Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos)

Background: Precut papillotomy after failed bile duct cannulation is associated with an increased risk of pancreatitis. EUS-guiclecl rendezvous drainage is a novel alternative technique, but there are no data comparing this approach with precut papillotomy. Objective: To evaluate the safety and efficacy of EUS-guided rendezvous drainage of the bile duct and compare its outcome with that of precut papillotomy. Design: Retrospective study. Setting: Tertiary care referral center. Patients: Consecutive patients with distal bile duct obstruction, in whom selective cannulation of the bile duct at ERCP failed after 5 attempts with a guidewire and sphincterotome, underwent an EUS-guided rendezvous procedure. The outcomes were compared with those in a historical cohort of patients who underwent precut papillotomy. Interventions: Patients in whom selective cannulation failed underwent EUS-guided rendezvous drainage by use of the short wire technique or precut. papillotomy by use of the Erlangen papillotome. At EUS, after the extrahepatic bile duct was punctured with a 19-gauge needle, a hydrophilic angled-tip guidewire 260 cm long was passed in an antegracle manner across the papilla into the duodenum. The echoendoscope was then exchanged for a duodenoscope, which was introduced alongside the EUS-placed guidewire. The transpapillary guidewire was retrieved through its biopsy channel, and accessories were passed over the wire to perform the requisite endotherapy. Main Outcome Measures: Comparison of the rates of technical success and complications between patients treated by the EUS-guided rendezvous and those treated by precut papillotomy techniques. Treatment success was defined as completion of the requisite endotherapy in one treatment session. Results: Treatment success was significantly higher for the EUS-guidecl rendezvous (57/58 patients) than for those undergoing precut papillotomy technique (130/144 patients) (98.3% vs 90.3%; P = .03). There was no significant difference in the rate of procedural complications between the EUS and precut papillotomy techniques (3.4% vs 6.9%, P = .27). Limitations: Retrospective nonrandomized study design; highly selective patient cohort. Conclusions: In this study, the EUS-guided rendezvous technique was found to be superior to precut papillotomy for single-session biliary access. Prospective randomized trials are needed to confirm these preliminary but promising findings. (Gastrointest Endosc 2012;75:354-9.)