Endoscopic Ultrasound-guided Rendezvous Technique Research Articles

Endoscopic ultrasound-guided rendezvous techniques for difficult biliary cannulation: Technical review.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard procedure for the diagnosis and treatment of biliary diseases. However, selective biliary cannulation, the essential first step in ERCP, can sometimes fail due to anatomical variations or technical limitations. In these cases, the endoscopic ultrasound-guided rendezvous technique (EUS-RV) offers a valuable salvage option. Nevertheless, it is crucial to be aware of potential adverse events associated with bile duct puncture. To optimize the success rate and safety of EUS-RV, understanding the basic techniques, technical tips for each procedural step, and troubleshooting strategies for potential difficulties is essential. This review article summarizes the clinical outcomes and technical considerations of EUS-RV, including a comprehensive analysis of the current evidence.

Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation : A Randomized Controlled Trial.

The standard salvage technique used for difficult bile duct cannulation is precut sphincterotomy, whereas endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively newer method. Prospective comparative data between these 2 techniques as salvage for biliary access in patients with benign biliary disease and difficult bile duct cannulation is lacking. To compare EUS-RV and precut sphincterotomy as salvage technique for difficult bile duct cannulation in benign biliary obstruction. Participant-masked, parallel-group, superiority, randomized controlled trial. (Clinical Trials Registry of India: CTRI/2020/07/026613). Tertiary care academic institute from July 2020 to May 2021. All patients with benign biliary disease and difficult bile duct cannulation requiring salvage strategy. Patients were randomly assigned by computer-generated randomized blocks sequence in 1:1 fashion to either EUS-RV or precut sphincterotomy. Patients with failure in EUS-RV were crossed over to precut sphincterotomy and vice versa. The primary outcome measure was technical success. The other outcome measures included procedure time, radiation dose, and adverse events. In total, 100 patients were randomly assigned to EUS-RV (n = 50) and precut sphincterotomy (n = 50). The technical success rate (92% vs. 90%; P = 1.00; relative risk, 1.02 [95% CI, 0.90 to 1.16]), median procedure time (10.1 vs. 9.75 minutes), and overall complication rate (12% vs. 10%; relative risk, 1.20 [CI, 0.39 to 3.68]) were similar between the 2 groups. Five patients (10%) in the EUS-RV group and 5 patients (10%) in the precut sphincterotomy group had developed post-endoscopic retrograde cholangiopancreatography pancreatitis. All failed cases in either salvage group could be successfully cannulated when crossed over to the other group. Single center study done by experts. Endoscopic ultrasound-guided rendezvous technique and precut sphincterotomy have similar success rates as salvage techniques in the technically challenging cohort of difficult bile duct cannulation for benign biliary disease, with acceptable complications rates. None.

Endoscopic ultrasound-guided rendezvous technique in a transduodenal long endoscopic position using a 22 G needle combined with a novel 0.018-inch guidewire.

The endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a salvage technique for failed biliary cannulation with benign disorders, but its success rate is not high [1] [2] [3]. The approach in a transduodenal, long endoscopic position (TDL) is preferred because it provides easier access to the bile duct, even if the bile duct is not dilated, as it stabilizes the scope position [4]. However, the TDL method, with a combination of a 19 G needle and 0.025-inch guidewire, directs the puncture needle toward the hepatic hilum because the range of motion of the scope and the needle is limited, making guidewire advance to the papilla challenging. Recently, a novel 0.018-inch guidewire (Fielder 18; Olympus, Tokyo, Japan) has been developed, which is similar to a 0.025-inch guidewire with good visibility, maneuverability, and stiffness ([Fig. 1]). Compared with the 19 G needle with 0.025-inch guidewire, a 22 G needle with the 0.018-inch guidewire has a more extensive range of motion for puncture, and the scope can be bent more acutely ([Fig. 2], [Fig. 3]). Therefore, the tip of the puncture needle can be directed toward the papilla, and the excellent maneuverability of this guidewire allows easier advance into the duodenum ([Fig. 4]). The 22 G needle may prevent bile leakage during the procedure due to its smaller diameter.

A Proposed Algorithm for Endoscopic Ultrasound-Guided Rendezvous Technique in Failed Biliary Cannulation.

Background: The selection of an approach route in endoscopic ultrasound-guided rendezvous (EUS-RV) for failed biliary cannulation is complicated. We proposed an algorithm for EUS-RV. Methods: We retrospectively evaluated consecutive EUS-RV cases between April 2017 and July 2020. Puncturing the distal extrahepatic bile duct (EHBD) from the duodenal second part (D2) (DEHBD/D2 route) was attempted first. If necessary, puncturing the proximal EHBD from the duodenal bulb (D1) (PEHBD/D1 route), puncturing the left intrahepatic bile duct (IHBD) from the stomach (LIHBD/S route), or puncturing the right IHBD from the D1 (RIHBD/D1 route) were attempted in this order. Results: A total of 16 patients were included. The DEHBD/D2 route was used in 10 (62.5%) patients. The PEHBD/D1 route was attempted in five (31.3%) patients, and the biliary puncture failed in one patient in whom the RIHBD/D1 route was used because of tumor invasion to the left hepatic lobe. The LIHBD/S route was applied in one (6.3%) patient. Successful biliary cannulation was achieved in all patients eventually. The time from the puncture to the guidewire placement in the DEHBD/D2 route (3.5 min) was shorter than that in other methods (14.0 min) (p = 0.014). Adverse events occurred in one (6.3%) patient with moderate pancreatitis. Conclusions: The proposed algorithm might be useful for the selection of an appropriate approach route in EUS-RV.

Salvage endoscopic ultrasound-guided rendezvous technique for disconnected pancreatic duct syndrome in a patient with severe acute pancreatitis.

Disconnected pancreatic duct syndrome (DPDS) is characterized by extraductal leakage of pancreatic juice and destruction of tissue surrounding the pancreas [1]. Many DPDS cases need surgical treatment [2]. Transpapillary pancreatic stenting and endoscopic ultrasound (EUS)-guided transmural drainage of PD and walled-off necrosis (WON) are also reported to be effective for DPDS [2] [3] [4]. The EUS-guided rendezvous technique (EUS-RV) was shown to be effective as a salvage procedure to connect to the disruption directly when drainage procedures to treat DPDS proved ineffective.

Endoscopic ultrasound-guided rendezvous technique using an intrahepatic bile duct approach with a “push endoscopic position”

Endoscopic ultrasound-guided rendezvous technique using an intrahepatic bile duct approach with a “push endoscopic position”

A Patient with Chronic Pancreatitis in whom Transpapillary Pancreatic Drainage was Successfully Performed by the Endoscopic Ultrasound-guided Rendezvous Technique

A Patient with Chronic Pancreatitis in whom Transpapillary Pancreatic Drainage was Successfully Performed by the Endoscopic Ultrasound-guided Rendezvous Technique

Endoscopic Ultrasound-Guided Rendezvous Technique for Failed Biliary Cannulation in Benign and Resectable Malignant Biliary Disorders.

Endoscopic ultrasound-guided rendezvous technique (EUS-RV) has emerged as an effective salvage method for unsuccessful biliary cannulation. However, its application for benign and resectable malignant biliary disorders has not been fully evaluated. To assess the efficacy and safety of EUS-RV for benign and resectable malignant biliary disorders. This was a multicenter prospective study from 12 Japanese referral centers. Patients who underwent EUS-RV after failed biliary cannulation for biliary disorder were candidates for this study. Inclusion criteria were unsuccessful biliary cannulation for therapeutic endoscopic retrograde cholangiopancreatography with benign and potentially resectable malignant biliary obstruction. Exclusion criteria included unresectable malignant biliary obstruction, inaccessible papillae 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 cannulation; procedure time, adverse events, and clinical outcomes were secondary outcomes. Twenty patients were prospectively enrolled. The overall technical success rate and median procedure time were 85% and 33min, respectively. Guidewire manipulation using a 4-Fr tapered tip catheter contributed to the success in advancing the guidewire into the duodenum. Adverse events were identified in 15% patients, including 2 with biliary peritonitis and 1 mild pancreatitis. EUS-RV did not affect surgical maneuvers or complications associated with surgery, or postoperative course. EUS-RV may be a safe and feasible salvage method for unsuccessful biliary cannulation for benign or resectable malignant biliary disorders. Use of a 4-Fr tapered tip catheter may improve the overall EUS-RV success rate.

Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique

Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique

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.

Innovations and techniques for balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine. Recently, many studies have reported that balloon-enteroscope-assisted ERCP (BEA-ERCP) is a safe and effective procedure. However, further improvements in outcomes and the development of simplified procedures are required. Percutaneous treatment, Laparoscopy-assisted ERCP, endoscopic ultrasound-guided anterograde intervention, and open surgery are effective treatments. However, treatment should be noninvasive, effective, and safe. We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications. BEA-ERCP still requires high expertise-level techniques and is far from a routinely performed procedure. Various techniques have been proposed to facilitate scope insertion (insertion with percutaneous transhepatic biliary drainage (PTBD) rendezvous technique, Short type single-balloon enteroscopes with passive bending section, Intraluminal injection of indigo carmine, CO2 inflation guidance), cannulation (PTBD or percutaneous transgallbladder drainage rendezvous technique, Dilation using screw drill, Rendezvous technique combining DBE with a cholangioscope, endoscopic ultrasound-guided rendezvous technique), and treatment (overtube-assisted technique, Short type balloon enteroscopes) during BEA-ERCP. The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients. A standard procedure for ERCP yet to be established for patients with a reconstructed intestine. At present, BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as first-line treatment. In this article, we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.

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

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. 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. 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. 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.

Endoscopic ultrasound-guided rendezvous technique for failed selective biliary cannulation

Endoscopic ultrasound-guided rendezvous technique for failed selective biliary cannulation

Endoscopic ultrasound-guided rendezvous for biliary access after failed cannulation

Selective cannulation fails in approximately 3 % of endoscopic retrograde cholangiography (ERC) procedures. An endoscopic ultrasound-guided rendezvous technique (EUS - RV) may salvage failed cannulation. The aims of the current study were to determine the safety and efficacy of EUS - RV. A total of 40 patients underwent salvage EUS - RV. EUS - RV was attempted immediately after failed biliary cannulation. A dilated intra- or extra-hepatic biliary duct (IHBD or EHBD) was punctured from the stomach or the small intestine under EUS guidance followed by cholangiography and antegrade manipulation of the guide wire into the small intestine. Finally, the echoendoscope was exchanged for an appropriate endoscope and biliary cannulation was achieved over or adjacent to the guide wire. EUS-RV appears safe and effective and may be considered as a primary salvage technique after failed cannulation. Antegrade manipulation of the guide wire into the small intestine was achieved in 29 of 40 patients (73 %; EHBD 25 /31 and IHBD 4/9). The reasons for failure were inability to advance the guide wire through an obstruction or a native ampulla. Re-attempt at ERC immediately after failed EUS - RV was made in seven of the 11 patients, and was successful in four. The remaining seven patients underwent percutaneous drainage within 3 days. Complications occurred in five patients (13 %), including pancreatitis, abdominal pain, pneumoperitoneum, and sepsis/death, which was unlikely to be related to the procedure. EUS - RV is safe and effective and should be considered as a primary salvage technique after failed cannulation. Immediate re-attempt at ERC after failed EUS - RV is warranted, as EUS-guided cholangiogram can facilitate biliary cannulation in some cases. Finally, prompt alternative biliary drainage should be available.