title: Combined interventional radiology followed by endoscopic therapy as a single procedure for patients with failed initial endoscopic biliary access.
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Tomizawa
authors.forename: Jose
authors.initials: J
authors.lastname: Di Giorgio
authors.forename: Ernesto
authors.initials: E
authors.lastname: Santos
authors.forename: Kevin M
authors.initials: KM
authors.lastname: McCluskey
authors.forename: Andres
authors.initials: A
authors.lastname: Gelrud
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001660:Biliary Tract Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects; D004322:Drainage; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania; D015641:Radiography, Interventional / Q000009:adverse effects; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D016896:Treatment Outcome