The success rate of deep biliary cannulation is high but still not perfect in endoscopic retrograde cholangiopancreatography (ERCP), even with aggressive techniques. With the development of linear-array echoendoscopes, the endoscopic ultrasonography–guided rendezvous technique (EUS-RV) has recently emerged as a salvage method for failed biliary cannulation. This review of current literature establishes that EUS-RV is a feasible and safe technique and should be considered as an alternative to percutaneous or surgical approaches. The availability of a percutaneous salvage (if EUS-RV fails) and well-trained endoscopists for both ERCP and EUS are mandatory in minimizing the potential complications of this procedure.
Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) has been widely used as the main therapeutic technique for biliary diseases. Therapeutic ERCP requires deep cannulation into the common bile duct (CBD). The success rate of deep cannulation is high but still not perfect, even with the use of advanced cannulation techniques such as precut sphincterotomy. In particular, periampullary diverticula, tumor infiltration, or altered surgical anatomy occasionally complicates biliary cannulation. Alternatives if deep biliary cannulation fails include repeat ERCP on a different day by the same or a more experienced endoscopist, or other alternatives such as percutaneous transhepatic biliary drainage (PTBD) or surgical intervention. However, a patient’s condition often may not allow waiting for another ERCP session on a different day, and both PTBD and surgical intervention are associated with considerable morbidity and occasional mortality.
Over the past decade, the development of the linear-array echoendoscope has enabled various endoscopic ultrasonography (EUS)-related diagnostic and therapeutic techniques such as fine-needle aspiration (FNA), pancreatic pseudocyst drainage, and celiac plexus neurolysis. The use of EUS-guided cholangiography was first reported in 1996. Following this report, an initial case report of EUS-guided biliary duct puncture followed by transduodenal stent placement after failed ERCP was published in 2001 and, more recently, the EUS-guided rendezvous (EUS-RV) technique has emerged as a salvage technique for failed cannulation in ERC.
EUS-RV
Indications for EUS-RV
After failed deep biliary cannulation using conventional techniques, the choice to perform EUS-RV should be cautiously made, based on comprehensive consideration for the reason behind biliary cannulation failure, the patient’s condition, and the available alternatives. EUS-RV should be performed by endoscopists who are experienced with both ERCP and EUS in an endoscopic facility featuring both fluoroscopy and EUS capabilities. If EUS-RV fails, immediate availability of the percutaneous approach is important in minimizing the risk of bile leakage from the punctured biliary duct. The authors recommend administration of broad-spectrum antibiotics before EUS-RV as prophylaxis against potential spillage of infected bile.
EUS-RV Technique
After failed biliary cannulation in ERC, EUS is performed using a linear scanning video echoendoscope and processor with color Doppler function. Following EUS examination of the biliary system including evaluation of the regional vasculature using color Doppler, the bile duct is punctured from the gut under EUS guidance using a 19-gauge or 22-gauge FNA needle that has been primed with contrast agent ( Fig. 1 A). Aspiration of bile confirms proper puncture of the biliary duct; next, limited cholangiography is performed to delineate the biliary obstruction (see Fig. 1 B).
Once the bile duct configuration and the level of the obstruction are identified, a 0.018- to 0.035-in guide wire is advanced through the needle and manipulated antegradely into the small bowel via the native ampulla or surgical anastomosis (see Fig. 1 C). A 22-gauge FNA needle accommodates a 0.018-in guide wire, and a 19-gauge FNA needle can accommodate a guide wire diameter of up to 0.035 in. The needle and the echoendoscope are withdrawn while keeping the guide wire in place. An appropriate endoscope dependent on the anatomy is then reinserted alongside the guide wire. Biliary cannulation is again attempted beside the antegradely placed guide wire (see Fig. 1 D). If this attempt fails, the distal end of the EUS-placed guide wire is grasped with forceps or a snare. The guide wire is pulled out through the mouth with the endoscope or through the accessory channel of the endoscope. A duodenoscope is then back-loaded over the guide wire and advanced again to the ampulla or anastomosis, if the guide wire is pulled through the mouth. Deep biliary cannulation is then performed over the EUS-placed guide wire (see Fig. 1 E). Following deep biliary cannulation, appropriate treatment is provided (see Fig. 1 F).
In Cases with Failed EUS-RV
The authors recommend an immediate repeat attempt at conventional ERCP if EUS-RV fails, especially in case the ampulla or orifice cannot be detected for some reason. EUS cholangiography can help to identify the biliary orifice and the configuration of the distal bile duct, which can facilitate repeat ERCP and increase the chance of its success. If this also fails, alternative biliary decompression, such as PTBD, should be considered to minimize the risk of bile leak.
EUS-RV
Indications for EUS-RV
After failed deep biliary cannulation using conventional techniques, the choice to perform EUS-RV should be cautiously made, based on comprehensive consideration for the reason behind biliary cannulation failure, the patient’s condition, and the available alternatives. EUS-RV should be performed by endoscopists who are experienced with both ERCP and EUS in an endoscopic facility featuring both fluoroscopy and EUS capabilities. If EUS-RV fails, immediate availability of the percutaneous approach is important in minimizing the risk of bile leakage from the punctured biliary duct. The authors recommend administration of broad-spectrum antibiotics before EUS-RV as prophylaxis against potential spillage of infected bile.
EUS-RV Technique
After failed biliary cannulation in ERC, EUS is performed using a linear scanning video echoendoscope and processor with color Doppler function. Following EUS examination of the biliary system including evaluation of the regional vasculature using color Doppler, the bile duct is punctured from the gut under EUS guidance using a 19-gauge or 22-gauge FNA needle that has been primed with contrast agent ( Fig. 1 A). Aspiration of bile confirms proper puncture of the biliary duct; next, limited cholangiography is performed to delineate the biliary obstruction (see Fig. 1 B).
Once the bile duct configuration and the level of the obstruction are identified, a 0.018- to 0.035-in guide wire is advanced through the needle and manipulated antegradely into the small bowel via the native ampulla or surgical anastomosis (see Fig. 1 C). A 22-gauge FNA needle accommodates a 0.018-in guide wire, and a 19-gauge FNA needle can accommodate a guide wire diameter of up to 0.035 in. The needle and the echoendoscope are withdrawn while keeping the guide wire in place. An appropriate endoscope dependent on the anatomy is then reinserted alongside the guide wire. Biliary cannulation is again attempted beside the antegradely placed guide wire (see Fig. 1 D). If this attempt fails, the distal end of the EUS-placed guide wire is grasped with forceps or a snare. The guide wire is pulled out through the mouth with the endoscope or through the accessory channel of the endoscope. A duodenoscope is then back-loaded over the guide wire and advanced again to the ampulla or anastomosis, if the guide wire is pulled through the mouth. Deep biliary cannulation is then performed over the EUS-placed guide wire (see Fig. 1 E). Following deep biliary cannulation, appropriate treatment is provided (see Fig. 1 F).
In Cases with Failed EUS-RV
The authors recommend an immediate repeat attempt at conventional ERCP if EUS-RV fails, especially in case the ampulla or orifice cannot be detected for some reason. EUS cholangiography can help to identify the biliary orifice and the configuration of the distal bile duct, which can facilitate repeat ERCP and increase the chance of its success. If this also fails, alternative biliary decompression, such as PTBD, should be considered to minimize the risk of bile leak.
Literature review
Mallery and colleagues first reported the use of EUS-guided biliary puncture with subsequent RV technique for 2 cases of malignant distal biliary obstruction after failed ERCP in 2004. Since then, several groups have reported that EUS-RV is an effective salvage technique to obtain deep biliary cannulation after failed ERCP ( Table 1 ).
| Authors | Year | Ref. | Overlapping Articles | No. of Patients | No. of Accessed Biliary Ducts | Overall Success Rate | ||
|---|---|---|---|---|---|---|---|---|
| EHBD | IHBD | |||||||
| 1 | Tarantino et al | 2008 | — | 8 | 4/8 (50%) | — | 50% (4/8) | |
| 2 | Maranki et al | 2009 | 49 | 8/14 a (57%) | 26/40 (65%) | 63% (34/54) | ||
| 3 | Kim et al | 2010 | 15 | 12/15 (80%) | — | 80% (12/15) | ||
| 4 | Iwashita et al | 2012 | — | 40 | 25/31 (81%) | 4/9 (44%) | 73% (29/40) | |
Selection of Device
Either 19-gauge or 22-gauge FNA needles can be used for this technique. Although only a 0.018-in guide wire is applicable for a 22-gauge needle, a 19-gauge needle allows larger guide wires (0.018–0.035 in) to pass through the needle. Theoretically, the usage of a 22-gauge needle can make needle puncture easier, especially in the transduodenal approach, and reduce the risk of bile leakage or bleeding because of the smaller caliber and more flexible needle of the needle itself. However, Maranki and colleagues reported that a 19-gauge needle was better despite being less maneuverable, because a 0.035-in guide wire provided better control than a 0.018-in guide wire. Kim and colleagues noted that the larger needle caliber permitted freer passage of different guide wires and decreased the risk of shredding the guide wire coating by the sharp needle edge. Kim and colleagues prefer using a combination of the 19-gauge needle with a 0.020-in or 0.021-in guide wire as the initial devices, with change to a 22-gauge needle with a 0.018-in guide wire if they have technical difficulty in using a 19-gauge needle. The authors prefer using a 19-gauge needle and a 0.035-in guide wire because of the improved maneuverability, visibility, stiffness, and ease of handling of the larger guide wire. In addition, using a larger needle allows the use of a smaller-caliber guide wire, whereas using a 22-gauge FNA needle limits one to using a 0.018-in guide wire.
Selection of Biliary Ducts for Puncture
EUS-RV can be divided into intrahepatic bile duct (IHBD) and extrahepatic bile duct (EHBD) approaches in terms of access to the biliary tree. Maranki and colleagues reported their experience with a predominantly IHBD approach for interventional EUS cholangiography. Their series included EUS-RV cases as well as patients who underwent hepaticogastrostomy, choledochoduodenostomy, and antegrade treatment via choledochoenteral fistula as salvage for failed EUS-RV. In this study, EUS-RV was defined as successful on the basis of manipulating the guide wire across the obstruction. IHBD was chosen as the access route in 40 of 49 patients because the investigators believed IHBD to have less risk of bile leak. This approach failed in 5 patients, because of the inability to advance the guide wire into the IHBD in 4 patients and inability to puncture the IHBD in 1 patient; these 5 patients underwent repeat attempts using the EHBD approach. The investigators successfully passed the guide wire into the small intestine in 26 of 40 patients with the IHBD approach, followed by stent placement in 25 of these 26 patients and balloon dilation of an anastomotic stricture in the remaining patient. A gastrohepatic stent was placed in 3 of the remaining 9 patients because of the inability to advance the guide wire across the obstruction, and the final 6 patients experienced failure resulting from inability to advance the guide wire. Therefore, the EUS-RV success rate with the IHBD approach was 65% (26/40).
In the authors’ recent series, the EHBD approach was used in the majority of patients with failed biliary cannulation. The EHBD approach (antegrade) was chosen for patients with distal obstruction to maximize the maneuverability of the guide wire and minimize the length of manipulation needed. The authors used the IHBD approach typically in patients with hilar strictures or surgically altered anatomy. EUS-RV with the IHBD approach was performed in 9 patients with successful EUS cholangiography obtained in all patients, but with failure to pass the guide wire through the stricture in 5 patients, for a success rate of 44% (4/9).
Kim and colleagues reported their retrospective experience with EUS-RV with only the EHBD approach in 15 patients after failed ERCP. Successful bile duct puncture followed by guide-wire placement into the biliary duct was obtained in all patients. However, the guide wire could not pass into the duodenum because of its inability to traverse a stricture in 2 patients and the dissection of a choledochocele in 1 patient. Thus, the overall success rate of EUS-RV was 80% (12/15). The authors have reported a success rate of 81% (25/31), with failures resulting from inability to pass the guide wire into the intestine. Maranki and colleagues reported the success rate of the EHBD approach to be 57% (8/14; 5 of whom converted from the IHBD approach), but did not report the reasons for the failures except in 4 patients who underwent transenteric biliary stent placement after failed advancement of the guide wire across the stricture.
These studies highlight that guide-wire manipulation is one of the most challenging aspects of EUS-RV. In this technique the guide wire has to pass through a long rigid needle, biliary ducts, obstruction, and ampulla or anastomosis into the small intestine. For this reason, the authors maintain that the EHBD approach is preferred over the IHBD approach because the shorter wire length maximizes the maneuverability and propulsive force of the wire at the tip. Although the authors were able to access the biliary system using the IHBD approach in all cases, it was more difficult to puncture smaller-caliber bile ducts. Perhaps for this reason, Maranki and colleagues failed to achieve IHBD access in 5 of 40 patients (13%). These observations suggest that the EHBD approach is preferable for EUS-RV whenever anatomically and technically possible. Although some theorize that the EHBD approach itself may increase the risk of bile leak, the authors believe that adequacy of the drainage is the most important risk factor to prevent bile leaks. In addition, there are no actual data to show that the EHBD approach is associated with a greater risk of bile leak.
Selection of Intestinal Locations for Biliary Duct Puncture
In EUS-RV with the IHBD approach, the biliary ducts in the left lobe are only approached from the stomach in patients with normal anatomy or the small intestine in cases with surgically altered anatomy. In the EHBD approach, the biliary duct is normally punctured from the bulb or the second portion of the duodenum. Kim and colleagues stated that the goal of biliary access is to puncture the biliary ducts with the long axis of the needle directed as close as possible, and in a parallel plane to the long axis of the duct with the needle tip directed toward the point of obstruction, because such an approach limits buckling of the guide wire and allows greater force to be exerted against the obstruction. This procedure is only possible from the second portion of the duodenum in most patients with normal anatomy, because the needle usually points to the liver hilum when passed from the duodenal bulb. Unfortunately, it may not be possible to perform the needle puncture from the second portion because of obstruction, tumor, or inability to visualize the needle and the bile duct in one plane, especially if the bile duct is not dilated near the ampulla. The authors recommend first trying to access the bile duct from the second portion of the duodenum using a 19-gauge FNA needle, with the approach from the bulb reserved for patients with failed access.
Complications
EUS-RV includes both ERCP and EUS-guided biliary access, and can cause complications resulting from both aspects. Reported complications associated with EUS-guided biliary access include abdominal pain, cholangitis, biloma, sepsis, bleeding, pneumoperitoneum, and bile peritonitis. EUS-RV requires only needle puncture and temporary guide-wire placement in contrast to EUS-guided enterobiliary fistulotomy or antegrade treatment, both of which require creation and dilation of a biliary enteric fistula. Although theoretically the risks of EUS-RV causing complications associated with biliary access should be lower than those of other EUS-guided biliary access techniques, bile peritonitis and pneumoperitoneum have been reported ( Table 2 ). Therefore, the prompt availability of alternative biliary drainage is very important in minimizing the potential risks of complications, especially in cases with unrelieved biliary obstruction. Another major factor in minimizing procedure-associated risk is to ensure adequate expertise of the endoscopist in the EUS and ERCP procedures.
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