In a 60-year-old man with inoperable adenocarcinoma of the pancreatic head, endoscopic
retrograde cholangiopancreatography (ERCP) was attempted in order to place a biliary
self-expanding metal stent (SEMS) across the stricture in the bile duct. However,
all attempts to gain access to the bile duct failed. It was then decided to perform
a rendezvous-procedure ERCP.
After percutaneous transhepatic puncture of the bile duct under ultrasound guidance,
a guide wire was positioned in the common bile duct, but despite several attempts
it was not possible to traverse the stricture with it. The duodenoscope was then placed
in the duodenum facing the papilla. Under endoscopic and fluoroscopic guidance, the
multipurpose catheter was abutted against the wall of the common bile duct near the
lower end, close to the papilla. The impression made by the multipurpose catheter
was visible endoscopically in the duodenum as an indentation, distal to but close
to the papilla. After this, a zebra guide wire was passed through the multipurpose
catheter, and with the multipurpose catheter still abutting the bile duct wall, the
guide wire was forced to pierce the common bile duct and the duodenal wall. It was
then grasped with a polypectomy snare and taken out through the biopsy channel of
the duodenoscope. A sphincterotome was then passed over the guide wire into the bile
duct. It was then removed, and a 6-cm covered biliary SEMS (Boston Scientific, Watertown,
Massachusetts, USA) was placed in the bile duct (Figure [1]). Free flow of bile was seen. The percutaneous intrahepatic tract was dilated to
12 Fr, and a 12-Fr suprapubic drainage catheter was positioned above the proximal
end of the SEMS (Figure [2]). The percutaneous transhepatic biliary catheter was later removed and the patient
was discharged from hospital.
Figure 1 A self-expanding metal stent (SEMS) has been placed using a rendezvous endoscopic
retrograde cholangiopancreatography procedure. It should be noted that the duodenal
end of the SEMS is distal to the normal opening of the bile duct.
Figure 2 The radiographic appearance. There is free flow of the contrast that has been injected
through the percutaneous transhepatic biliary drainage catheter.
Placement of SEMS is an established modality for palliative treatment in patients
with biliary obstruction due to inoperable cancers [1]
[2]. Access to the bile duct is sometimes not possible during ERCP, and in these cases
a combined radiographic and endoscopic procedure may be attempted [3]
[4].
Endoscopy_UCTN_Code_TTT_1AR_2AZ
