Endoscopic Ultrasound-guided Rendezvous Research Articles

Endoscopic ultrasound-guided rendezvous in pancreas divisum with a nondilated pancreatic duct.

Pancreas divisum is the most common congenital malformation of the pancreas, in which a single pancreatic duct does not form in the 7th week of gestation. It usually causes no symptoms or complications, but a small percentage of persons with this malformation develop recurrent acute pancreatitis. Patients with recurrent acute pancreatitis may benefit from endoscopic sphincterotomy of the minor papilla to open up the outflow of the dorsal pancreatic duct [1] [2].

EUS-guided versus PTC-guided rendezvous in case of failed ERCP: a case-control study.

Endoscopic ultrasound-guided rendezvous (EUS-RV) is a recently added alternative salvage technique to percutaneous transhepatic cholangiography rendezvous (PTC-RV) for achieving biliary cannulation in failed ERCP. Comparative data on these two techniques are lacking. The aim of this study is to evaluate the efficacy and safety of EUS-RV versus PTC-RV in a tertiary referral center. A case-control study was conducted in the tertiary referral center, Ghent University Hospital. All consecutive patients that underwent a rendezvous procedure between February 2014 and March 2022 for failed biliary cannulation were included. Patients that underwent PTC-RV (between February 2014 and February 2018) were compared to those who underwent EUS-RV (between March 2018 and March 2022). A sub-analysis was performed for malignant biliary strictures (MBO), benign biliary strictures (BBO) and common bile duct stones (CBDS). The primary endpoints of interest were technical success rate and complication rate. These outcome variables were compared among techniques using Fisher's exact test. Statistical analyses were performed using STATA version 15. A total of 59 consecutive procedures in 57 patients were included for analysis; 20/59 (33.9%) were PTC-RV; the remaining 39/59 (66.1%) procedures were EUS-RV. Two patients in the PTC-RV group underwent two procedures. Of the PTC-RV procedures, 18/20 (90.0%) were technically successful, as compared to 28/39 EUS-RV procedures (71.8%) (P = 0.184; Fig.1). Adverse events were reported in 7/20 PTC-RV procedures (35.0%) and in 13/39 EUS-RV procedures (33.3%) (P = 1.000). In 5/20 PTC-RV procedures (25.0%) and 4/39 EUS-RV procedures (10.3%), the adverse event was considered major (defined as AGREE classification of 3 or more; P = 0.249). EUS-RV has an acceptable success rate and is not associated with an increased risk of adverse events as compared to PTC-RV.

S346 Gallbladder to the Rescue: Transcystic Endoscopic Ultrasound-Guided Rendezvous

S346 Gallbladder to the Rescue: Transcystic Endoscopic Ultrasound-Guided Rendezvous

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

Endoscopic ultrasound-guided rendezvous for extrahepatic bile duct recanalization after surgical transection.

Endoscopic ultrasound-guided rendezvous for extrahepatic bile duct recanalization after surgical transection.

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.

Endoscopic ultrasound-guided rendezvous for access to the right posterior bile duct in a surgical candidate.

Endoscopic ultrasound-guided rendezvous for access to the right posterior bile duct in a surgical candidate.

Endoscopic ultrasound-guided rendezvous in benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire.

Background and study aims The aim of this study was to assess the efficacy and safety of endoscopic ultrasound-guided rendezvous (EUS-RV) for benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire. Patients and methods Patients who underwent EUS-RV after failed biliary or pancreatic cannulation for benign disorder were candidates for this study. For EUS-RV, a 22-gauge needle and a 0.018-inch guidewire were used. Inclusion criteria were unsuccessful biliary or pancreatic cannulation for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with benign biliary or pancreatic obstruction. Exclusion criteria included malignant biliary or pancreatic obstruction, inaccessible papilla 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 or pancreatic cannulation, and the secondary outcome was the rate of adverse events. Results Thirty-one patients were evaluated. The overall technical success rate was 80.6 % (81.5 % in biliary and 75 % in pancreatic cases). Adverse events (AEs) were identified in 12.9 % of patients, including one with biliary peritonitis, one with abdominal pain and one with severe pancreatitis plus pneumomediastinum. Only one of the AEs (3.3 %) was directly related to the rendezvous procedure. Conclusions EUS-RV may be a safe and feasible salvage method for unsuccessful cannulation for benign disorders. Use of a 22-gauge needle with a 0.018-inch guidewire may be the first option for benign pathology.

Endoscopic ultrasound guided biliary drainage: a multicenter retrospective experience of a technique slowly gaining acceptance in Egypt.

Background and aim:Endoscopic ultrasound-guided biliary drainage is an alternative to failed endoscopic retrograde cholangiopancreatography. Unfortunately, this procedure remains relatively less explored in Egypt due to its high cost, lack of adequate training, and the perception of increased risk. This study is the first multicenter Egyptian experience of an endoscopic ultrasound-guided biliary drainage in patients with malignant biliary obstruction.Patients and methods:We retrospectively reviewed 15 patients (10 men and five women) with malignant biliary obstruction who from October 2013 to May 2019, following a failed or inaccessible endoscopic retrograde cholangiopancreatography, underwent an endoscopic ultrasound-guided choledochoduodenostomy, endoscopic ultrasound-guided hepaticogastrostomy, or endoscopic ultrasound-guided rendezvous. Their mean age was 57.4 years and mean bilirubin was 18.2 mg/dL. The outcome parameters included technical and clinical success. Technical success was defined as the successful placement of a stent in the biliary system, while clinical success was defined as a greater than 50% decrease in the bilirubin levels 2 weeks after the procedure. Patients were monitored for complications during and after the procedure.Results:In total, 15 patients underwent endoscopic ultrasound-guided biliary drainage (eight underwent endoscopic ultrasound-guided choledochoduodenostomy, five underwent endoscopic ultrasound-guided hepaticogastrostomy, and two underwent endoscopic ultrasound-guided rendezvous). The technical and clinical success rates were 100% (15/15 patients) and 93.3% (14/15 patients), respectively. The complication rate was 26.6% (4/15 patients). All complications were mild and self-limited, and included fever, mild biliary peritonitis, pneumoperitoneum, and a slight migration of one plastic stent during insertion.Conclusion:Although slowly gaining acceptance in Egypt, endoscopic ultrasound-guided biliary drainage is an effective and safe procedure in patients with a malignant biliary obstruction after a failed or inaccessible endoscopic retrograde cholangiopancreatography.

Usefulness of combined percutaneous-endoscopic rendezvous techniques after failed therapeutic endoscopic retrograde cholangiography in the era of endoscopic ultrasound guided rendezvous.

The rendezvous approach is a salvage technique after failure of endoscopic retrograde cholangiography (ERC). In certain circumstances, percutaneous-endoscopic rendezvous (PE-RV) is preferred, and endoscopic ultrasound-guided rendezvous (EUS-RV) is difficult to perform. We aimed to evaluate PE-RV outcomes, describe the PE-RV techniques, and identify potential indications for PE-RV over EUS-RV.Retrospective analysis was conducted of a prospectively designed ERC database between January 2005 and December 2016 at a tertiary referral center including cases where PE-RV was used as a salvage procedure after ERC failure.During the study period, PE-RV was performed in 42 cases after failed therapeutic ERC; 15 had a surgically altered enteric anatomy. The technical success rate of PE-RV was 92.9% (39/42), with a therapeutic success rate of 88.1% (37/42). Potential indications for PE-RV over EUS-RV were identified in 23 cases, and either PE-RV or EUS-RV could have effectively been used in 19 cases. Endoscopic bile duct access was successfully achieved with PE-RV in 39 cases with accessible biliary orifice using one of PE-RV cannulation techniques (classic, n = 11; parallel, n = 19; and adjunctive maneuvers, n = 9).PE-RV uses a unique technology and has clinical indications that distinguish it from EUS-RV. Therefore, PE-RV can still be considered a useful salvage technique for the treatment of biliary obstruction after ERC failure.

A novel "hitch-and-ride" deep biliary cannulation method during rendezvous endoscopic ultrasound-guided ERCP technique.

Background and study aim Endoscopic ultrasound-guided rendezvous (EUS-RV) is increasingly reported as a treatment option after failed endoscopic retrograde cholangiopancreatography. We developed a novel "hitch-and-ride" catheter for biliary cannulation to reduce the risk of guidewire loss during EUS-RV. Patients and methods We retrospectively evaluated safety and technical success of EUS-RV between June 2011 and May 2016. Biliary cannulation during EUS-RV using three methods - over-the-wire, along-the-wire, and hitch-and-ride - were compared. Results A total of 30 EUS-RVs were attempted and the technical success rate was 93.3 %, with two failures (one bile duct puncture and one guidewire insertion). After 28 cases of successful guidewire passage, cannulation was attempted by the over-the-wire (n = 13), along-the-wire (n = 4) or hitch-and-ride (n = 11) method. Only the hitch-and-ride method achieved biliary cannulation without guidewire loss or conversion to the other methods. Time to cannulation was shorter with the hitch-and-ride method (4 minutes) than with over-the-wire and along-the-wire methods (9 and 13 minutes, respectively). The adverse event rate of EUS-RV was 23.3 %. Conclusion A novel hitch-and-ride catheter was feasible for biliary cannulation after EUS-RV.

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.

Endoscopic Ultrasound Guided Rendezvous Drainage of Biliary Obstruction Using a New Flexible 19-Gauge Fine Needle Aspiration Needle

Background and Aim. A successful endoscopic ultrasound guided rendezvous (EUS-RV) biliary drainage is dependent on accurate puncture of the bile duct and precise guide wire manipulation across the ampulla of Vater. We aim to study the feasibility of using a flexible 19-gauge fine aspiration needle in the performance of EUS-RV biliary drainage. Method. This is a retrospective case series of EUS-RV biliary drainage procedures at a single center. Patients who failed ERCP during the same session for benign or malignant biliary obstruction underwent EUS-RV using a flexible, nitinol covered, 19-gauge needle for biliary access and guide wire manipulation. Result. 24 patients underwent EUS-RV biliary drainage via extrahepatic access while 1 attempt was via intrahepatic access. The technical success rate was 80%, including 83.3% of cases via extrahepatic access. There was no significant difference in success rate of inpatient and outpatient procedures, benign or malignant indications, or type of guide wire used. Adverse events included mild pancreatitis (3 patients) and cholangitis (1 patient). Conclusion. A flexible 19-gauge needle for biliary access can be safe and effective when used to perform EUS-RV biliary drainage. Direct comparison between the nitinol needle and conventional metal needles in the performance of EUS guided biliary drainage is needed.

A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction.

Background and study Aims: Selective biliary cannulation is unsuccessful in 5 % to 10 % of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard, but endoscopic ultrasound guided rendezvous (EUSr) have been increasingly used for biliary decompression in this patient population. Our aim was to compare the initial success rate, long-term efficacy, and safety of PBD and EUSr in relieving MDBO after failed ERC Patients and methods: A retrospective study involving 50 consecutive patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008 – 2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002 – 2008). Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates after biliary decompression. Results: The mean age at presentation was 66.5 (± 12.6 years), 28 patients (54.9 %) were female. The etiology of MDBO was pancreaticobiliary malignancy in 44 (88 %) and metastatic disease in 6 (12 %) cases. Biliary drainage was technically successful by EUSr in 19 (76 %) cases and by PBD in 25 (100 %) (P = 0.002). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (P = 0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (P = 0.001). Conclusions: Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful, patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions.Meeting presentations: Annual Digestive Diseases Week 2015

Mo1446 Endoscopic Ultrasound-Guided Rendezvous for Difficult Biliary Cannulation: a Multicenter Prospective Pilot Study

Biliary cannulation is indispensable step in therapeutic ERCP for biliary disorder. Although the reported success rate of biliary cannulation is high, there are still cases with difficult biliary cannulation. EUS guided rendezvous (EUS-RV) can salvage failed cannulation. Aims: To determine the safety and efficacy of EUS-RV with a standardized algorithm in terms of a scope position in a prospective cohort undergoing therapeutic ERCP.

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.

Endoscopic papillectomy

Although few controlled trials exist in the field, endoscopic papillectomy has evolved over the recent years with new data on preoperative staging and improved methods for its safe and successful completion. In 2006, a consensus guideline was published by the American Society of Gastrointestinal Endoscopy evaluating the role of endoscopy in managing ampullary adenomas. The recent literature of endoscopic papillectomy has focused on the preoperative management of ampullary tumors, with a paper evaluating the role of endoscopic ultrasound. Also, a randomized controlled trial has shown that the use of pancreatic duct stents is associated with less incidence of postendoscopic papillectomy pancreatitis, although the study was probably underpowered. Several methods can be used to help locate the pancreatic duct postendoscopic papillectomy (endoscopic ultrasound-guided rendezvous and methylene blue injection). The recurrence and complication rate in more recent papers continue to be acceptable, at about 30 and 20%, respectively. Endoscopic papillectomy is a reasonable alternative to transduodenal surgical excision, but more controlled studies with long-term data are needed to evaluate preoperative staging accuracy and recurrence rates.