EUS-guided rendezvous technique for refractory benign biliary stricture

Post written by Yukitoshi Matsunami, MD, from the Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
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In this video, we describe an EUS-guided rendezvous technique for refractory benign biliary stricture caused by postoperative bile-duct injury. A 60-year-old man underwent right-sided liver lobectomy for multiple liver metastases from an ascending colon cancer. After surgery, bile leakage and cholangitis occurred because of postoperative bile duct injury. We performed an EUS-guided rendezvous technique.

The B3 hepatic duct was punctured transgastrically with a 22-gauge FNA needle under EUS guidance. After the puncture, a guidewire was advanced from the left hepatic duct to the bile leakage cavity. Then, the FNA needle was removed, and the cannula was advanced over the guidewire. Next, the guidewire was advanced from the bile leakage cavity to the common bile duct in an antegrade fashion and further into the duodenum through the major papilla. The echoendoscope was then removed, and the guidewire and cannula were left in place. The endoscope was advanced to the second portion of the duodenum, and the guidewire tip was grasped with a biopsy forceps and pulled out through the working channel as the EUS-guided rendezvous technique. Finally, a 7F, 15-cm biliary stent was deployed in the left hepatic duct through the bile leakage cavity with no adverse events. Since then, there has been no recurrence of symptoms.

The postoperative bile duct injury can cause benign biliary stricture, resulting in cholangitis and bile leakage. Conventional ERCP may not be always successful. However, there are some cases in which surgery can be avoided by interventional EUS as in this case.

The key of this case is the successful manipulation of the guidewire antegradely through the left hepatic duct into the common bile duct and across the ampulla. This is technically challenging. We used 0.032-inch Radifocus® guidewire (Terumo, Japan), which is angle-tipped, soft, and highly flexible for antegrade manipulation from the left hepatic duct to the common bile duct through the bile leakage cavity. Also there is a risk of shearing the wire tip with repeated guidewire manipulations through an EUS needle. To avoid this, we used ERCP cannula. Cannula also helps provide traction for wire manipulation.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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