LAUSR

AN 81‐YEAR‐OLD WOMAN was admitted to our department for management of common bile duct (CBD) stones with CBD stricture on magnetic resonance cholangiopancreatography (Fig. 1). Endoscopic retrograde cholangiopancreatography (ERCP) was performed, but biliary cannulation failed. Due to the failure of the ERCP, we performed an endoscopic ultrasound-guided rendezvous (EUS-RV) technique. Bile duct puncture and contrast injection using a 19-G needle (EZ Shot 3 Plus; Olympus, Tokyo, Japan) were performed. Then, insertion of a 0.025inch guidewire (VisiGlide; Olympus Medical Systems, Tokyo, Japan) via a 19-G needle was attempted to manipulate the anterograde guidewire into the duodenum across the ampulla. Unfortunately, the guidewire could not be advanced into the duodenum but only passed into the main pancreatic duct (MPD; Fig. 2a). Guidewire manipulation into the duodenum was unsuccessful even after several attempts with guidewire change or needle angle adjustment. Therefore, we placed the guidewire across the CBD and the MPD and changed the echoendosocpe to a duodenoscope (Fig. 2b). Grasper forceps were advanced into the MPD to grab the guidewire (Fig. 2c). We slowly pushed out the grasper forceps into the duodenum. Successful biliary cannulation alongside the guidewire was achieved, and a fully covered metal stent (FCMS; 10 mm diameter, 5 cm total length; M.I. Tech, Seoul, South Korea) was placed to prevent bile leakage (Fig. 2d; Video S1). One month later, complete CBD stone removal was performed following removal of the FCMS. The EUS-RV technique is an alternative option after salvage failed biliary cannulation; however, the procedure can be associated with additional failure due to guidewire manipulation requirements. In our patient, biliary stricture with papillary stenosis due to periampullary diverticulum might have prevented the guidewire from passing into the duodenum, although guidewire insertion into the MPD through the CBD was possible. Therefore, our technique might help achieve successful EUS-RV in similar situations. Authors declare no conflict of interest for this article.