployment failure. Endoscopic deployment of plastic stents is a first-line therapy for patients with biliary stricture after LDLT.