EUS-guided rendezvous for difficult biliary cannulation: a multicenter prospective pilot study

Biliary cannulation is inevitable step in ERCP. EUS-guided rendezvous (EUS-RV) can salvage failed cannulation. Aims: To determine the safety and efficacy of EUS-RV with a standardized algorithm in terms of scope position in a prospective cohort. Methods: From 8/2012 to 10/2013, 674 patients with the naive papilla underwent ERCP for biliary disorders at three centers. EUS-RV was attempted after failed cannulation in 20 patients. In the standardized approach, the extra-hepatic bile duct (EHBD) was initially approached from the 2nd portion of the duodenum (D2) followed by either EHBD from the bulbs (D1) or intra-HBD (IHBD) from the stomach. A guidewire was placed antegradely into the duodenum. Finally the EUS was exchanged for a duodenoscope followed by achievement of cannulation.Result: The bile duct was accessed from D2 (10), but from D1 (5) and stomach (4) because of no dilation (6) and tumor invasion (3) of distal EHBD. In the remaining one, biliary puncture failed due to collateral vessels. The guidewire was successfully manipulated in 80% (16/20): 100% (10/10) with D2 approach and 56% (5/9) with others. The overall success rate was 80% (16/20). Failed EUS-RV was salvaged with PTCD (2), repeat ERCP (1), and conservative management (1). Complications were recognized in 3 (15%). Conclusion: EUS-RV is safe and effective salvage. Approaching from D2 may improve the success rate.