The rendezvous technique involving insertion of a guidewire in a percutaneous transhepatic gallbladder drainage tube for biliary access in a case of difficult biliary cannulation

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic method and treatment approach for biliary diseases. However, biliary cannulation can be difficult in some cases. We performed ERCP in a 97-year-old woman with abdominal pain resulting from acute cholangitis caused by choledocholithiasis and observed difficult biliary cannulation. Eventually, the patient was successfully treated with the rendezvous technique. We could not cannulate the biliary duct during ERCP twice. Therefore, we placed a percutaneous transhepatic gallbladder drainage (PTGBD) tube without intrahepatic dilation. The rendezvous technique was performed using the PTGBD tube. The patient did not experience pancreatitis or perforation.

Full text

Case report
The rendezvous technique involving insertion of a
guidewire in a percutaneous transhepatic gallbladder
drainage tube for biliary access in a case of difcult
biliary cannulation
Fumiko Sunada1, Naoki Morimoto2, Mamiko Tsukui1, 2 and Hidekazu Kurata1
1Department of Gastroenterology, Tochigi Medical Center, Japan
2Department of Gastroenterology and Hepatology, Jichi Medical School Hospital, Japan
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a
diagnostic method and treatment approach for biliary diseases.
However, biliary cannulation can be difcult in some cases. We
performed ERCP in a 97-year-old woman with abdominal pain
resulting from acute cholangitis caused by choledocholithiasis
and observed difcult biliary cannulation. Eventually, the patient
was successfully treated with the rendezvous technique. We could
not cannulate the biliary duct during ERCP twice. Therefore, we
placed a percutaneous transhepatic gallbladder drainage (PTGBD)
tube without intrahepatic dilation. The rendezvous technique was
performed using the PTGBD tube. The patient did not experience
pancreatitis or perforation.
Key words: endoscopic retrograde cholangiopancreatography, dif-
cult biliary cannulation, percutaneous transhepatic
gallbladder drainage, rendezvous technique
(J Rural Med 2017; 12(1): 46–49)
Introduction
Endoscopic retrograde cholangiopancreatogr aphy (ERCP)
is a diagnostic method and treatment approach for biliary
diseases. Selective biliary cannulation has been reported to
fail in 15–35% of cases1). For overcoming difcult biliary
cannulation, several methods have been reported. Recently,
the sequential double-guidewire technique and transpan-
creatic precut sphincterotomy were shown to be useful in
cases of difcult biliary cannulation. No signicant differ-
ence in cannulation success rate was found between the two
methods2– 4). The rendezvous technique is useful for cases
in which cannulation cannot be performed with the sequen-
tial double-guidewire technique and transpancreatic precut
sphincterotomy5). However, the rendezvous technique is
complicated. We had a patient with difcult biliary cannula-
tion, who could not be treated with the sequential double-
guidewire technique or transpancreatic precut sphincter-
otomy. Eventually, the patient was successfully treated with
the rendezvous technique. Here, we report this case, with
consideration of the literature.
Case report
A 97-year-old woman was admitted to our hospital be-
cause of acute obstructive cholangitis and common bile
duct stones. She had no signicant medical history or rel-
evant family history. On physical examination, she reported
acute right abdominal pain. Blood examination revealed a
white blood cell count of 17,900/µL, aspartate aminotrans-
ferase level of 269 IU/L, alanine aminotransferase level of
120 IU/L, total bilirubin level of 1.9 mg/dL, and C-reactive
protein level of 0.56 mg/dL. Abdominal ultrasonography
revealed gallbladder swelling, and abdominal computed
tomography revealed several bile duct stones measuring 8
mm in diameter (Figure 1). Therefore, she was diagnosed
with acute cholangitis due to choledocholithiasis. We at-
tempted ERCP (Olympus JF260V; Olympus, Tokyo, Japan);
J Rural Med 2017; 12(1): 46–49
©2017 The Japanese Association of Rural Medicine
Received: August 31, 2016
Accepted: December 13, 2016
Correspondence: Fumiko Sunada, Department of Gastroenterology,
Tochigi Medical Center Shimotsuga, 420-1 Kawatsure, Tochigi 329-
4498, Japan
E-mail: f-sunada@jichi.ac.jp
This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd)
License <https://creativecommons.org/licenses/by-nc-nd/4.0/>.

47
however, we could not cannulate the bile or pancreatic duct.
She did not have an intradiverticular papilla. We then at-
tempted the precut procedure, but could not cannulate the
duct. Therefore, a percutaneous transhepatic gallbladder
drainage (PTGBD) tube (Hanako 7-Fr pigtail percutaneous
transhepatic biliary drainage [PTCD] tube; Hanako Medi-
cal, Tokyo, Japan) was placed under ultrasonographic guid-
ance, without dilation of the intrahepatic bile duct. We again
attempted ERCP, but were unsuccessful. We then used the
PTGBD route (rendezvous technique), which was relocated
near the cystic duct to align the cystic duct in a straight line
as much as possible (Figure 2), and placed a guidewire (Jag-
wire angle tip, 0.035 in × 450 cm; Boston Scientic, Natick,
MA) from the cystic duct to the ampulla. The duodenal en-
doscope was caught with the guidewire and was pulled out
from the instrument channel (Figures 3 and 4). A papillo-
tome was then inserted, and sphincterotomy was performed.
Five days later, choledocholithotripsy was performed and
no post-ERCP pancreatitis or other complications occurred.
She was discharged from the hospital 4 days after the nal
procedure for common bile duct stones.
Discussion
Selective biliary cannulation is a necessary step for ther-
apeutic ERCP. When biliary cannulation is performed by
experienced surgeons, the success rate is more than 90%6).
However, biliary cannulation can fail in some cases, and
the risk of pancreatitis increases in these cases. The occur-
rence rate of post-ERCP pancreatitis has been reported to
be 7.3–17%, even when methods for difcult bile duct cases
were used2–4, 7).
The initial step involves identication of the bile duct
with a catheter or wire-guided cannulation using a papil-
lotome and catheter. For success, the papilla of Vater should
be closely observed in the frontal view6). If this step is suc-
cessful, the risk of pancreatitis after ERCP would be lower.
In unsuccessful cases, several methods have been reported.
If cannulation of the pancreatic duct can be performed and
a guidewire can be placed in the pancreatic duct, the pan-
creatic guidewire-indwelling method is useful. It is referred
to as the sequential double-guidewire technique. Dumon-
ceau et al. were the rst to report this method8). The authors
mentioned that this method can be successfully performed
in cases in which the papilla of Vater cannot be observed
from the front. Another method is transpancreatic precut
sphincterotomy. This method is quite advanced. Bile duct
cannulation is possible by cutting the opening of the papilla
of Vater or ampulla, and identifying the ampulla of the bile
duct or the point of bile drainage. The precut method can
be performed with a needle knife3) or papillotome3, 7). The
needle knife procedure is associated with easy hand control.
The procedure involving a papillotome has the advantage
of a xed papilla of Vater. Cutting is initiated from the pan-
Figure 1 Abdominal computed tomography scan showing choledo-
cholithiasis (8 mm in diameter).
Figure 2 The PTGBD tube placed near the cystic duct as much as
possible.

48
creatic duct. Recently, the use of guidewire transpancreatic
precut sphincterotomy has been reported3). If this approach
is not successful, the surgery might be prolonged. In addi-
tion, the risk of complications increases when the surgery is
unsuccessful.
Another approach is the two-devices-in-one-channel
method, which has been reported to be useful9). This meth-
od is benecial when the papilla is located deep inside a
diverticulum. The rendezvous technique can also be per-
formed5). The rendezvous technique involves transpapillary
endoscopic therapy using PTCD or PTGBD. The process
using PTCD is easier than that using PTGBD. The angle
between the hepatic and common bile ducts is almost 180°,
and the guidewire has a straight course. However, in PTG-
BD, the angle between the cystic duct and common bile duct
is acute, and the route to the cystic duct is not straight but
is spiral. Thus, the guidewire is difcult to insert from the
gallbladder through the common bile duct. Reports on the
PTGBD process are few. We attempted to position the PTG-
BD tube as close to the cystic duct as possible. We attempted
to ensure a straight line to the cystic duct as much as pos-
sible through the guidewire. This procedure does not confer
any risk of pancreatitis. The guidewire is passed through
the PTBD or PTGBD tube to the duodenum, and the endo-
scope is introduced. Continuous endoscopic sphincterotomy
is then performed. A stula from the skin to the liver should
be created before performing the rendezvous technique, and
this procedure is greatly complicated. Presently, the endo-
scopic ultrasonography-guided rendezvous technique is of-
ten performed10). However, this procedure requires exclusive
devices. To overcome difcult biliary cannulation, experi-
ence and knowledge of the abovementioned techniques are
necessary.
Conclusion
We successfully performed the rendezvous technique in
a patient with difcult biliary cannulation, who could not be
treated with the sequential double-guidewire technique or
by transpancreatic precut sphincterotomy. We believe that
the rendezvous technique should be considered in patients
with difcult biliary cannulation.
Conicts of Interest: The authors declare no conicts
of interest with regard to this article.
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Figure 3 The rendezvous technique involving a percutaneous tran-
shepatic gallbladder drainage tube.
Figure 4 Guidewire placement and duodenal endoscopy.

49
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