A modified Rendezvous ERCP technique in duodenal diverticulum

Abstract

Aim: To postoperative endoscopic retrograde cholangiopancreatography (ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone (CBDS) having a T-tube with retained CBDSs.

Methods: Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct (CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guide-wire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were successfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast.

Results: An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%.

Conclusion: The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.

Keywords: Antegrade cannulation; Endoscopic retrograde cholangiopancreatography; Intradiverticular papilla; Retained stones; T-tube.

Figure 1

A sterile guide-wire was inserted via the T-tube to the common bile duct stone then to the papilla. A: Retained stone with a T-tube in the common bile duct; B: The antegrade insertion of a guide-wire through the T-tube; C: The extension of the guide-wire through the papilla into the duodenum.

Figure 2

Schematic diagram of a guide-wire.

Figure 3

Appearance of the technique. A: A guide-wire through the papilla during an endoscopic sphincterotomy; B: The guide-wire taken out by a snare; C: The guide-wire inserted in the tip of the sphincterotome, which is inserted via the endoscope channel of the duodenoscope; D: The stone is extracted by a basket catheter.

Figure 4

Control images of the common bile duct stone after the extraction of the stone.