Double balloon enteroscopy with EUS guided rendezvous for failed biliary access in patients with Roux-en-Y gastric bypass. These are our disclosures. Our first case presentation is that of a 71-year-old female with a history of Roux-en-Y gastric bypass who was referred to our center for management of choledocolithiasis and symptomatic pancreatolithiasis. The patient expressed concern over possible weight gain with the EDGE procedure and elected to proceed with a double balloon enteroscopy assisted ERCP instead. She did consent to having EUS directed interventions if necessary. The patient was brought to the endoscopy suite and a double balloon ERCP was performed under general anesthesia in the prone position. Using a double balloon enteroscope, the ampulla was reached without difficulty. The pancreatic duct was then cannulated using a standard sphincterotome and an 0-5 mm guide wire. A pancreatogram was subsequently obtained. On pancreatogram, as seen here, the patient was found to have two small stones in the ventral pancreatic duct. A pancreatic sphincterotomy was performed and both stones were evacuated using balloon sweeps. Following this, despite multiple attempts, deep cannulation of the common bile duct could not be achieved. Considering the distal common bile duct stricture, retrograde access to the common bile duct using advanced cannulation was not considered to be feasible. It was hence decided to proceed with EUS guided rendezvous biliary access. A prophylactic plastic stent was subsequently placed into the pancreas. The biliopancreatic limb was intermittently tattooed while withdrawing the enteroscope. Using a curvilinear echoendoscope, a suitable biliary radical was identified in segment 2 of the liver. The radical was punctured under ultrasound guidance using a 19-gauge FNA needle and a cholangiogram was obtained. The cholangiogram revealed a dilated common bile duct with small filling defects and a distal biliary benign appearing stricture. An angled 025 millimeter soft tip guide wire was passed through the 19-gauge FNA needle and navigated across the hilum into the common bile duct and finally across the ampulla into the duodenum. The wire was coiled several times in the small bowel. The echoendoscope was subsequently withdrawn, leaving the guide wire in place. The enteroscope was then reinserted alongside the guide wire and using the previously placed tattoo as a guide, the ampulla was reached. The rendezvous wire was identified adjacent to the pancreatic stent. A modified sphincterotome was then wedged onto the guide wire and comfortably railroaded into the common bile duct. Deep cannulation of the common bile duct was achieved and a second angled 025 millimeter guide wire was advanced alongside the rendezvous wire deep into the intrahepatic ducts. Following this, a sphincterotomy was performed and the ampullary os was dilated to 10 millimeters using a CRE balloon. Following this, using a standard 15 millimeter extraction balloon, all biliary stones, sludge and clots were evacuated from the duct. The rendezvous wire was then withdrawn from the patient by applying gentle traction. As seen here, the patient was noted to have significant amount of post-sphincterotomy bleeding. Considering the bleed and the presence of a distal common bile duct stricture, it was decided to proceed with placement of a fully covered self-expanding metal stent. The patient tolerated the procedure well and was discharged home the next day. Our second case presentation is that of a 70-year-old female with a history of Roux-en-Y gastric bypass in her early 50s. She presented to the emergency room with abdominal pain and was found to have abnormal liver chemistries. She underwent an MRI to further evaluate. As seen here on MRI, the patient was found to have a dilated common bile duct with small filling defects indicated by the yellow arrow. The patient was hence brought to the endoscopy suite and a double balloon ERCP was performed under general anesthesia in the prone position. Using a double balloon enteroscope, the ampulla was reached without difficulty. As is visualized, multiple attempts at cannulating the common bile duct using a standard sphincterotome and a soft tip guide wire were unsuccessful and resulted in repeated pancreatic ductal cannulation. Given the repeated cannulation and injection of the pancreatic duct, a plastic stent was placed for prophylaxis. Following this, despite multiple attempts using a taper tip cannula and a needle knife, deep cannulation of the CBD could not be achieved. It was hence decided to proceed with rendezvous biliary access. The biliopancreatic limb was intermittently tattooed and the endoscope withdrawn. A linear echoendoscope was advanced beyond the EG junction and using a 19-gauge needle, a suitable biliary radical was identified and punctured in the left lobe. A cholangiogram was obtained that revealed a distal CBD stricture. An O2-5 angled guide wire was then navigated across the hilum into the common bile duct. As seen here, the wire kept coiling in the distal CBD, but with some persistence we were able to advance the wire into the duodenum where it was coiled several times. Following this, the echoendoscope was withdrawn, leaving the guide wire in place. A double balloon enteroscope was then advanced towards the ampulla and deep cannulation of the common bile duct was achieved by railroading a modified sphinctrotome over the guide wire into the common bile duct. This was followed by a sphinctroplasty where the ampullary os was dilated to 8 mm using a standard dilating balloon. Once stable access to the common bile duct was achieved, the rendezvous wire was pulled by applying gentle traction. This was followed by balloon sweeps where sludge was evacuated from the common bile duct. This was followed by brushings and subsequently biopsies of the distal CBD. Following this, a fully covered self-expanding metal stent was successfully deployed. The patient tolerated the procedure well and was discharged home the next day. In conclusion, we demonstrate successful EOS-guided rendezvous biliary access in patients with Roux-en-Y gastric bypass anatomy and failed retrograde biliary cannulation during double balloon ERCP. EOS-guided biliary access should be considered a viable option for such patients if the ampulla can be reached via enteroscopy. Thank you for your attention.

video

case presentations

Roux-en-Y gastric bypass

biliary access

EOS-guided rendezvous