SINGLE-SESSION EUS-GUIDED CHOLECYSTODUODENOSTOMY AND TRANSCYSTIC RENDEZVOUS AS RESCUE OF FAILED ERCP BILIARY ACCESS

Introduction:

EUS-guided rendez-vous (EUS-RV) carries a 30% failure rate. Several transluminal endoscopic interventions within the gallbladder (GB) via EUS-guided anastomoses have recently been reported in non-surgical patients with prior EUS-guided GB drainage (EUS-GBD). We report single-session EUS-guided cholecystoduodenostomy and transduodenal cholecystoscopy aiming at transcystic RV to overcome failed ERCP.

Description:

An elderly male with multiple comorbidities and Billroth-I gastrectomy presented with cholangitis and CBD and GB stones. The papilla could barely be seen, hidden among redundant folds so EUS-RV was chosen for biliary access. After EUS-guided puncture of the CBD, echoendoscope instability resulted in guidewire dislodgment and contrast extravasation. Interposed vessels, decompressed CBD and US artifact precluded a second CBD puncture, whereas lack of intrahepatic bile duct dilation ruled out transhepatic EUS-RV. We decided to perform EUS-GBD to obtain a portal for transcystic antegrade CBD access. A 15 × 10-mm lumen-apposing metal stent (LAMS) was placed free-hand into the GB. LAMS was balloon dilated and cholecystoscopy was performed through it with a standard upper endoscope. An 8.5 Fr transcystic catheter was used to help direct the guidewire into the duodenum across the papilla. The gastroscope was removed leaving the catheter-guidewire in place and a duodenoscope was then passed alongside it. The guidewire was retrieved with a snare and over-the-wire RV sphincterotomy with stone removal was completed. The patient was admitted for post-procedure abodominal pain and right-inferior-lobe pneumonia, being finally discharged.

Comments:

EUS-guided cholecystoduodenostomy with a LAMS afforded single-session transcystic antegrade RV for sphincterotomy and stone removal after failed cannulation and EUS-RV in an elderly patient with Billroth-I anatomy. This approach might be considered in selected non-surgical patients with CBD stones and in situ gallbladders if standard biliary access is not possible, as the GB offers a larger target than the CBD and LAMS provide a relatively leak-proof platform for intervention.