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

Endoscopic ultrasound-guided rendezvous (EUS-RV) is an alternative technique for patients in whom selective bile duct cannulation (SBDC) has failed during endoscopic retrograde cholangiopancreatography (ERCP). However, EUS-RV has several challenging steps. Herein, we present a method for troubleshooting the EUS-RV using a nasobiliary drainage tube (NBD) in a patient with a large periampullary diverticulum (PAD) and severe gastroptosis. An 80-year-old woman presented with nausea. Contrast-enhanced computed tomography revealed a common bile duct (CBD) stone. Although ERCP was performed twice, the ampulla of Vater (AV) could not be identified due to the large PAD. Therefore, EUS-RV was performed. The CBD was punctured from the descending part of the duodenum. Although a guidewire was advanced through the AV, the PAD hindered guidewire insertion to the anal side of the duodenum. During the switch to duodenoscopy, the guidewire was withdrawn due to gastroptosis. A subsequent attempt to puncture the CBD through the duodenal bulb resulted in guidewire entrapment. To manage the prolonged procedure, a 5-French NBD was temporarily placed in the CBD. An NBD was subsequently inserted into the duodenum via the PAD using esophagogastroduodenoscopy under fluoroscopic guidance after 1 week. After switching to duodenoscopy, SBDC was successful along the NBD that was not withdrawn, and the stone was removed. NBD use in EUS-RV may be effective in difficult cases of guidewire manipulation into the distal duodenum due to PAD and guidewire maintenance due to gastroptosis. Further, NBD is a readily available device, making its use convenient.