Post written by Joan B. Gornals, MD, PhD, from the Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, University of Barcelona, Catalonia, Spain.

A 60-year-old man with pancreatic cancer and liver metastases who had been referred previously for biliary drainage was recommended palliative treatment. After a failed ERCP, same-session EUS-guided biliary drainage was chosen. A minimally dilated common bile duct (CBD) up to 9 mm was identified from the bulb. An EUS-guided choledochoduodenostomy (CDS) using a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EC-LAMS) (8 x 8 mm, HotAxios) was performed from a long-scope position using a free-hand plus preloaded guidewire technique. The cautery-enabled catheter was advanced less than 1 finger’s width at too perpendicular an angle, hitting the opposite CBD wall. The guidewire could not be inserted deeply, and an EUS image detected a partial malposition of the internal flange. Attempts at advancing the guidewire in an upward/downward direction (failed rendezvous [RV] approach) were unsuccessful, and the LAMS was removed. Because the CBD was still dilated, a second attempt at EUS-guided CDS using a smaller EC-LAMS was made. However, this technically failed because of a considerable amount of bile between the CBD and duodenal wall. An EUS-guided RV as an emergent rescue was performed. This maneuver was technically demanding because of the small CBD diameter, but it was possible to advance a guidewire through the papilla until it reached the duodenum. Finally, a fully covered metal stent was inserted, sealing the disruption of the CBD wall.

Adverse events after EUS-CDS using EC-LAMS are possible, and a CBD <15 mm has been reported as a risk factor for technical failure.

This incident occurred in an experienced unit. Knowledge in EUS-guided rendezvous is crucial to solve dramatic scenarios as a failed EUS-CDS using LAMS.

Knowledge of endoscopic rescue options (EUS-guided Rendezvous, coaxial SEMS) is crucial to resolve potentially serious unplanned events, such as a failed EUS-CDS using a LAMS. A teaching video, with technical helping notes in case of failed EUS-CDS using LAMS, is provided.

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