Post written by Sundeep Lakhtakia, MD, DM, from the Asian Institute of Gastroenterology, AIG Hosiptals, Telangana, India.

A patient with past cholecystectomy presented with symptomatic CBD stones. He had unsuccessful ERCPs due to duodenal deformity and non-visualized papilla located within a large duodenal diverticulum. This video case has 2 interesting segments.

In first part, EUS guided biliary rendezvous (EUS-RV) was performed by puncturing the dilated CBD from the first part of duodenum using a novel steerable needle that is designed to angulate to 90⁰ on withdrawal of stylet. The curved terminal part of needle was then manually rotated (from the control at its hub) to direct the needle tip toward the papilla. A hydrophilic guidewire was passed though needle into CBD and gently manipulated across the papilla into the duodenum. The echoendoscope was then exchanged with a duodenoscope for the biliary rendezvous procedure.

The second part of the video shows the technical challenge faced at biliary cannulation. Attempts to selectively cannulate the CBD beside the protruding guidewire (parallel rendezvous) failed due to the unstable duodenoscope position. A needle-knife pre-cut was performed, followed by prophylactic PD stent placement and thereafter further pre-cut and successful biliary access. Biliary balloon sphincteroplasty was performed and CBD stones were extracted.

Following unsuccessful ERCP, EUS-guided biliary intervention is generally considered for malignant biliary obstruction and occasionally for benign biliary conditions. The EUS-guided rendezvous (EUS-RV) procedure is desired for CBD stones where guidewire manipulation across the papilla is the most crucial step. A novel trans-duodenal EUS-access needle was used in this case, whose terminal end curves to the desired angle on removal of the stylet. The tip can be easily rotated toward the direction of the papilla by external control that facilitates smooth passage of the guidewire across the papilla into the duodenum without the risk of sheering. The video further shows the challenge of ‘parallel rendezvous’ in which the CBD is accessed after PD stent and pre-cut.

In special situations, the novel steerable EUS-access needle can be considered for biliary access, instead of the standard EUS-FNA needle. It provides dual advantages. First, the curved needle tip (on withdrawal of stylet) allows smooth manipulation of the guidewire toward the intended direction (papilla) and across to allow rendezvous procedure or even antegrade stent placement. Second, the risk of shearing of the guidewire is avoided.

In the present form, the steerable needle can only be considered for dilated CBD for trans-duodenal access and not for trans-gastric hepatic access.

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