Forewards and backwards. Three endoscopes for biliary access. These are our disclosures. An 85-year-old male with a history of urothelial cancer who presented with jaundice, fatigue, pruritus, and an unintentional weight loss. An MRCP on admission showed moderate intra- and extrahepatic biliary duct dilatation. The common bile duct measured up to 11 millimeters with abrupt cutoff at the level of the pancreatic head for a length of approximately 2.5 centimeters. And the gallbladder was also noted to be markedly distended. This case began with the gall of transpapillary drainage of the bile ducts. However, the ERCP was technically difficult and complex due to challenges in cannulation because of an unusual anatomic variant of the papilla. We performed varying techniques in an attempt to cannulate the common bile duct, including double-wire technique and stenting of the ventral pancreatic duct, but we remained unsuccessful in doing so. The amyloid became more edematous, and biliary cannulation was not achieved. At this point, we made the decision to attempt biliary decompression through EUS-guided biliary drainage. On echo endoscope, we noted the gallbladder was markedly distended, and we used a 19-gauge needle to puncture the CBD from the gastric antrum. Blood from the CBD was aspirated and confirmed to be bile. We obtained this cholangiogram showing a patent cystic duct, intrahepatic ducts, and a distended gallbladder, as denoted by the blue arrow. We attempted to pass a 4-millimeter balloon dilator into the CBD, but due to less than optimal positioning of the endoscope and the lack of 1-to-1 apposition, we decided to forgo this plan. Given the distended gallbladder, a patent cystic duct seen on cholangiogram, and an optimal EUS window, we made the decision to proceed with an EUS-guided cholecystogastrostomy. The echo endoscope was advanced into the gastric antrum where the gallbladder was adequately visualized. Color flow Doppler was used to ensure the absence of interposed blood vessels, and a 15-millimeter luminoposing metal stent using electrocautery enhanced delivery system was deployed into the gallbladder. The distal flange was placed into the gallbladder, and the proximal flange into the stomach. At this point, copious bile drained into the stomach, and the stent was dilated to 15 millimeters to facilitate further biliary interventions in the future, if needed. Two anchoring 7-french-by-5-centimeter double pigtail stents were placed within the stent to aid in the prevention of food impaction in the gallbladder. The final radiograph showed proper positioning of all three stents. Over the subsequent week, our patient's bilirubin continued to trend downward nicely, more than 50% of the initial presenting value. And as an extension of the improving bilirubin, his jaundice and pruritus also improved. However, the diagnosis remained uncertain, and the decision was made to perform a rendezvous with the goal of passing a guide wire from the gallbladder through the papilla to obtain brushings. One week after our initial procedure, we again attempted to cannulate the major papilla, but we were again unsuccessful. We then exchanged our duodenoscope for a gastroscope and attempted to negotiate a guide wire through the cystic duct with a sphincteratome, but due to the anatomy and difficulty, this was also unsuccessful. At this point, we exchanged our gastroscope for a small-caliber scope and entered the gallbladder through the previously placed stent, as seen here on the left. For better visualization of the cystic duct, we retroflexed a small-caliber scope in the gallbladder and were able to visualize the cystic duct as seen on the right. A guide wire was negotiated across the cystic duct and into the bile duct, with successful access into the duodenum through the papilla. Keeping the guide wire and small-caliber scope in position with the guide wire traversing the bile duct, we disconnected the small-caliber scope and reinserted the duodenoscope and the guide wire was identified at the papilla. We made the decision to keep the small-caliber scope in place because the rendezvous procedures often fail when you remove or manipulate the scope. Therefore, to prevent the guide wire from being displaced, we decided to keep the small-scope in place. We performed a needle-knife papillotomy over the guide wire and performed a biliary sphincterotomy. The bile duct was deeply cannulated and brushings for cells for cytology were obtained. A 10 mm by 6 cm covered metal stunt was placed into the common bile duct. Over the course of the week, the patient's bilirubin continued to trend downward and cytology was actually noted to be negative for malignant cells. In conclusion, in failed biliary cannulation, an EUS-guided cholangiogram can evaluate both the biliary tree and cystic duct patency. EUS-guided gallbladder drainage can relieve obstructive jaundice when a patent cystic duct is present in the context of a distal CBD stenosis. Rendezvous procedures can be performed via a cholecystogastrostomy and two scopes, both the duodenoscope and small-caliber scope, can be used simultaneously to facilitate a rendezvous procedure. In this case, the ability to retroflex the small-caliber scope inside the gallbladder allowed successful cannulation of the cystic duct. This allowed access to the bile duct from the papilla and stent placement.

urothelial cancer

jaundice

biliary drainage

EUS-guided biliary drainage

cystic duct patency