title: Percutaneous transgallbladder rendezvous for enteroscopic management of choledocholithiasis in patients with surgically altered anatomy.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  To evaluate the feasibility and safety of percutaneous transgallbladder (PTGB)-RV in patients with SAA.
  
  
  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.
  
  
  CONCLUSIONS
  PTGB-RV seems to be a feasible and relatively safe salvage technique in patients with SAA.
authors.affiliation: First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Okuno
authors.forename: Takuji
authors.initials: T
authors.lastname: Iwashita
authors.forename: Ichiro
authors.initials: I
authors.lastname: Yasuda
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Mabuchi
authors.forename: Shinya
authors.initials: S
authors.lastname: Uemura
authors.forename: Masanori
authors.initials: M
authors.lastname: Nakashima
authors.forename: Shinpei
authors.initials: S
authors.lastname: Doi
authors.forename: Seiji
authors.initials: S
authors.lastname: Adachi
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Mukai
authors.forename: Hisataka
authors.initials: H
authors.lastname: Moriwaki
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002760:Cholangiopancreatography, Endoscopic Retrograde; D042883:Choledocholithiasis / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D004106:Dilatation / Q000379:methods; D058582:Double-Balloon Enteroscopy; D004322:Drainage / Q000379:methods; D016145:Endoscopy, Digestive System / Q000379:methods*; D005240:Feasibility Studies; D005704:Gallbladder; D005743:Gastrectomy; D005763:Gastroenterostomy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000628:therapy*; D015641:Radiography, Interventional; D012189:Retrospective Studies; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional