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CC BY 4.0 · Journal of Digestive Endoscopy 2025; 16(04): 241-244
DOI: 10.1055/s-0045-1813672
News and Views

Precut Papillotomy versus EUS-Guided Rendezvous in Difficult Biliary Cannulation for Malignant Distal Biliary Obstruction: Time to Think Outside the Box?

Authors

  • Sanish Ancil

    1   Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

  • Jimil Shah

    1   Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

  • Vaneet Jearth

    1   Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Abstract

The rates of difficult biliary cannulation (DBC) while attempting endoscopic retrograde cholangiopancreatography (ERCP) go up to 11% even in experienced hands. Salvage techniques such as the double guidewire technique, precut papillotomy (PCP), and transpancreatic precut papillotomy are beneficial for patients with DBC. Notably, with the advent of endoscopic ultrasound (EUS), different procedures, such as the EUS rendezvous technique (RV) and EUS-guided transmural biliary drainage, have come into play. In this news and views, we will review a recently published open-label, parallel-group randomized clinical trial that compared PCP and EUS-RV as therapeutic options for DBC in patients with malignant distal biliary obstruction. With a focus on multidisciplinary decision-making, the practicality of employing EUS-RV in malignant disease and the evidence-based approach according to the underlying disease requiring biliary drainage (benign vs. malignant) will be covered.


Keywords

ERCP - EUS - difficult biliary cannulation - biliary drainage

Introduction

The rates of difficult biliary cannulation (DBC) while attempting endoscopic retrograde cholangiopancreatography (ERCP) go up to 11% even in experienced hands. Though definition of DBC can be varied, the European Society of Gastrointestinal Endoscopy definition of DBC consisting of > 5 cannulation attempts, > 5 minutes of cannulation attempt, and/or > 1 inadvertent pancreatic duct (PD) cannulation or opacification remains the most accepted definition across the globe.[1] [2] The risk of post-ERCP pancreatitis (PEP) increases with the number of biliary cannulations attempts and the duration of the procedure.[3] Salvage techniques such as the double guidewire technique (DGT), precut papillotomy (PCP), and transpancreatic precut papillotomy (TPPP) are beneficial for patients with DBC.[4] Notably, with the advent of endoscopic ultrasound (EUS), different procedures such as EUS rendezvous technique (RV) and EUS-guided transmural biliary drainage (TMD) procedures has come into picture.[5]

ERCP is the preferable approach for malignant distal biliary obstruction (DBO); however, technical success may be restricted by duodenal invasion by tumor or tight stricture. Additionally, stent dysfunction due to tumor ingrowth and PEP is well-known limitations. Since the early 2000s, EUS-guided biliary drainage (EUS-BD) has emerged as a promising alternative to ERCP. EUS-BD can be categorized based on the drainage route and the mode of access. The bile duct can be accessed from either the intrahepatic or extrahepatic portions, with a 19-G or 22-G fine-needle aspiration needle. EUS-BD includes direct transmural drainage (EUS-TMD), antegrade transpapillary placement of a biliary stent, or guidewire rendezvous with a duodenoscope, facilitating subsequent conventional ERCP management, referred to as EUS-RV.[6]

Since its initial description in 2004 by Mallery et al, the technical success of EUS-RV has been validated, with studies indicating success rates ranging from 85 to 100%.[7] [8] [9] The success rate of PCP in DBC following a failed ERCP exceeds 90%.[10] The adverse events linked to precut are similar to those typically observed with ERCP, including bleeding, pancreatitis, and perforation. In contrast, the adverse events associated with EUS-RV encompass bile leak, peritonitis, and pancreatitis.[8] [11] [12]

A recent systematic review and meta-analysis of four studies found no significant differences in technical success rates or postprocedure complications, including pancreatitis and bleeding, between PCP and EUS-RV. Two of the four studies in the meta-analysis contained malignant patients, whereas the other two had patients with benign etiology.[6] In a recently published trial by Choudhury et al, 100 patients of DBC were randomized in to either PCP or EUS-RV. In that study, both the groups had similar technical success and complication rates. Both groups had similar rates of PEP as well.[13] However, evidence for EUS-RV in cases of malignant disease was significantly limited due to only retrospective data. Dhir et al in their retrospective comparative study comprising of 58 patients from the EUS-RV group and 144 patients from the PCP group showed superiority of EUS-RV over the PCP. The rate of technical success was significantly higher in the EUS cohort than in the PCP group (57/58 [98.3%] vs. 130/144 [90.3%]; p = 0.03). Eight of 14 patients for whom the precut procedure had initially failed experienced success after a second attempt at ERCP done after 72 hours; thus, the overall success rate in the precut group was 95.8% (138/144). Complications such as pancreatitis and bleeding occurred in the precut group; however, the only complication encountered in patients who underwent EUS-RV was pericholedochal leak resulting in pain. There was a small sample size, hence the higher complication rate encountered even though not statistically significant in the precut arm, should be taken in this context.[9] In another retrospective study by Lee et al, comparing two cohorts, the ERCP failure rate was lower when both EUS-guided biliary access and precut were available compared with when only precut was possible for failed access. Success for EUS-guided biliary access (95.1% vs. 75.3%) was significantly higher than for precut, p < 0.001. When analyzing outcomes based on clinical indication, EUS-guided biliary access had the greatest benefit over precut in malignant obstruction with success rates of 93.5% versus 64.0%, respectively; p < 0.001.[14]

Recently, Dhir et al conducted first prospective randomized controlled trial (RCT) with a large sample size to compare PCP and EUS-RV in DBC for malignant DBO caused by advanced unresectable malignancy. Of the 208 enrolled patients, 104 were assigned to each treatment arm through randomization. No statistically significant differences were observed in technical success rates (93.3% for PCP vs. 97.1% for EUS-RV; p = 0.33; odds ratio [OR] 0.4) and overall adverse event rates (11.5% for PCP vs. 5.8% for EUS-RV; p = 0.14; OR 0.5). The incidence of pancreatitis showed higher trend in the PCP group, with rates of 8.7% compared with 1.9% in the control group (p = 0.06; OR 4.8). Although statistically nonsignificant, the rates of inadvertent PD cannulation were higher in the EUS-RV group compared with the PCP group, and prophylactic PD stenting was not performed in the study. The mean duration of the procedure was significantly greater for EUS-RV (47 minutes compared with 27 minutes; p = 0.25), as anticipated due to the procedural steps involved in EUS-RV. The study concluded that PCP and EUS-RV exhibit comparable rates of success, adverse events, mortality, and length of stay. The authors concluded that EUS-RV may serve as an alternative to PCP for patients with malignant distal biliary obstruction (DBO) and DBC. In the study, the failure rates in the PCP arm were attributed to periampullary diverticulum (n = 3), small flat papilla (n = 2), and tumoral infiltration (n = 2). The bailout procedures performed included EUS-RV and percutaneous transhepatic BD (PTBD). In patients undergoing EUS-RV, failure was attributed to tight strictures that hindered guidewire negotiation. The rescue procedures employed were either the precut technique or PTBD.[15]


Commentary

ERCP is the standard therapeutic option for treating malignant DBO caused by pancreatic, bile duct, or ampulla cancer. Even among skilled endoscopists, selective bile duct cannulation can fail in 10 to 20% of cases during ERCP. Malignancy complicates the situation, as ERCP may be unsuccessful in patients with duodenal stenosis, ampullary infiltration, or tight biliary strictures. If the standard ERCP cannulation technique is unsuccessful, alternative options consist of advanced ERCP cannulation methods, including double guidewire technique (DGT) with or without pancreatic stenting, TPPP, PCP, and EUS-RV assisted ERCP. The increasing expertise in EUS-BD, encompassing EUS-RV and EUS-TMD, has led to a reduction in the need for PTBD, particularly in high-volume centers.[16] [17] [18]

Dhir et al assessed the role of PCP and EUS-RV in RCT involving patients with malignant DBO resulting from unresectable cancer, finding comparable success rates for both procedures. The study was conducted at high-volume centers, where PCP was performed by endoscopists with experience exceeding 500 PCP procedures and EUS-RV practitioners with over 100 EUS-BD procedures. The effectiveness of PCP is constrained in the presence of small papillae, large periampullary diverticula, and duodenal infiltration.[15] The EUS-RV approach is favored by some endoscopists for BD because it eliminates the necessity for a permanent bilioenteric fistula and the dilation of the fistulous tract, thereby reducing adverse events such as bleeding, pneumoperitoneum, and pneumomediastinum, while preserving the physiological route of ERCP. Before determining the indication for EUS-RV, it is essential to carefully consider the patient's clinical status, the endoscopist's skill level, and available backup options. The endoscopist should possess proficiency in EUS and ERCP procedures, supported by competent interventional radiology and surgical resources in the event of unsuccessful EUS-RV. A significant limitation of the EUS-RV is its applicability solely to patients with accessible papillae, which may be unfeasible in cases of altered anatomy or duodenal stenosis. Additionally, EUS-RV is a multistep procedure that necessitates the use of various endoscopic accessories, resulting in a relatively extended procedure duration.

Determining the most appropriate approach for DBC is essential, contingent upon the specific biliary disease prerequisite for ERCP. EUS-RV is primarily employed in instances of benign conditions where the ampulla is accessible. EUS-RV may serve as an effective salvage option for DBC in the management of benign conditions such as stones or strictures, as ERCP following EUS-RV utilizes a physiological route and offers therapeutic benefits for both the underlying disease and BD.[19] While established guidelines for the use of EUS BD techniques are lacking, EUS-TMD appears to be a more suitable option for BD in cases of unresectable cancer causing DBO, provided that EUS expertise and adequate backup are available. This encompasses EUS-choledocoduodenostomy, EUS-hepaticogastrostomy, and EUS-antegrade stenting when the papilla is inaccessible. EUS-guided gallbladder drainage serves as an effective palliative intervention for malignant DBO when other treatment modalities are unsuccessful.[20] EUS-TMD presents advantages over EUS-RV, particularly in cases of malignant DBO, as it minimizes papillary trauma and the associated risk of pancreatitis. It also decreases the necessity for change of scope and accessories, thereby conserving time, and does not require stenting through the malignant stricture (with the exception of EUS-AG), which lowers the risk of tumor ingrowth that can result in stent dysfunction and the need for reintervention.[21] A recent retrospective analysis by Joan B Gornals et al indicated that the EUS-TMD group exhibited greater technical success (OR, 16.96; 95% confidence interval [CI], 4.69–81.62; p < 0.001) and overall success (OR, 3.09; 95% CI, 1.18–8.16; p < 0.026), alongside a lower rate of adverse events (OR, 0.30; 95% CI, 0.11–0.78; p = 0.014) compared with EUS-RV in malignant disorders.[22]

Consequently, while PCP and EUS-RV demonstrate comparable safety and efficacy for DBC when performed by skilled therapeutic endoscopists, outcomes of EUS-RV as rescue option in malignant disease needs more evidence from larger RCTs. It is essential for endoscopists to make treatment decisions that are appropriately tailored to the patient's anatomical and clinical requirements.



Conflict of Interest

None declared.


Address for correspondence

Vaneet Jearth, MD, DM
Department of Gastroenterology, Post Graduate Institute of Medical Education and Research
Chandigarh 160012
India   

Publication History

Article published online:
21 November 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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