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Rendezvous technique: double-balloon endoscopy and SpyGlass direct visualization system in a patient with severe stenosis of a choledochojejunal anastomosis.

This is the first report on the successful rendezvous technique of double-balloon endoscopy (DBE) (EI-530B; Fujifilm, Osaka, Japan) combined with the percutaneous SpyGlass® direct visualization system (SDVS) (Boston Scientific Corp., Natick, MA, USA) to treat severe stenosis of a choledochojejunal anastomosis in a patient with pancreaticoduodenectomy. A 71-year-old manwith a history of intraductal papillary mucinous neoplasm who had undergone pylorus-preserving pancreaticoduodenectomy 6 months previouslywas admitted for obstructive jaundice and acute cholangitis. Hewas referred for endoscopic retrograde cholangiopancreatography (ERCP) using a “short” DBE for internalization of biliary drainage. Locating the choledochojejunal anastomosis was difficult, but was successfully achieved by detecting the ulcer-scar-like lesion and a little biliary flow in the underwater observation (●" Video 1). However, the procedure failed because of a severe stenosis consisting of a long stricture with a small orifice in the choledochojejunal anastomosis, which was denoted a type A2 stricture in the classification ofMönkemüller and Jovanovic [1] and hindered the advancement of several devices. As an alternative, percutaneous transhepatic cholangiodrainage (PTCD) was applied, but this was again precluded by the severe stenosis. As the patient firmly refused to undergo further surgery, DBE-assisted ERCP was reattempted. Indigo carmine was used to mark the location of the choledochojejunal anastomosis and, using a needle knife (KD-V441M; Olympus Medical Systems, Tokyo, Japan), the membranous anastomotic stenosis was incised (●" Video 2). When a blind incision was made in thepresumeddirectionof thebiliary duct, the cholangiographic image showed leakage of contrast medium into the abdominal cavity (●" Fig.1), indicating that the presumed orientation was incorrect. To assure the correct direction of the incision, the SDVS was inserted via the PTCD route and successfully functioned as a visible light guide, facilitating accurate incision into the biliary duct (●" Video 3). Consequently, guidewires were advanced through the choledochojejunal anastomotic stenosis and dilatation using an 8-mm dilator balloon (QBD-8X3; Cook Medical, Bloomington, IN, USA) was successful, allowing placement of two endoscopic biliary drainage tubes consisting of 5-Fr plastic stents (ZEBD-5-4; Cook Medical) (●" Video 4). A severe stenosis in a choledochojejunal anastomotic site is a significant problem.