Rendezvous biliary recanalization with combined percutaneous transhepatic cholangioscopy and double-balloon endoscopy

Despite advances in biliary stenting in patients with altered gastrointestinal anatomy, it is still a challenging procedure [1]. We present a case where percutaneous transhepatic cholangioscopy (PTCS) was combined with double-balloon endoscopy (DBE) for biliary stenting in a patient with complete obstruction of a choledochojejunostomy.

A 71-year-old woman, who had a history of distal cholangiocarcinoma and had undergone pancreaticoduodenectomy 7 years previously, experienced recurrent cholangitis. DBE-assisted balloon dilation had been performed 7 months previously for stricture of the choledochojejunal anastomosis. However, she developed complete obstruction of the anastomosis ([Fig. 1]). A 7.2-Fr percutaneous transhepatic biliary drainage (PTBD) catheter was initially placed, and the fistula tract was dilated up to 12 Fr within 4 weeks. DBE-assisted endoscopic retrograde cholangiopancreatography was then attempted. First, the double-balloon endoscope (EI-580BT; Fujifilm, Tokyo, Japan) was advanced to the afferent limb, and a percutaneous transhepatic cholangiogram revealed complete obstruction of the anastomosis. Next, a PTCS scope (BF type P260F; Olympus, Tokyo, Japan) was inserted via the PTBD route. However, a guidewire (0.018-inch, Pathfinder Exchange; Boston Scientific Japan, Tokyo, Japan) through the PTCS scope could not pass the anastomosis ([Video 1]). Therefore, we attempted direct precutting (KD-V451M; Olympus) at the anastomosis, using the double-balloon endoscope and guided by transillumination from the percutaneous transhepatic cholangioscope’ ([Fig. 2], [Video 1]). A small incision was carefully made in order to create a fistula ([Fig. 3]). This was followed by successful passage of the guidewire (0.032-inch, Radifocus Guidewire M; Terumo, Tokyo, Japan) completely through the anastomotic obstruction ([Fig. 4], [Video 1]). We then grasped the guidewire with an ultraslim basket catheter (Zero Tip Retrieval Basket; Boston Scientific) using the cholangioscope ([Fig. 5], [Video 1]). Finally, a 12-Fr PTBD catheter was placed across the obstruction without any complications ([Fig. 6], [Video 1]).

Fig. 1 Percutaneous transhepatic cholangiogram showing complete obstruction of the choledochojejunal anastomosis in a patient who had undergone pancreaticoduodenectomy 7 years previously.

Video 1 Biliary recanalization, using a rendezvous technique with combined percutaneous transhepatic cholangioscopy and double-balloon endoscopy, for a completely obstructed choledochojejunostomy.

Fig. 2 Left panel: The choledochojejunal anastomosis has an appearance similar to an ulcer scar. Right panel: Transillumination from the percutaneous transhepatic cholangioscope guides direct precutting using the double-balloon endoscope.

Fig. 3 Radiograph showing direct precutting at the choledochojejunal anastomosis, under fluoroscopic guidance and transillumination from the percutaneous transhepatic cholangioscope. Left inset: enteroscopy view. Right inset: percutaneous transhepatic cholangioscopy view.

Fig. 4 Radiograph showing the guidewire passing through the obstruction. Inset: percutaneous transhepatic cholangioscopy view.

Fig. 5 The guidewire is grasped by means of a snare under fluoroscopic and percutaneous transhepatic cholangioscopic guidance.

Fig. 6 Insertion of the percutaneous transhepatic biliary drainage catheter, using a rendezvous technique, across the previously obstructed choledochojejunal anastomosis. Inset: percutaneous transhepatic cholangioscopic view.

The rendezvous technique in combination with PTCS and DBE facilitates biliary recanalization of complete biliary obstruction [1] [2]. However, blind incision has the risk of gastrointestinal tract perforation or bile leakage. Although caution should be exercised, incision guided by transillumination from the peroral transhepatic cholangioscope is a safe and less invasive technique compared with surgery.

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• References

• 1 Shimatani M, Takaoka M, Ikeura T. et al. Rendezvous technique: double-balloon endoscopy and SpyGlass direct visualization system in a patient with severe stenosis of a choledochojejunal anastomosis. Endoscopy 2014; 46 (Suppl. 01) E275-E276
• 2 Bukhari MA, Haito-Chavez Y, Ngamruengphong S. et al. Rendezvous biliary recanalization of complete biliary obstruction with direct peroral and percutaneous transhepatic cholangioscopy. Gastroenterology 2018; 154: 23-25