Rendezvous cannulation with sphincterotomy and stone extraction using a forward-viewing endoscope in a 4.6 kg infant. No Disclosures ERCP is a treatment of choice for choledocal lithiasis and is typically performed with a side-viewing duodenoscope. Commonly manufactured duodenoscopes all have an outer diameter of greater than 12.5 mm. Expert consensus guidelines recommend limiting their use to those weighing greater than 10 kg. Previously, an infant duodenoscope with an outside diameter of 7.5 mm allowed for ERCP in patients weighing less than 10 kg, but this endoscope is no longer available for purchase or rent. Currently, there is not a duodenoscope capable of performing ERCP in the infant population available anywhere on the world market. The patient was a 39-day-old, full-term, exclusively breastfed female who presented with jaundice and colic stools for 4 days. Her weight at the time of presentation was 4.6 kg. Blood work demonstrated a cholestatic elevation in liver enzymes. Hepatic ultrasound reported a dilated common bile duct of 4 mm. MRCP revealed obstructive choledocal lithiasis with two biliary stones at the distal common bile duct. Rendezvous cannulation of the major papilla with sphincterotomy and stone extraction using a forward-viewing endoscope was our intervention. The procedure was performed in the interventional radiology suite, in the supine position and under general anesthesia. A 16 French forward-viewing endoscope was advanced to the duodenum without difficulty and was able to identify the major papilla in the expected location. Attempts were made to pass a 29 and 34 French forward-viewing endoscope as well as a 32 French duodenoscope, however none were able to navigate beyond the pyloric channel. Under the same anesthetic, interventional radiology attempted to obtain percutaneous biliary access which was achieved via the gallbladder after initial attempts through intrahepatic ducts failed. An 035 inch, 450 cm long soft-tip guide wire was passed percutaneously and seen to terminate in the duodenum. The 27 French forward-viewing endoscope was positioned in the duodenal bulb and the snare was used to secure the guide wire and pull it through the endoscope. A triple lumen sphincter tome was passed through the scope over the wire so that biliary cannulation was achieved. A cholangiogram re-demonstrated choledocal lithiasis. A biliary sphincterotomy was made using a single cutting cycle. The duct was swept with an 8.5 mm stone extraction balloon over the wire which produced a small amount of debris. The radiologist performed anti-grade flushes through the percutaneous catheter, which produced a large stone fragment. Flushes were repeated until no stone or debris was seen. A final cholangiogram demonstrated a decompressed common bile duct with no further filling defects. Total procedure time was 174 minutes, total anesthesia time was 227 minutes, and total fluoroscopy time was 12 minutes. The patient had an episode of melena the evening of the procedure with a 3 gram drop in her hemoglobin noted the following day. She was discharged 2 days after her procedure after having normalization of her stool pattern and stabilization of her hemoglobin without the need for further intervention. At the 2 week follow up, the child was asymptomatic and had normalization of her liver enzymes and resolution of her biliary dilation on ultrasound. Her hemoglobin had normalized. ERCP with a side-viewing duodenoscope remains a standard of care for the management of choledocal lithiasis in most patients. In an era where there is a lack of appropriate equipment to perform traditional ERCP in the infant population, utilization of a rendezvous cannulation technique and a forward-viewing endoscope can effectively manage choledocal lithiasis in this patient population, avoiding more invasive surgical options. While our treatment was a success, the procedure time, anesthesia time, and radiation exposure were much higher than what is typically needed for a traditional ERCP with a duodenoscope. This case describes successful treatment of choledocal lithiasis in a small infant utilizing a rendezvous cannulation technique and a forward-viewing scope. While our technique was successful, this case highlights the need for a smaller caliber duodenoscope capable of performing ERCP in neonates and small infants.

choledochal lithiasis

rendezvous cannulation technique

forward-viewing endoscope

sphincterotomy

neonatal ERCP