In this video we will show management of a 77 year old with recent cholecystectomy at an outside hospital. Intraoperative cholangiogram showed a nondilated bile duct with multiple small stones. Subsequent ERCP at that hospital failed with multiple attempts at guidewire cannulation for over one hour, with multiple PD wire passes, but no pancreatic stent. The patient developed post-ERCP pancreatitis. The patient was referred back to her surgeons, who then referred her to our center for endoscopic management of the bile duct stones.
On arrival to our center, the patient was complaining of abdominal pain, and had an amylase of >1,000. Review of outside MRCP done postoperatively and post ERCP attempt showed a number of stones in a small duct, and showed fluid collection in the head of the pancreas and around the head of the pancreas. CT at our center showed pleural effusions and acute fluid collection in and around the head of the pancreas and around the duodenum. We performed ERCP with pancreatic wire access, with the goal of placing pancreatic stents to cool off the acute pancreatitis. With a guidewire in the pancreas, attempted biliary cannulation resulted in passage of the guidewire in multiple directions in the retroperitoneum despite minimal pressure, suggesting that there had been retroperitoneal perforation during the aggressive attempt at wire cannulation at the initial ERCP. To settle down the pancreatitis we placed dual side-by-sdie stents, one long (10cm) 3f stent and one short 5F stent. We performed a very limited needle knife incision but did not attempt any further cannulation attempts because of concern for opening up the perforations and contaminating the retroperitoneum.
The patient improved, and amylase normalized within a day. However within the next day after that, the patient spiked a fever and liver enzymes rose.
Our plan was to go directly to EUS rendezvous to obtain bile duct access for ERCP with minimal papillary instrumentation. The cartoon shows transduodenal puncture of the bile duct with antegrade passage of a guidewire through the papilla, to obtain access for standard retrograde ERCP. At EUS, the needle punctures the very small bile duct containing at least one or two small floating stones. As the needle punctures the bile duct through the duodenum, the wire passes initially retrograde up towards the liver. Then the wire is redirected distally by repositioning the EUS scope. However, the wire does not pass freely. A cholangiogram is done through the EUS needle, showing the tiny bile duct, and that the wire has now passed appropriately through the duct and papilla into the duodenum. After several loops of wire are passed into the duodenum, the EUS scope is carefully removed.
An ERCP scope is passed, the guidewire grasped and pulled into the channel. Remember though, that this guidewire exits back out the bile duct a few cm above the papilla, so the goal is cannulation beside that guidewire with a papillotome and second wire. Here the papillotome and wire pass freely up the duct and a wire is passed into the intrahepatic ducts. A balloon dilation of the papilla is performed, with the pancreas protected by the previous pancreatic stents. Several stones are removed and a 8.5Fr biliary stent is placed.
The patient did well with resolution of pain, normalization of LFTs and amylase. At repeat ERCP a few weeks later additional stones and the stents were removed. The patient has done well since.
Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed pancreatic and bile ducts. Gastrointest Endosc. 2004;59:100-7
Kim Y, Gupta K, Mallery S, Li R, Kinney T, Freeman ML. Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series. Endoscopy 2010; 42: 1–7
Shah JN, Marson F, Weilert F, Bhat YM, Nguyen-Tang T, Shaw RE, Binmoeller KF.Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla. Gastrointest Endosc. 2012 Jan;75(1):56-64. Epub 2011 Oct 21.
Rajeev Attam, MD, University of Minnesota
Mustafa Arain, MD, University of Minnesota
Martin L. Freeman, M.D., University of Minnesota