Endoscopic ultrasound-guided transhepatic rendezvous and stent placement in benign biliary stricture in buildout 2 anatomy with a peridiverticular papilla. ERCP in patients with surgically altered anatomy can often be challenging with lower dates of technical success. Issues are often faced in reaching the papilla, identifying it or cannulating the papilla. EOS biliary drainage represents a potential alternative to either gain access or ensure stent placement in these patients. Factors guiding choice of EOS BD are the type of anatomy and the type of disease, either benign or malignant. In patients with benign disease, if the papilla is accessible, EOS rendezvous can be done. And in those with inaccessible papilla, EOS-guided antigrade intervention can be attempted. In malignant disease, on the other hand, transmural procedures like cholerotico-duodenostomy and hepaticogastrostomy can be done, or transpapillary EOS-guided antigrade stent placement can be done. Our patient, a 55-year-old man, known carcinoma of the stomach, would undergo a distal gastrectomy two months back with history of intraoperative bile duct injury presented with persistent biliary-type pain since two months. His total bilirubin was 3.1 mg% with raised alkaline phosphatase. A CT scan done showed dilated intrahepatic biliary radicals with a dilated common bile duct with a stricture in the mid-distal CBD. There was also a periampillary diverticulum seen in this patient. The case was discussed in a multidisciplinary team meeting, and the patient was planned for ERCP and plastic stent placement in view of a benign biliary stricture. Alternative approach of PTBD was also considered, and the procedure was planned under general anesthesia. Initially, a duodenoscope was passed across the gastrogygenostomy, however, it could not be introduced into the afferent limb due to the angulation. Hence, the scope was changed to an apogea endoscope with a distal attachment. This could be passed into the afferent limb, and the blind end of the afferent limb could be identified. Subsequently on pulling the scope back, we could identify a duodenal diverticulum, and at the inner lower edge of the diverticulum, the papilla was identified. Several attempts were made at cannulating this papilla using an ERCP cannula, however, all the attempts failed, and hence the patient was planned for an EOS-guided rendezvous procedure. The scope was changed to a linear echo endoscope. On nearest examination, the common hepatic duct appeared 12 mm in diameter at the porta with dilated intrahepatic radicals. Puncture was taken into the dilated IHBR in the segment 2 of the liver using a 19-gauge FNA needle. Once puncture was taken, position in the biliary radical was confirmed by contrast injection. Flutoscopy guidance was also used during the procedure. Subsequently after contrast injection, a guide wire was negotiated into the common hepatic duct at the porta. The stricture was seen in the mid-distal CBD. Subsequently the tract was dilated using a 6-francistotome, and the guide wire was negotiated deep into the duodenum and coiled there. The scope was again exchanged to an upper endoscope with a distal attachment. Now after passage of the guide wire, the papilla at the inner lower edge of the diverticulum became everted, and cannulation of the papilla became easy. Cannulation using an ERCP cannula could be achieved deep into the left hepatic duct, and a guide wire was passed here. Subsequently after guide wire passage, the ERCP cannula was exchanged for a precut sphinctrotome. Once the sphinctrotome, sphinctrotomy was done using a precut sphinctrotome, as a buildortosphinctrotome was not available. After sphinctrotomy, a 7-french biliary stent was placed into the left hepatic duct. To achieve optimal drainage of both the systems, cannulation was again attempted by the side of the stent using an ERCP cannula. Now guide wire was passed again deep into the right hepatic duct after cannulation. Subsequently after cannulation, another 7-french stent was passed into the right hepatic duct. During deployment of the stent, there was slight malposition of the stent seam. The stent was repositioned using the help of a rapid force set. At the end of the procedure, there was near complete drainage of contrast seam. The previously placed guide wire after rendezvous was removed. The scope was removed out. The patient was admitted for observation for one day. There were no intra or immediate post-procedure complications. The patient reported symptomatic benefit with the bilirubin normalizing over the next week. On follow-up, at one and two months, there were no symptoms. The patient is now planned for multiple plastic stent placement at three months. Passing a duodenoscope across in bilirubin anatomy is often difficult. And cannulation using an apogee endoscope is successful in up to 93% cases. In our patient, a duodenoscope could not be negotiated and cannulation was complicated due to a diverticulum. Trans-hepatic rendezvous can be done in these cases, but it's associated with a lower rate of technical success and higher rate of complication. However, we did not have a choice due to the altered anatomy in our patient. To conclude, ERCP in a build-out-to-anatomy may be more difficult secondary to a peridiverticular papilla. Apogee endoscope can be used for cannulation in cases where duodenoscope cannot be passed. An EOS-guided rendezvous, although technically challenging, may help gain access to the bilirubin in complex post-surgical anatomy. Thank you.

distal gastrectomy

persistent biliary-type pain

dilated common bile duct

periampillary diverticulum

EOS-guided rendezvous procedure