Authors
M. SOMERS (1), M. NIEKEL (2), S. BOUHADAN (1), A. JAUREGUI (1), H. DE SCHEPPER (1), S. FRANCQUE (1), E. MACKEN (1) / [1] UZA, Universitair Ziekenhuis Antwerpen, Edegem, Belgium, Department of gastroenterology and hepatology, [2] UZA, Universitair Ziekenhuis Antwerpen, Edegem, Belgium, Department of radiology
Bile duct stone extraction via PTC rendezvous assisted single balloon ERCP. Therapeutic ERCP procedures in patients with surgically altered intestinal anatomy remain challenging. During the last years, several endoscopic techniques have been proposed to increase successful cannulation of the biliary tract (single balloon ERCP (SB-ERCP), surgically assisted ERCP, internal EUS-directed transgastric ERCP and transprosthetic endoscopic therapy). With the single balloon ERCP technique, some of the limitations of the duodenoscope in the setting of an altered intestinal anatomy can be overcome. Nonetheless, one of the major obstacles in SB-ERCP is obtaining biliary access in patients with a native papilla. This can be due to the limited length of the enteroscope, postoperative adhesions or sharp bends of the reconstructed intestine and a rather tangential view of the papilla with the forward viewing enteroscope compared with the side-viewing duodenoscope, without the possibilities made possible by the use of the elevator. We present a case of a 89-year-old patient with a history of gastric cancer and partial gastrectomy who presented with symptomatic choledocholithiasis, cholangitis and sepsis. Patient presented with fever and right upper quadrant pain since three days, despite antibiotic therapy (amoxicillin-clavulanic acid) started by the generalist. Lab results showed a high leukocyte count (19,2x10^9), elevated C-reactive protein (229 mg/l), elevated liver tests (GOT 212 U/l, GPT 200 U/l, gamma-GT 70 U/l) and elevated bilirubin (3.8 mg/dl). Abdominal ultrasound showed dilated intrahepatic bile ducts. Additional MRCP confirmed the presence of several large bile duct stones. Patient was referred to our hospital for a SB-ERCP, but, despite careful inspection, the papilla could not be seen. Therefore, a percutaneous transhepatic cholangiography (PTC) was done by the radiologist, leaving a drain into the duodenum. During a second SB-ERCP procedure a designated radio-opaque guidewire (0.035 inch, 550 cm) was advanced trough the biliodouodenal drain, then firmly grasped with a snare forceps and brought out of the patient, allowing the enteroscope to advance to the papilla. Cannulation and contrast injection of the bile duct confirmed the presence of several stones in the common bile duct (CBD). After sphincterotomy and balloon extraction of several concrements, a very large residual stone (+/- 20 mm) could not be removed and was impacted in the distal CBD. A 7 French, plastic stent was placed to maintain biliary drainage. An additional SB-ERCP is scheduled for additional stone removal. During the last decades, more patients with surgically altered bowel anatomy are being referred for ERCP, owing to a rise in prevalence of bariatric surgery, surgical interventions of pancreaticobiliary lesions and liver transplantation (1). One of the possible options to reach the biliary tract in these patients is single balloon assisted ERCP. In a meta-analysis of 15 trials (461 patients) the SB-ERCP procedural success rate, defined as the ability to provide successful intervention, was reported to be 61.7 % (1), meaning that in one third of the patients the procedure is unsuccessful. Although the rendezvous technique is well known in classic ERCP, we present this case to show that a rendezvous procedure combined with a SB-ERCP (using a long guidewire) can be helpful to accomplish biliary tract cannulation in difficult cases. References 1. Inamdar S., Slattery E., Sejpal DV., Miller LS., Pleskow DK., Berzin TM., et al. Systematic review and meta-analysis of single-balloon enteroscopy–assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc 2015;82(1):9–19.
