Abstract
An 86-year-old male was admitted to our hospital for evaluation of obstructive jaundice and upper abdominal pain. Two months earlier, he had undergone palliative Billroth II gastroenterostomy for bleeding due to duodenal cancer. Computed tomography demonstrated a dilated bile duct and lower bile duct stricture due to probable duodenal cancer invasion. Therefore, endoscopic retrograde cholangiopancreatography (ERCP) was attempted using a long pediatric colonoscope (PCF-240L). Although we could endoscopically reach the papilla of Vater, repeated attempts to cannulate the bile duct were unsuccessful. Endoscopic ultrasonography (EUS) demonstrated a dilated intrahepatic bile duct in the left lobe (B2) ; therefore, an EUS-guided rendezvous technique was performed. We punctured the dilated bile duct (B2) via the transgastric approach under EUS guidance using a 19-gauge FNA needle, and a long 0.035-inch guidewire was advanced across the lower bile duct stricture and papilla into the duodenum. The echoendoscope was then removed and a long pediatric colonoscope (PCF-240L) was inserted. The transpapillary guidewire was retrieved with a grasping forceps, biliary cannulation was successfully performed, and a plastic stent was deployed. There were no procedure-related complications and the serum bilirubin level decreased to the normal range. In the context of failed conventional ERCP, the EUS-guided rendezvous technique appears to be an effective alternative method of biliary drainage in patients with surgically altered gastrointestinal anatomy and an endoscopically accessible papilla.
