Successful biliary drainage in a patient with a giant hiatal hernia and pancreatic prolapse using the percutaneous–endoscopic rendezvous technique

In patients who have a giant hiatal hernia, it is often difficult to advance a duodenoscope to the papilla of Vater [1]. In extremely rare cases of pancreatic prolapse into the thoracic cavity, endoscopic retrograde cholangiopancreatography (ERCP) is challenging because the orientation of the bile and pancreatic ducts is inverted [2] [3]. Herein, we report a case of successful biliary drainage, performed using the percutaneous–endoscopic rendezvous technique, in a patient with a giant hiatal hernia and pancreatic prolapse [4].

An 88-year-old woman was transferred from another hospital for treatment of obstructive jaundice due to distal bile duct cancer. Contrast-enhanced computed tomography revealed a giant hiatal hernia with pancreatic prolapse into the thoracic cavity ([Fig. 1]). Magnetic resonance cholangiopancreatography revealed that the orientation of the bile duct was inverted ([Fig. 2]). Although ERCP was attempted with a duodenoscope, access to the papilla was difficult owing to the giant hiatal hernia. We did reach the papilla using a forward-viewing scope (SIF-H290S; Olympus, Tokyo, Japan), but attempted biliary cannulation failed, even after performing precutting.

Fig. 1 Contrast-enhanced computed tomography showing a giant hiatal hernia with pancreatic prolapse into the thoracic cavity.

Fig. 2 Magnetic resonance cholangiopancreatography showing the inverted bile duct.

Subsequently, the percutaneous–endoscopic rendezvous technique was performed. The B5 bile duct was punctured percutaneously, and the guidewire (VisiGlide 2; Olympus) was advanced to the duodenum. The forward-viewing scope was advanced to the papilla, and biliary cannulation was achieved alongside the guidewire ([Fig. 3]). Finally, a covered self-expanding metal stent (WallFlex Biliary RX Stent, 10 × 60 mm; Boston Scientific Corp., Natick, Massachusetts, USA) was successfully deployed ([Video 1]; [Fig. 4]). The patient was discharged 4 days after the procedure without any adverse events. She had no symptoms until a year later, when the jaundice again flared up.

Fig. 3 Fluoroscopic views during the percutaneous–endoscopic rendezvous technique showing: a the guidewire being advanced to the duodenum, although the orientation of the bile duct was inverted; b the hiatal hernia having been released and biliary cannulation achieved after the scope had been advanced into the duodenum.

Fig. 4 Fluoroscopic view after deployment of a covered self-expanding metal stent; the hernia relapsed immediately after endoscopic retrograde cholangiopancreatography was completed.

More recently, endoscopic ultrasonography-guided biliary drainage has been developed but, in patients with a giant hiatal hernia, there is a risk of mediastinitis occurring from the punctured thoracic cavity. Consideration of a multidisciplinary approach is indispensable to ensure patient safety in difficult cases.

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Video 1 Successful biliary drainage is performed in a patient with a giant hiatus hernia and pancreatic prolapse using the percutaneous–endoscopic rendezvous technique.

• References

• 1 Sakai H, Iwai N, Okuda T. et al. Single-balloon-assisted ERCP in a patient with a giant hiatal hernia. Gastrointest Endosc 2021; 94: 1147-1148
• 2 Itoi T, Watanabe H, Gotoda T. et al. Therapeutic endoscopic retrograde cholangiopancreatography using a large dilating balloon in a patient with upside-down stomach and bile duct stones (with video). J Hepatobiliary Pancreat Sci 2015; 22: 177-179
• 3 Khirfan K. A rare cause of difficult endoscopic retrograde cholangiopancreatography. Gastroenterology 2020; 158: e10-e11
• 4 Martin DF. Combined percutaneous and endoscopic procedures for bile duct obstruction. Gut 1994; 35: 1011-1012