FAILED EUS-GUIDED HEPATICOGASTROSTOMY (EUS-HG). DON'T GIVE UP. EUS-RENDEZVOUS-HG CAN RESCUE YOU

Background:
Two main reasons for a failed EUS- guided hepaticogastrostomy (EUS-HG) are, inability to access the bile ducts due to non-dilated intrahepatic ducts (IHD), and failure of tract dilation due to cirrhosis/ductal scarring or stent passage from misaligned vector forces. We present 5 cases that failed traditional EUS-HG, treated with EUS-rendezvous-HG.
RESULTS: 5 non-surgical patients, median age 52, (3 M) who failed conventional EUS-HG were treated successfully using 3 techniques. There were no adverse events over a median follow up of 28 months. (Tables 1 and 2)
Technique 1: EUS to IR balloon rendezvous. N=3.
Case 1: A 53 year old female with multiple surgeries and a Whipple procedure, presented with cholangitis and leakage around 2 long standing percutaneous biliary drains (PTBD) due to an afferent limb syndrome. EUS-HG into segment 2 failed to resolve the leak around the PTBD (in segment 3) not easily identifiable at EUS despite contrast injection. However, inflating an IR balloon allowed successful access and creation of an EUS-rendezvous-HG.
Technique 2: IR to IR rendezvous followed by endo-IR rendezvous. N=1.
Case 2: A 55 year old male with multiple comorbidities, prior Whipple procedure and R hepatectomy developed a perihepatic abscess from chronic dehiscence of his hepatico-jejunostomy. Having failed every other attempt to close this leak, an attempt was made for EUS-HG to divert bile from the leak site. Conventional EUS-HG failed due to non-dilated ducts as did an attempt to inflate an IR balloon. So, he underwent an IR to IR rendezvous. A peripheral branch of the L IHD closest to the gastric wall was accessed via the drain, dilated with a 4mm balloon, allowing opening of a loop snare. A transhepatic percutaneous needle puncture of this L IHD was then performed through the loop snare with subsequent puncture of the gastric lumen allowing placement of a guidewire and a successful rendezvous-HG.
Technique 3: EUS to Endo rendezvous. N=1.
Case 3: A 36 year old male with prior severe pancreatitis, benign biliary stricture, gastric outlet, and cirrhosis, had undergone a surgical gastrojejunostomy and hepaticoduodenostomy. He presented with recurrent cholangitis from food occluding his bile duct at the hepaticoduodenostomy (just proximal to the duodenal stricture). He had failed double pigtail biliary stents to keep the food out. So, he was taken for an EUS-HG to provide a more proximal diversion of his biliary tree. Although the L IHD was successfully punctured and a guidewire passed downstream, dilation of the tract failed due to dense scarring. However, after a successful rendezvous with the guidewire, we were able to create an EUS Rendezvous-HG in a retrograde fashion.
Conclusion:
When conventional EUS-HG fails, an EUS-rendezvous-HG with IR or oneself could successfully allow internal drainage rather than a long term PTBD.