PREDICTORS OF SUCCESS AND RESCUE OPTIONS OF EUS-GUIDED RENDEZVOUS (EUS-RV) FOR BILIARY ACCESS AFTER FAILED ERCP CANNULATION

Aims:

Failed cannulation occurs in 3% of ERCPs. EUS-RV can overcome failure. We aimed to identify predictors of success and rescue options of EUS-RV.

Methods:

Review of prospective database on 6843 consecutive ERCPs between 2010 – 2017. Inclusion: patients with biliary obstruction and failed cannulation undergoing EUS-RV.

Results:

79 consecutive EUS-RV (57% male, median age 76.5, 69.5% benign). Procedural variables shown in Table-1. Primary technical success was 63.3% (3.5% failed biliary puncture, 65.5% failed guidewire placement, 31% failed cannulation). Variables associated with technical success in univariate analysis were flexible RV (antegrade passage of the guidewire through a catheter across papilla/stricture) versus rigid RV (through needle) (89.9% vs. 56.7% p = 0,01), transgastric versus transduodenal access (94.1 vs. 54.8%, p = 0.003), intrahepatic versus extrahepatic access (83,3 vs. 57,4%, p = 0,05), and benign stricture (25%, versus remainder indications 67.6%, p = 0,02). In multivariate analysis, transgastric access and indication other than benign stricture remained significant. In 75.9% (22/29) of failed EUS-RV, rescue biliary drainage was achieved during the same session (40% transmural-EUS, 32% methylene-blue cholangiography, and 12% re-ERCP), final technical success rate of 91%. 68 EUS-RV patients had one-month follow-up available; 6 complications occurred in 5 procedures (8.8%): bleeding 2, perforation 2, acute pancreatitis 1, biliary leakage 1; 3 of them were severe, requiring surgery (1 death).

Tab. 1

Access	- Transgastric, (21,5%) - Transduodenal, (78,5%)
Target	- Intrahepatic-bile-duct, (22,8%) - Extrahepatic-bile-duct, (77,2%)
Target dilation	- Present, (70,3%) - Absent, (29,7%)
Cannulation	- Parallel, (46.2%) - Over-the-wire, (53,8%)
RV rigid/flexible	- Rigid, (76,9%) - Flexible, (23,1%)

Conclusions:

Primary success rates of EUS-RV remain low. Flexible catheters to direct antegrade passage of the guidewire could improve them. 75% of failed EUS-RV can be rescued in the same session either by transmural-EUS or reattempted ERCP following methylene-blue/contrast EUS-cholangiography, resulting in 91% final technical success rates.