SINGLE-SCOPE MONO-RAIL EUS-GUIDED RENDEZVOUS TO SALVAGE FAILED DUODENAL INTUBATION AND FAILED BILIARY CANNULATION

Introduction:

All reported variants of EUS-guided rendezvous (EUS-RV) require echoendoscope exchange. Exchanging the echoendoscope is tricky because it entails the risk of guidewire loss (Baron & Levy, PMID: 22622737). We describe a new variant of EUS-RV that does not require echoendoscope exchange. This was combined with the previously reported mono-rail RV, using a home-made sphincterotome.

Description:

93-year-old old woman. Cholangitis. MRI: gallbladder hydrops, cholelithiasis, choledocholithiasis, hiatal hernia containing stomach and intestinal loops. ERCP: impossible to pass pylorus with duodenoscope, despite compression, postural changes and others for 1-hour. Second ERCP: the duodenoscope loops again in stomach. We proceed to a EUS-guided approach with possible anterograde removal of choledocholithiasis and/or access + drainage from the gallbladder. Transgastric EUS-guided biliary access was ruled out due to the lack of intrahepatic bile-duct dilation. With the echoendoscope in the bulb, we punctured with19G needle the distal CBD passing antegradelly through papilla a 0.025 guidewire. After removing the needle and pushing the guide, we unexpectedly accessed the second duodenal portion. We introduced with a snare the distal end of the guide inside the channel, although the guidewired slipped out by the mounting friction before retrieving it. We cut a slot at the tip of a standard sphincterotome, sliding it under endoscopic vision over the distal end of the guide. With a second guide through the sphincterotome lumen, we obtained bile-duct access and completed sphincterotomy and extraction of choledocholithiasis.

Conclusions:

Rigidity of the echoendoscope allowed the transpyloric passage when it had been impossible to achieve it with a duodenoscope in a patient with giant hiatal hernia. This serendipitous finding is intriguing. We were able to perform the ERCP with the echoendoscope itself without the need for exchange, an auto-rendezvous mono-rail technique, which others might also find useful in extreme cases such as the one presented.