Troubleshooting of Endoscopic Ultrasound-guided Rendezvous Using a Nasobiliary Drainage Tube.

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Biliary Interventions

Background:

• Selective bile duct cannulation (SBDC) failure during ERCP necessitates alternative techniques like EUS-RV.
• EUS-RV presents unique challenges, particularly with anatomical variations such as large periampullary diverticulum (PAD) and severe gastroptosis.
• Difficulties in guidewire manipulation and maintenance can prolong EUS-RV procedures.

Purpose of the Study:

• To present a novel troubleshooting method for EUS-RV using a nasobiliary drainage tube (NBD).
• To demonstrate the efficacy of NBD in managing guidewire manipulation and maintenance challenges during EUS-RV in a complex patient case.
• To highlight the convenience and availability of NBD as an interventional tool.

Main Methods:

• EUS-RV was performed on a patient with a CBD stone, large PAD, and severe gastroptosis after failed ERCP attempts.
• A 5-French NBD was temporarily placed in the CBD to facilitate guidewire manipulation and maintenance.
• Subsequent esophagogastroduodenoscopy under fluoroscopic guidance allowed NBD insertion into the duodenum via the PAD.
• SBDC was achieved using the retained NBD, followed by stone removal.

Main Results:

• The patient presented with a common bile duct (CBD) stone and anatomical challenges (large PAD, severe gastroptosis) hindering ERCP and initial EUS-RV attempts.
• Guidewire manipulation and maintenance were significantly challenged by the PAD and gastroptosis during EUS-RV.
• Temporary placement and subsequent duodenal insertion of an NBD enabled successful SBDC and stone removal.
• The NBD facilitated guidewire passage through the PAD and maintained its position despite gastroptosis.

Conclusions:

• Nasobiliary drainage tube (NBD) use is an effective troubleshooting strategy for endoscopic ultrasound-guided rendezvous (EUS-RV) in complex cases.
• NBD assists in overcoming guidewire manipulation difficulties caused by periampullary diverticulum (PAD) and maintains guidewire position in cases of severe gastroptosis.
• NBD is a readily available and convenient device for managing challenging EUS-RV procedures, improving success rates for selective bile duct cannulation.