English (United Kingdom)

https://curated-unify.zendy.io/wp-json/zendy-region/v1/featured_content/oa?rat=en

https://curated-unify.zendy.io/wp-json/zendy-region/v1/highlighted_journal/

Global: Zendy Plus annual

Presents the access of premium content as premium feature

Premium Content

Presents the keyphrase highlighting as premium feature

Keyphrase Highlighting

Presents the summarisation as premium feature

Summarisation

Insights

Presents the pdf analysis as premium feature

PDF Analysis

Presents the zaia usage as premium feature

ZAIA

Global: Zendy Plus monthly

Global: Zendy Tools annual

Global: Zendy Tools monthly

Global: Zendy Free Plan

Endoscopic retrograde cholangiopancreatography (ERCP) is a first-line therapeutic method for obstructive biliary pathologies. Rarely, this procedure fails to obtain access and/or drainage of the biliary tree [1]. Until recently, such patients could be managed only via a percutaneous or surgical approach. An emerging alternative is endoscopic ultrasound (EUS)-assisted biliary access and drainage, namely rendezvous procedure. However, this technique is unsuccessful in 25% of patients [2]. We present a case of a 63-year-old man with diagnosis of pancreatic head tumor, stage IIA (according to American Joint Committee of Cancer, seventh edition), who was scheduled for surgery when he developed acute cholangitis. The patient had undergone antrectomy and gastrojejunostomy with Billroth II reconstruction 20 years previously due to a pyloric stenosis. On the blood tests, he had elevated inflammatory parameters (17000 leucocytes/mm3, 93% neutrophils, C-reactive protein 9.5mg/dL) and cholestasis (alkaline phosphatase 472U/L, gamma-glutamyl transferase 1192U/L, alanine aminotransferase 222U/L, aspartate aminotransferase 105U/L, total bilirubin 9.4mg/dL, and direct bilirubin 7.9mg/dL). The imaging tests revealed a dilated common bile duct (CBD), with a diameter of 13mm. An ERCP was attempted but cannulation was not achieved, although pre-cut was performed. Therefore, an EUS-guided transjejunal puncture of the CBD was performed using a 19-gauge needle (●" Fig.1). The cholangiography showed dilation of the CBD as described above, with a distal stenosis. A 0.035-inch guidewire was then passed through the needle into the CBD, but its constant proximal orientation prevented a rendezvous procedure (●" Fig.2). We then attempted an EUS retrograde approach, with direct puncture of the CBD, through the papilla and with fluoroscopic control (●" Fig.3). A plastic stent (10Fr/5cm) was placed, resulting in immediate output of bile and pus (●" Figs.4–8). The patient recovered well clinically and underwent cephalic duodenopancreatectomy 1 week later. Fig.2 Constant proximal guidewire orientation prevented the rendezvous procedure. Fig.1 Transjejunal endoscopic ultrasoundguided puncture of the distal common bile duct with a 19-gauge needle.

Transpapillary EUS-guided retrograde puncture of the biliary tree as an alternative for failed rendezvous procedure