Digestive and Liver Disease
Volume 42, Issue 6 , Pages 419-424, June 2010

Endoscopic Ultrasound-guided cholangiopancreatography and rendezvous techniques

  • Vanessa M. Shami
    • ,
  • Michel Kahaleh

      Affiliations

    • Corresponding Author InformationCorresponding author at: Digestive Health Center of Excellence, MSB 2153, Box 800708 University of Virginia Health System Charlottesville, VA 22908-0708, United States. Tel.: +1 434 243 9259; fax: +1 434 924 0491.

Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA, United States

Received 11 August 2009; accepted 24 September 2009. published online 09 November 2009.

Article Outline

Abstract 

Endoscopic ultrasound-guided cholangiopancreatography (EUCP) has become an alternative to percutaneous drainage or surgery in patients with obstructive jaundice or pancreatic obstruction after failed conventional ERCP. The different techniques of biliary and pancreatic drainage are described and the literature is reviewed. Due to the technical complexity associated with this procedure, it should be reserved for endoscopists at tertiary care centers with advanced training in both EUS and ERCP.

Keywords: ERCP, EUS, EUS-guided ERCP, Rendezvous

 

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1. Introduction 

Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement has become the standard of care for biliary decompression in patients with obstructive jaundice [1], [2], [3] and for pancreatic strictures that are due to chronic pancreatitis [4], [5], [6] and other causes [7]. Biliary and pancreatic duct decompression in expert hands is successful in 90–95% of cases [8], [9]. Failure to cannulate the bile duct may result from anatomic variation due to prior surgery, periampullary diverticula, tortuous ducts, impacted stones, or tumour infiltration [10], [11], [12]. Pancreatic duct cannulation is typically successful in 90% of cases [9]. Failures commonly result from pancreatic inflammation or surgically altered anatomy [12].

Following initial failed ERCP, the recommended next step is reattempted of the ERCP by a more experienced endoscopist at a tertiary referral centre [13], [14]. Alternative means of achieving biliary decompression include percutaneous transhepatic drainage (PTC) [15], [16], [17], and surgical intervention [18]. However both PTC and surgical intervention are associated with significant morbidity [19], [20], [21].

The evolution of the linear-array echoendoscope as well as the ability to accurately guide a needle into the interventional field has greatly expanded the therapeutic potential of endoscopic ultrasound (EUS). Endoscopic ultrasound provides detailed imaging by approximating the frequency transducer to the area of interest. In the past decade, EUS has developed into a useful technique for fine needle aspiration (FNA) [22], pancreatic pseudocyst drainage [23], [24], [25], and celiac plexus block and neurolysis [26], [27], [28], [29], [30], [31], [32]. Anatomically, the biliary tree and the pancreatic duct are in approximation to the stomach and duodenum, thereby allowing visualization of the ducts. The natural progression was to extend the capabilities of EUS to the pancreaticobiliary system. Initial EUS-guided cholangiopancreatography was reported by Wiersema et al. in 1996 and involved 11 patients who failed standard biliary or pancreatic opacification [33]. More recently, this technique has been well established in achieving both biliary and pancreatic drainage.

1.1. Patient selection 

Patients who present with biliary or pancreatic duct obstruction that failed conventional ERCP at a tertiary care centre by an experienced endoscopist should be considered for endoscopic ultrasound-guided ERCP (EUCP). Contra-indication includes coagulopathy and severe hemodynamic instability precluding general anaesthesia. Detailed cross sectional imaging of the pancreaticobiliary tree, as well as surrounding structures with CT or MRI is vital to identify the level of obstruction and to define the patient's anatomy. All patients should receive intravenous periprocedural antibiotics. Secondary to the duration and complexity of the procedure, patients should undergo general anaesthesia.

1.2. Endoscopist selection 

Since EUS-guided ERCP is a technically challenging procedure that bears a fair amount of risk when compared to conventional ERCP, it is mandatory that the endoscopist has expertise in both EUS and ERCP. This goal can be accomplished either with a single operator who is highly skilled at both EUS and advanced endoscopy, or by two different endoscopists, one with experience in interventional EUS, and the other in therapeutic ERCP. Furthermore, the procedure should be performed at a tertiary care centre where experienced pancreatobiliary surgeons and interventional radiologists are available in the event of a complication.

1.3. Techniques 

A linear-array echoendoscope with a working channel of at least 3mm should be selected. The Olympus GF-UCT 140 and the Pentax EG 38UT have working channels of 3.7 and 3.8mm, respectively, and are ideal for the placement of large diameter stents.

Puncture of the target duct is typically performed with either a 19- or a 22-gauge needle (EUSN-19-T or EUS-1-CS; Cook Endoscopy). The 19-gauge needle is preferred because it accommodates a 0.035-in. guidewire (Terumo; Boston Scientific, Natick, MA), which provides more control than the 0.018-in. guidewire (Pathfinder; Boston Scientific). Dilation of an enterocholedochal or pancreatic fistula is then accomplished using either a 4- or 6-mm wire-guided balloon catheter (MaxForce; Boston Scientific) or a 6F or 7F bougie (SBDC-6 or -7; Wilson-Cook, Winston-Salem, NC).

1.3.1. EUS-guided biliary drainage 

EUS-guided biliary drainage is typically attempted with either transgastric-transhepatic (intrahepatic) or transenteric-transcholedochal (extrahepatic) approach. If the intrahepatic ducts are significantly dilated (2mm or more), the intrahepatic approach is preferred as this technique can provide antegrade stent placement across the ampulla without the need for a rendezvous procedure.

1.4. Intrahepatic approach 

The intrahepatic approach is performed with the echoendoscope positioned in the cardia or lesser curvature of the stomach to allow visualization of the dilated left intrahepatic biliary system. Once colour Doppler has excluded overlying vasculature, the EUS needle is advanced into the intrahepatic duct, bile is aspirated, and a small amount of contrast is injected to opacify the biliary tree, confirming position inside the bile duct (Fig. 1, Fig. 2). A guidewire is then advanced in an antegrade fashion through the EUS needle and into the bile duct (Fig. 3). With fluoroscopic and EUS guidance, the guidewire is manipulated beyond the biliary obstruction and across the ampulla into the duodenum. Once the guidewire has traversed the ampulla, the procedure can be completed in either an antegrade fashion or with a rendezvous technique.

In an antegrade fashion, a 6 or 7F bougie or balloon catheter is utilized to dilate the tract (Fig. 4), followed by antegrade stent deployment across the stricture (Fig. 5).

If the rendezvous technique is chosen, the echoendoscope must be carefully removed while leaving the guidewire in place. A duodenoscope is inserted and advanced to the duodenum, with visualization of the ampulla and the wire exit of the ampullary orifice. The wire is then grasped with a snare and withdrawn through the accessory channel. Since access to the common bile duct has been achieved, the procedure can be completed using standard ERC with stent placement.

If the guidewire cannot be advanced into the duodenum, a transenteric fistula can be created by dilating the tract with a 4–6mm wire-guided balloon catheter or a 6–7F bougie, followed by stent placement.

1.5. Extrahepatic approach 

To visualize the extrahepatic bile duct, the echoendoscope is not only typically positioned in the duodenum but can also be positioned in the distal antrum, depending on the anatomy. After colour Doppler is used to identify adjacent vasculature, the EUS needle is then inserted into the bile duct and the guidewire is advanced in an antegrade fashion across the ampulla and into the duodenum (Fig. 6, Fig. 7). The remainder of the procedure is similar to that described above for the intrahepatic approach.

1.5.1. EUS-guided pancreatic drainage 

By positioning the echoendoscope in the stomach, the main pancreatic duct is identified with EUS guidance and punctured with the EUS needle. A small amount of contrast material is injected and a pancreatogram is performed to confirm successful access to the pancreatic duct (Fig. 8). A guidewire is advanced through the needle and into the pancreatic duct, with subsequent antegrade advancement of the wire into the duodenum, if possible (Fig. 9). If the guidewire cannot be advanced in an antegrade fashion, it should be advanced retrograde into the pancreatic duct. After ductal access has been achieved, a pancreatogastric fistula is enlarged with a 6F or 7F bougie followed by balloon dilation with a 4- or 6-mm MaxForce dilator (Fig. 10). Intraductal strictures should be dilated with either the bougie or balloon catheter. A 7F stent is then placed through the pancreatogastric fistula (Fig. 11).

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2. Discussion 

2.1. EUS-guided biliary drainage 

Wiersema et al. described the use of EUS-guided cholangiography in 10 patients in 1996 [24]. In his series, biliary opacification guided repeat ERC with precut sphincterotomy in 5 of 7 patients. In 2001, Giovannini et al. performed a choledochoduodenal fistula created under EUS guidance with transbulbar stent placement [34]. Two years later, Burmester et al. reported a series of 4 patients undergoing creation of a EUS-guided enterobiliary fistulae in 3 patients [35]. EUS-guided drainage of obstructed biliary ducts via a rendezvous technique was performed in 2 patients by Mallery et al. [36] Kahaleh et al. reported a series of 23 patients undergoing EUS-guided ERC, with biliary decompression achieved in 21 patients [37]. Most recently, our group has reported the largest study of EUS-guided ERC performed in 49 patients. The overall success rate was 84% (41/49), with an overall complication rate of 16%. 35 patients underwent the intrahepatic approach, with a success rate of 83% (29/35). 14 patients underwent the extrahepatic approach (including 5 of whom had initially undergone the intrahepatic approach but were converted to the extrahepatic approach), with success in 12/14 patients, or 86% [38]. Table 1 summarizes the published literature of EUS-guided biliary drainage to date with a cumulative success and complication rate of respectively 81/93 (87%) and 19/93 (20%).

Table 1. Published series of EUCP.
AuthorYearNo. of patientsTechniqueComplicationsRate of successa
Biliary drainage
Burmester et al. [35]20034Intrahepatic (1), extrahepatic (2)Bile leak (1)75% (3 of 4)
Mallery et al. [36]20042Extrahepatic (2)Wire passed out of bililary lumen (1)100% (2 of 2)
Puspok et al. [40]20056Extrahepatic (6)None83% (5 of 6)
Bories et al. [41]200711Intrahepatic (11)Ileus (1), Stent shortening (2), early blockage (1)91% (10 of 11)
Will et al. [42]20078Intrahepatic (7), extrahepatic (1)Slight pain (2), cholangitis (1)88% (7 of 8)
Tarantino et al. [43]20088Extrahepatic (8)Death from cirrhosis (1)100% (8 of 8)
Yamao et al. [39]20085Extrahepatic (5)Pneumoperitoneum (1)100% (5 of 5)
Maranki et al. [38]200949Intrahepatic (35), extrahepatic (14)Biliary peritonitis (1), pain (1), pneumoperitoneum (4), aspiration pneumonia (1), self-resolving bleeding (1)84% (41 of 49)

Pancreatic drainage
Francois et al. [47]20024Pancreaticogastrostomy (4)Stent dislocation (1)100% (4 of 4)
Kahaleh et al. [48]20032Pancreaticogastrostomy (2)Haematemesis due to stent adjacent to vessel (1)100% (2 of 2)
Mallery et al. [36]20044Rendezvous (4)Transient fever (1)25% (1 of 4)
Papachristou et al. [49]20072Rendezvous (2)None100% (2 of 2)
Kahaleh et al. [51]200713Pancreaticogastrostomy (10)Bleeding (1), Contained perforation (1)77% (10 of 13)
Tessier et al. [52]200736Pancreaticogastrostomy (26), Pancreaticobulbostomy (7)Haematoma (1), pancreatitis (1)92% (33 of 36)
Will et al. [53]200712Pancreaticogastrostomy (5), rendezvous (4)Pain (4), bleeding (1), perforation (1), pseudocyst (1)75% (9 of 12)

aSuccess as defined by adequate drainage of the applicable duct.

The main complications associated with EUS-guided biliary drainage include pneumoperitoneum, post-procedure pain, and bleeding, most of which tend to be managed conservatively. The risk of bile leak and perforation leading to biliary peritonitis was found to be fairly small based on the reported case series. Of the 93 cases reported, there were 5 cases of pneumoperitoneum, 1 biliary leak, 1 case of biliary peritonitis and 1 case where the wire was passed outside of the bile duct lumen [35], [36], [38], [39]. There was also 1 case of ileus, 2 cases of stent malfunction, 1 early blockage, 1 death from complications of cirrhosis, 3 episodes of pain, 1 case of cholangitis, 1 aspiration pneumonia, and 1 case of self-resolving bleeding [38], [40], [41], [42], [43]. The overall complication rate in these 93 cases was 20% (19/93).

2.2. EUS-guided pancreatic drainage 

In 1996 Wiersema [24] and Gress et al. [44] each reported one case of EUS-guided pancreatography. One approach to achieving pancreatic drainage involves the creation of a pancreaticoenteric fistula followed by rendezvous [36], [45], [46]. Another technique requires the creation of a pancreaticogastric fistula as the main method for duct drainage [47], [48]. The rendezvous technique was described by Mallery et al. in whose series successful drainage was reported in only 25% (1 of 4) of patients [36] (Table 1). In 1 case, the pancreatic duct could not be punctured, and in 2 of the cases, the wire could not be advanced through the stricture. More recently, Papachristou et al. reported 2 cases of successful pancreatic drainage with the rendezvous technique in patients with nondilated pancreatic ducts [49]. When the pancreatic duct cannot be decompressed from the second portion of the duodenum, creation of a pancreaticogastric fistula is the preferred method to achieve duct drainage [50]. In a study at our institution, 13 patients with chronic pancreatitis and intractable pain were included; 7 of these patients had prior surgical diversions [51]. Successful creation of a pancreaticogastric fistula was achieved in 10 (77%) patients, followed by stent placement. In 2 cases, the needle could not be oriented to allow advancement of the guidewire for access, thus no endoprosthesis was placed. Complications of the procedures included 1 case of bleeding requiring hemoclip placement and 1 case contained perforation that resolved spontaneously. Tessier et al. reported the largest retrospective series to date of 36 patients who underwent either pancreaticogastrostomy or pancreaticobulbostomy. Success was achieved in 92% of cases (33 of 36), and complications, including haematoma and severe pancreatitis, occurred in 2 patients [52]. In 2007, Will et al. reported 12 patients through 14 interventions who underwent EUS-guided pancreatic duct drainage [53]. Pancreatography was successful in all patients, and drainage of the pancreatic duct was achieved in 9 patients. The transgastric approach, with creation of a pancreaticogastric fistula, was done in 5 patients, whereas 4 patients underwent the rendezvous technique with subsequent ERCP. The complication rate was 43%, with post-procedural pain occurring in 4 patients, bleeding in 1 patient, and perforation in 1 patient.

Table 1 summarizes the published literature of EUS-guided pancreatic drainage to date with a cumulative success and complication rate of respectively 61/73 (83%) and 14/73 (19%).

EUCP has several advantages over percutaneous drainage, including the ability to visualize overlying vascular structures in real time using colour Doppler while attempting needle puncture of the biliary or pancreatic ducts, potentially decreasing vascular injury. EUCP allows drainage without the need for an external drain, which can be a source of infection and discomfort. While the reported complication rate for EUS-guided pancreatic drainage is somewhat high, the complication rate for EUS-guided biliary drainage is more favourable, making it an attractive alternative to PTC.

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3. Summary 

EUCP should be considered as an alternative to PTC or surgery in patients with obstructive jaundice or pancreatic strictures who have failed conventional ERCP. Since the procedure is technically challenging, it should be performed by trained interventional endoscopists at a tertiary care centre, with experienced pancreatobiliary surgeons and interventional radiologists available in the event of complications. In the presence of dilated intrahepatic ducts, the preferred method for biliary drainage is the intrahepatic approach with antegrade stent placement, avoiding the need for a rendezvous procedure. In the pancreatic duct, the antegrade approach is recommended for pancreatic drainage. EUCP is a technique that is increasingly utilized in tertiary care centres and is evolving as a feasible alternative technique to PTC or surgery.

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Conflict of interest statement 

None declared.

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PII: S1590-8658(09)00395-8

doi:10.1016/j.dld.2009.09.009

Digestive and Liver Disease
Volume 42, Issue 6 , Pages 419-424, June 2010

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