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 Table of Contents  
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 133-134

Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique

1 Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
2 Division of Endoscopy, Hokkaido University Hospital, Sapporo, Japan

Date of Submission25-Jan-2017
Date of Acceptance22-Apr-2017
Date of Web Publication24-Aug-2017

Correspondence Address:
Masaki Kuwatani
Division of Endoscopy, Hokkaido University Hospital, Kita15 Nishi7, Kita-ku, Sapporo 0608638
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_31_17

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How to cite this article:
Kawakubo K, Kuwatani M, Kato S, Sugiura R, Sano I, Sakamoto N. Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique. Endosc Ultrasound 2018;7:133-4

How to cite this URL:
Kawakubo K, Kuwatani M, Kato S, Sugiura R, Sano I, Sakamoto N. Direct puncture of the ampulla as a modified Endoscopic ultrasound-guided rendezvous technique. Endosc Ultrasound [serial online] 2018 [cited 2020 Jul 15];7:133-4. Available from: http://www.eusjournal.com/text.asp?2018/7/2/133/213651

Endoscopic ultrasound-guided rendezvous technique (EUS-RV) is one of the salvage methods for biliary access after failed endoscopic retrograde cholangiopancreatography (ERCP).[1] The technical success rate is reported to be around 80%.[2] The most frequent reason for the failure is inability to manipulate a guidewire across the stricture or the papilla through the needle.[3] To avoid severe complications such as biliary peritonitis, the development of a salvage therapy is mandatory. We report a patient who underwent a modified EUS-RV after failed guidewire manipulation through the ampulla.

A 62-year-old male was admitted for acute cholangitis due to the bile duct cancer. We performed ERCP for biliary drainage, but biliary cannulation failed. Precut sphincterotomy did not open the biliary orifice, so EUS-RV was planned for biliary access. A linear echoendoscope (UCT260, Olympus, Japan) was advanced into the duodenum and the distal bile duct was visualized with a short endoscopic position. After successful puncture of the bile duct, a guidewire could not pass through the papilla. Thereafter, the ampulla was directly punctured toward the duodenal lumen under EUS guidance followed by guidewire insertion to the duodenum [Figure 1]. Following echoendoscope removal, duodenoscopy showed that the guidewire passed through the periampullary area just apart from the pancreatic orifice. Then, the biliary access was obtained by catheter insertion alongside the guidewire [Figure 2] and endoscopic nasobiliary drainage was successfully performed.
Figure 1: X-ray image showing that the needle is passing through the papilla. The needle tip (arrow) was located inside the duodenal lumen

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Figure 2: Duodenoscopic image showing that the guidewire was passing through the periampullary region apart from the pancreatic orifice where the pancreatic stent was placed

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EUS-RV comprises 3 different approach routes; transgastric-hepatic, transduodenal with a long endoscopic position, and transduodenal with a short endoscopic position.[4] There are still scanty evidences about which approach route is the most appropriate.[2] One recent study suggested that a transduodenal route with a short endoscopic position is the most reliable EUS-RV for biliary access.[5] However, the further large study is necessary to validate this data. We, for the first time, reported a modified EUS-RV method after failed conventional transduodenal EUS-RV with a short endoscopic position. This method could be a salvage therapy after conventional EUS-RV failed to pass a guidewire through the papilla.

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There are no conflicts of interest.

  References Top

Kawakubo K, Kawakami H, Kuwatani M, et al. Recent advances in endoscopic ultrasonography-guided biliary interventions. World J Gastroenterol 2015;21:9494-502.  Back to cited text no. 1
Iwashita T, Doi S, Yasuda I. Endoscopic ultrasound-guided biliary drainage: A review. Clin J Gastroenterol 2014;7:94-102.  Back to cited text no. 2
Iwashita T, Lee JG, Shinoura S, et al. Endoscopic ultrasound-guided rendezvous for biliary access after failed cannulation. Endoscopy 2012;44:60-5.  Back to cited text no. 3
Kawakubo K, Isayama H, Sasahira N, et al. Clinical utility of an endoscopic ultrasound-guided rendezvous technique via various approach routes. Surg Endosc 2013;27:3437-43.  Back to cited text no. 4
Iwashita T, Yasuda I, Mukai T, et al. EUS-guided rendezvous for difficult biliary cannulation using a standardized algorithm: A multicenter prospective pilot study (with videos). Gastrointest Endosc 2016;83:394-400.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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