title: Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series.
abstract: Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66 +/- 18.2 years; malignant = 10, benign = 5). Mean diameter of measured bile ducts was 14.3 +/- 5.17 mm (range 4-23 mm). The reasons for initial ERCP failure were tumor infiltration or edema (n = 9), intradiverticular papilla (n = 2), pre-existing duodenal stent (n = 1), and anatomic anomalies (n = 3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100 %), with drainage being successful in 12 / 15 (80 %). Failures occurred in three patients due to inability to traverse the biliary stricture (n = 2) or dissection of a choledochocele with the guide wire (n = 1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.
authors.affiliation: Internal Medicine, Gacheon Gil Medical Center of Gacheon Medical School, Incheon, Korea.
authors.forename: Y S
authors.initials: YS
authors.lastname: Kim
authors.forename: K
authors.initials: K
authors.lastname: Gupta
authors.forename: S
authors.initials: S
authors.lastname: Mallery
authors.forename: R
authors.initials: R
authors.lastname: Li
authors.forename: T
authors.initials: T
authors.lastname: Kinney
authors.forename: M L
authors.initials: ML
authors.lastname: Freeman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D001649:Bile Duct Diseases / Q000000981:diagnostic imaging*; D001652:Bile Ducts / Q000000981:diagnostic imaging*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D003138:Common Bile Duct Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000556:secondary; D004386:Duodenum; D016145:Endoscopy, Digestive System; D019160:Endosonography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged