Percutaneous transhepatic biliary drainage guided endoscopic retrograde cholangiopancreatography rendezvous technique for biliary stent placement: A case report

Abstract

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal diagnostic and therapeutic modality for the assessment and management of pancreatic and bile duct disorders. Percutaneous transhepatic biliary drainage (PTBD) is a prevalent and progressively favored primary treatment modality for malignant obstructive jaundice, providing rapid biliary decompression, achieving high technical success rates, and serving as a conduit for subsequent interventions. Rendezvous techniques are poised to play a lasting role, given the rising demand for palliative care interventions following failed conventional ERCP.

CASE SUMMARY

This report details the case of a 69-year-old male patient who presented with complaints of jaundice, lower abdominal discomfort, and fatigue. The patient underwent two ERCP procedures with biliary stenting, and his PTBD catheter required regular replacement. However, the PTBD catheter failed to provide adequate drainage. The underlying condition was bile duct stenosis caused by malignant tumor compression, which proved refractory to conventional ERCP treatment. A guidewire was advanced through the existing PTBD tract, followed by the successful implantation of a biliary stent, which achieved intrahepatic biliary drainage. The PTBD catheter was intentionally left in place as a precaution against potential re-obstruction.

CONCLUSION

The PTBD-guided ERCP rendezvous technique is an effective salvage strategy when standard ERCP fails and can be flexibly applied by clinicians.

Key Words: Endoscopic retrograde cholangiopancreatography; Percutaneous transhepatic cholangiography; Obstructive jaundice; Biliary stent; Case report

Core Tip: This report highlights an innovative percutaneous transhepatic biliary drainage-guided endoscopic retrograde cholangiopancreatography rendezvous technique for biliary stent placement after failed conventional endoscopic retrograde cholangiopancreatography. It demonstrates an effective salvage strategy that leverages an existing percutaneous transhepatic biliary drainage tract to overcome complex anatomical challenges in malignant obstructive jaundice, providing a valuable therapeutic option for refractory cases.

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal diagnostic and therapeutic modality for the management of pancreatic and bile duct disorders[1,2]. Both ERCP and percutaneous transhepatic biliary drainage (PTBD) are frequently employed in the management of obstructive jaundice resulting from malignant neoplasms[3,4]. The term rendezvous is originally a French phrase meaning “meeting” or “dating”. In gastroenterology, the practice of utilizing both antegrade and retrograde approaches to the biliary system during a single treatment session has been referred to as a “rendezvous” procedure. A preliminary literature search identified approximately 30 reports on PTBD-guided ERCP rendezvous technique since its first description in 1987[5], detailed case reports remain scarce.

This report details the successful application of a PTBD-guided ERCP rendezvous technique for biliary stent placement after failed conventional ERCP in a patient with complex anatomy. The altered gastrointestinal anatomy presents specific anatomical challenges that make this case instructive.

CASE PRESENTATION

Chief complaints

A 69-year-old male patient presented with jaundice, lower abdominal dull pain, and fatigue.

History of present illness

The patient’s symptoms, which began seven days prior, were attributed to inadequate drainage from the indwelling PTBD catheter.

History of past illness

The patient had a complex oncologic and procedural history, summarized chronologically: Four years before the current admission, the patient underwent a laparoscopic sigmoidectomy for malignant tumor. Two years before the current admission, the patient underwent a left lobe hepatectomy, cholecystectomy and conventional chemotherapy for malignant tumor metastasis. One year before the current admission, the patient presented with obstructive jaundice due to malignant tumor recurrence. An ERCP procedure was performed, and a stent was implanted in the bile duct. However, the stent subsequently became dislocated. Following conservative treatment, a PTBD catheter was placed and subsequently replaced on a regular basis at our hospital. Two months before the current admission, an ERCP procedure was performed to remove the bile duct stent. Furthermore, the patient underwent two pyloric stent placements due to pyloric obstruction resulting from a tumor.

Physical examination upon admission

The patient’s vital signs were as follows: (1) Body temperature: 36.5 °C; (2) Heart rate: 100 bpm; (3) Respiratory rate: 20 breaths/minute; and (4) Blood pressure: 97/65 mmHg. There was a postoperative scar in the anterior midline of the abdomen.

Laboratory examinations

Admission liver function tests showed the following: (1) Alanine aminotransferase: 66 U/L [reference range (RR): 9-50 U/L]; (2) Aspartate transaminase: 61 U/L (RR: 7-40 U/L); (3) Gamma-glutamyl transferase: 322 U/L (RR: 10-60 U/L); (4) Total bilirubin: 35.8 μmol/L (RR ≤ 26 μmol/L); and (5) Direct bilirubin: 23.2 μmol/L (RR ≤ 8 μmol/L). These findings, particularly the elevated total bilirubin and markedly increased gamma-glutamyl transferase, are consistent with obstructive jaundice. Venous blood ions showed the following: (1) Potassium: 3.27 mmol/L (RR: 3.5-5.3 mmol/L); (2) Sodium: 126 mmol/L (RR: 137-147 mmol/L); (3) Chlorine: 91 mmol/L (RR: 99-110 mmol/L); (4) Magnesium: 0.74 mmol/L (RR: 0.75-1.02 mmol/L); (5) Phosphorus: 0.74 mmol/L (RR: 0.85-1.51 mmol/L); (6) Calcium: 2.01 mmol/L (RR: 2.11-2.52 mmol/L); and (7) Iron: 3.37 μmol/L (RR: 10.6-36.7 mmol/L). The observed hypokalemia, hyponatremia, and other electrolyte disturbances likely reflect an electrolyte imbalance secondary to chronic bile loss.

Imaging examinations

Admission magnetic resonance imaging (Figure 1) showed a tumor in the hepatoportal region. This tumor caused metastases to the intrahepatic bile ducts and the pylorus within the right hepatic lobe. Additionally, multiple small metastatic lymph nodes were noted in the hepatogastric hiatus and retroperitoneum. Imaging performed after PTBD and biliary/duodenal pyloric stenting revealed alterations in the stenosis at the hepatoportal area of the right hepatic duct, along with dilated intrahepatic bile ducts.

Figure 1 Admission magnetic resonance imaging. A: The tumor shows ill-defined margins with involvement of the right intrahepatic bile ducts and the pylorus (circle); B: Multiple small metastatic lymph nodes (circle); C: Dilated intrahepatic bile ducts (arrow).

Abdominal computed tomography (Figure 2), performed after PTBD, provided further detail. It showed proximal deformation and luminal narrowing of the descending duodenal stent, along with distal stent stenosis. Metastases were identified in the hepatogastric hiatus and multiple small retroperitoneal lymph nodes. These findings illustrate the anatomical complexity that contributed to the procedural difficulty.

Figure 2 Admission computed tomography. A: Percutaneous transhepatic biliary drainage catheter (arrow); B: Deformation and luminal narrowing of the descending duodenal stent (circle) and the hepatogastric hiatus and multiple small retroperitoneal lymph nodes (arrow).

Pathological examination of the intestinal lesion (performed at an external institution) revealed multiple moderately to poorly differentiated adenocarcinomas in the sigmoid colon, with focal mucinous adenocarcinoma components. No pathological examination was performed on the hepatic tumor.

FINAL DIAGNOSIS

The final diagnosis includes: (1) Obstructive jaundice; (2) Primary sigmoid colon adenocarcinoma with metastatic disease to the liver, pylorus, and peritoneum; and (3) Liver insufficiency.

TREATMENT

Endoscopic access

The procedure was performed with the patient in the prone position. A JF-260V duodenoscope was advanced into the stomach, where the previously placed pyloric stent was noted to be in a good position (Figure 3). However, due to gastric antral deformity, repeated attempts to advance the endoscope past the stent were unsuccessful. To overcome this, a straight-viewing endoscope was successfully passed through the stent into the descending duodenum, and a guidewire was left in place. The duodenoscope was then withdrawn while maintaining guidewire access, and we exchanged it for a side-viewing endoscope. The guidewire was subsequently back-loaded through the working channel of the side-viewing endoscope, bringing its proximal end into the stomach, and a dilation balloon was threaded over it. The balloon was positioned at the proximal end of the stent, and the endoscope was then advanced through the stent into the descending duodenum.

Figure 3  Pyloric stenting well-positioned.

Rendezvous technique

Attempts to achieve bile duct cannulation using a needle-knife and guidewire were unsuccessful, so we switched to a rendezvous approach. Contrast injection via the indwelling PTBD catheter (trans-PTBD cholangiography) opacified the intrahepatic bile ducts. However, the extrahepatic ducts were not opacified, suggesting the presence of a hilar stenosis. A guidewire was then advanced through the PTBD catheter. After several attempts, the guidewire was selectively maneuvered through the biliary confluence and antegradely advanced across the papilla. This guidewire was then captured in the duodenal lumen using a snare introduced through the endoscopic working channel and gently withdrawn (Figure 4). Over this established guidewire, a needle-knife sphincterotomy was performed, followed by cholangiography, which demonstrated biliary opacification.

Figure 4  Schematic illustration of the guidewire slowly withdrawn by the coiled device (Supplementary material).

Stent placement

Fluoroscopy revealed tight stenoses at both the hepatic hilum and the distal common bile duct. The stenoses were sequentially dilated using an 8.5 Fr dilation catheter passed over the guidewire. Subsequently, an 8.5 Fr × 12 cm multi-flap plastic biliary stent was deployed over the same guidewire, resulting in immediate visualization of bile outflow (Figure 5). Finally, over a guidewire placed through the original PTBD tract, the drainage catheter was exchanged for a new 10 Fr PTBD catheter. The overall conceptual diagram for ERCP and PTBD is presented in Figure 6.

Figure 5  Multi-flap plastic biliary stent and visible bile flow.

Figure 6  Overall conceptual diagram of the endoscopic retrograde cholangiopancreatography and percutaneous transhepatic biliary drainage (Supplementary material).

OUTCOME AND FOLLOW-UP

Following the ERCP procedure, the patient exhibited a resolution of the jaundice and a decrease in discomfort. The patient, having no adverse effects, was discharged four days later and continued to receive palliative care at the hospital until passing away one year later.

DISCUSSION

Performing ERCP in patients with a history of multiple major abdominal surgeries and malignant metastases poses significant technical challenges due to altered anatomy and adhesions. In such cases, patients with malignant obstructive jaundice are often deemed ineligible for or unable to tolerate curative surgery. The patient presented with a tumor in the hepatic hilum exerting pressure on the bile duct, resulting in obstructive jaundice and a progressively worsening condition. This rendered surgical intervention a significant challenge. The patient had a history of two prior ERCP attempts and multiple PTBD catheter exchanges. The biliary stent was successfully implanted by accessing the guidewire of the ERCP through the PTBD catheter, thereby achieving intrahepatic drainage of bile. Given the patient’s history of biliary stent migration, the PTBD catheter was retained to ensure continued biliary access and prevent recurrent obstruction.

In instances where patients are unable, unwilling, or unsuccessful in undergoing an ERCP procedure, a PTBD can be considered as an alternative[6]. Nevertheless, prolonged PTBD use for biliary drainage renders the drain catheter susceptible to displacement or obstruction[7]. A protracted loss of bile can precipitate fluid-electrolyte imbalances[8], as illustrated in the present case.

When ERCP access is challenging, it is advised to refrain from employing excessive force to prevent visceral injury, particularly in patients with a history of major abdominal surgery resulting in visceral adhesions and ligamentous calcification[9]. The guidewire can be inserted through the PTBD catheter and gradually advanced out of the papilla to prevent damage to the liver tissue and biliary tract.

Literature review and technique efficacy

A preliminary literature search of PubMed and Google Scholar databases was conducted using the keywords: (1) Endoscopic retrograde cholangiopancreatography; (2) Percutaneous transhepatic biliary drainage; and (3) Rendezvous. Our preliminary literature search identified approximately 30 reports on PTBD-guided ERCP rendezvous technique since its first description in 1987[5]. Liu et al[10] reported 36 patients with obstructive jaundice in whom ERCP had failed; a rendezvous approach using the PTBD guidewire allowed successful stent placement, with a mean 44.75% reduction in total bilirubin within 4 days. Dickey[11] described how the PTBD guidewire can be damaged when passing through the papilla and can be withdrawn using forceps or a snare; he proposed circumventing this with parallel cannulation at rendezvous. In this case, the guidewire was successfully extracted without incident, and this parallel cannulation was not employed. Ginestet et al[12] suggested that when ERCP fails to achieve biliary drainage, endoscopic ultrasound-guided biliary drainage may be preferred over percutaneous biliary drainage. In contrast, our patient already had pre-existing PTBD access, so we chose the PTBD-guided ERCP rendezvous technique, which successfully restored endoscopic access and enabled completion of the procedure. In addition to percutaneous transhepatic cholangiography rendezvous, endoscopic ultrasound-guided rendezvous is also feasible, Hanssens et al[13] reported that endoscopic ultrasound-guided rendezvous has an acceptable success rate and is not associated with an increased risk of adverse events as compared to percutaneous transhepatic cholangiography rendezvous. Bokemeyer et al[14] reported that the most frequent procedure-related complications included inflammatory complications such as acute pancreatitis, acute cholangitis and peritonitis, followed by major bleeding, pulmonary complications, anesthesia-related complications and liver biloma.

It is essential to anticipate potential intra- and post-procedural complications and implement appropriate preventive strategies. In our patient, gastric antral deformity and the presence of a pyloric stent posed specific risks during endoscopic access, including perforation, mucosal injury, or stent dislodgement. To minimize these risks, blind or excessive force was avoided, and endoscope exchange over a guidewire was performed when necessary. During the rendezvous technique, the guidewire encountered difficulty traversing the complex hilar stricture. Excessive tension risked biliary or papillary injury, as well as guidewire fracture. Therefore, the guidewire was carefully maneuvered through the stenosis, captured using an endoscopic snare to facilitate passage, and maintained in a tension-free state to prevent excessive traction. Post-procedural complications such as pancreatitis and cholangitis may occur, warranting close monitoring of clinical symptoms (e.g., fever, abdominal pain) and laboratory parameters, with prophylactic antibiotics considered in high-risk patients. In complex ERCP cases, the risk of catheter migration or occlusion is increased. The use of a multi-flap plastic stent – which provides better adaptation to irregular strictures – is recommended. In addition, it is essential to educate patients and caregivers on daily catheter care and the importance of avoiding strenuous activities that may elevate intra-abdominal pressure. Fortunately, the procedure proceeded smoothly and effectively with no adverse outcomes in the present case. It is good that the procedure went on smoothly and effectively with no adverse effects in the present case.

This case illustrates the application of a tailored PTBD-guided rendezvous technique in a complex clinical scenario, underscoring the importance of flexible procedural planning when confronting altered anatomy and prior surgical interventions. It can serve as a salvage option in complex cases where conventional ERCP fails. However, conclusions are limited by the nature of a single case report, including potential selection bias and lack of long-term comparative data.

CONCLUSION

This case demonstrates that the PTBD-guided ERCP rendezvous technique is an effective salvage strategy when standard ERCP fails, particularly in patients with altered gastrointestinal anatomy. Clinicians can apply this flexible approach based on individual patient conditions to improve outcomes.