title: EUS-guided rendezvous for difficult biliary cannulation using a standardized algorithm: a multicenter prospective pilot study (with videos).
abstract: OBJECTIVE
  Biliary cannulation is necessary in therapeutic ERCP for biliary disorders. EUS-guided rendezvous (EUS-RV) can salvage failed cannulation. Our aim was to determine the safety and efficacy of EUS-RV by using a standardized algorithm with regard to the endoscope position in a prospective study.
  
  
  METHODS
  EUS-RV was attempted after failed cannulation in 20 patients. In a standardized approach, extrahepatic bile duct (EHBD) cannulation was preferentially attempted from the second portion of the duodenum (D2) followed by additional approaches to the EHBD from the duodenal bulb (D1) or to the intrahepatic bile duct from the stomach, if necessary. A guidewire was placed in an antegrade fashion into the duodenum. After the guidewire was placed, the endoscope was exchanged for a duodenoscope to complete the cannulation.
  
  
  RESULTS
  The bile duct was accessed from the D2 in 10 patients, but from the D1 in 5 patients and the stomach in 4 patients because of no dilation or tumor invasion at the distal EHBD. In the remaining patient, biliary puncture was not attempted due to the presence of collateral vessels. The guidewire was successfully manipulated in 80% of patients: 100% (10/10) with the D2 approach and 66.7% (6/9) with other approaches. The overall success rate was 80% (16/20). Failed EUS-RV was salvaged with a percutaneous approach in 2 patients, repeat ERCP in 1 patient, and conservative management in 1 patient. Minor adverse events occurred in 15% of patients (3/20).
  
  
  CONCLUSIONS
  EUS-RV is a safe and effective salvage method. Using EUS-RV to approach the EHBD from the D2 may improve success rates.
authors.affiliation: First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
authors.forename: Takuji
authors.initials: T
authors.lastname: Iwashita
authors.affiliation: Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan.
authors.forename: Ichiro
authors.initials: I
authors.lastname: Yasuda
authors.affiliation: Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan.
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Mukai
authors.affiliation: Department of Gastroenterology, Gifu Prefectural General Hospital, Gifu, Japan.
authors.forename: Keisuke
authors.initials: K
authors.lastname: Iwata
authors.affiliation: Department of Gastroenterology, Gifu Prefectural General Hospital, Gifu, Japan.
authors.forename: Nobuhiro
authors.initials: N
authors.lastname: Ando
authors.affiliation: Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan.
authors.forename: Shinpei
authors.initials: S
authors.lastname: Doi
authors.affiliation: Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan.
authors.forename: Masanori
authors.initials: M
authors.lastname: Nakashima
authors.affiliation: First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
authors.forename: Shinya
authors.initials: S
authors.lastname: Uemura
authors.affiliation: Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan.
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Mabuchi
authors.affiliation: First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
authors.forename: Masahito
authors.initials: M
authors.lastname: Shimizu
mesh_terms: D000368:Aged; D000465:Algorithms; D001650:Bile Duct Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D017734:Bile Ducts, Extrahepatic; D002404:Catheterization / Q000379:methods*; D004322:Drainage / Q000379:methods*; D019160:Endosonography / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D025321:Surgery, Computer-Assisted / Q000379:methods*; D016896:Treatment Outcome