Post written by Michael Lajin, MD, from SHARP Health, San Diego, California, USA.

A 51-year-old male presented with abdominal pain due to recurrent pyogenic cholangitis. MRCP showed severe intrahepatic ductal dilatation involving the lateral segment of the left liver lobe with multiple intraductal stones. A transpapillary cholangioscope was unable to reach the targeted peripheral ducts.  

EUS-guided hepaticogastrostomy was attempted. However, attempts to dilate the hepaticogastrostomy tract using non-electrocautery dilators failed due to the inability of these devices to penetrate the gastric wall. A rendezvous technique was performed by manipulating the wire successfully downstream through the papilla. The echoendoscope was then removed, and the exiting wire was grasped and pulled out to the mouth using a duodenoscope.

After controlling the 2 ends of the wire, an endoscope was advanced over the “entering” end of the wire to the site of the hepaticogastrostomy. Using gentle tension on the “exiting” end of the wire, the dilating devices were able to penetrate the hepaticogastrostomy tract. The tract was dilated, and a stent was deployed.

Eight weeks later, several sessions of cholangioscopy with EHL were performed until the targeted duct was completely cleared. The hepaticogastrostomy stent was then removed.

MRCP 6 months after the procedure demonstrated decompression of the targeted duct without stones, and the patient remains asymptomatic.

This case report demonstrates the rendezvous technique could facilitate EUS-guided hepaticogastrostomy when the mechanical dilators fail to penetrate the gastric wall. EUS-guided hepaticogastrostomy can be used as a primary approach to manage difficult stones in patients with recurrent pyogenic cholangitis.

A, Preprocedural MRCP image showing intrahepatic ductal dilation of the lateral segment of the left liver lobe with stones (yellow arrow). B, Postprocedural MRCP image showing decompression of the duct and clearance from stones (red arrow).

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