Year : 1999 | Volume
: 5 | Issue : 3 | Page : 140--145
Combined percutaneous and endoscopic approach for internal biliary drainage: The rendezvous maneuver-a report of four cases
Mohammed Ali Al Karawi1, Faisal M Sanai1, Saeed Al Ahmary1, Abdelrahman El Sheikh Mohammed1, Bassam Sammak2,
1 Department of Gastroenterology, Armed Forces Hospital, Riyadh, Saudi Arabia
2 Department of Radiology, Armed Forces Hospital, Riyadh, Saudi Arabia
Mohammed Ali Al Karawi
Head Gastroenterology Department, Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
|How to cite this article:|
Al Karawi MA, Sanai FM, Al Ahmary S, Mohammed AE, Sammak B. Combined percutaneous and endoscopic approach for internal biliary drainage: The rendezvous maneuver-a report of four cases.Saudi J Gastroenterol 1999;5:140-145
|How to cite this URL:|
Al Karawi MA, Sanai FM, Al Ahmary S, Mohammed AE, Sammak B. Combined percutaneous and endoscopic approach for internal biliary drainage: The rendezvous maneuver-a report of four cases. Saudi J Gastroenterol [serial online] 1999 [cited 2020 Jul 3 ];5:140-145
Available from: http://www.saudijgastro.com/text.asp?1999/5/3/140/33535
In the management of inoperable malignant strictures and tight benign distal biliary strictures, there are two different methods available, the antegrade percutaneous transhepatic and the endoscopic retrograde transpapillary approach. However, in some rare instances both these approaches may be unsuccessful in their desired objective. In such a scenario, a combination of the above two techniques, the Rendezvous Maneuver, can be utilized in achieving internal biliary drainage. Four patients were referred to our endoscopy unit after external drainage had been unsatisfactory in providing adequate relief from the obstructive jaundice in the referring hospitals. Endoscopic stent insertion, attempted separately, had also not been possible. Three of these patients had malignant biliary strictures and one had a benign post-operative biliary stricture with a retained stone above it. Subsequently, the four patients underwent the Rendezvous procedure. There were no procedure related adverse events. Ail four patients achieved successful and adequate drainage without any complications when the Rendezvous Maneuver was utilised. The effect on drainage was termed successful when there was one-third or more decrease in the serum bilirubin from the initial value within one week of the procedure. Better quality of life for the three malignant cases was achieved.
Long-term follow up of these three patients was not studied as these patients were referred back to their original hospitals after completion of the procedure. The fourth patient with the stone lying above the post-operative stricture was asymptomatic one year after the procedure upon follow-up. We conclude that in those inoperable patients with biliary strictures or where the retrograde technique is not feasible, the Rendezvous Maneuver can achieve satisfactory drainage.
Therapeutic biliary endoscopy is a relatively recent introduction in the management of diseases related to the biliary tree. Of the various problems encountered by the endoscopist, strictures of the biliary tree probably poses one of the most frustrating of therapeutic dilemmas. The role of interventional radiology has been groundbreaking in this field and endoscopists have learnt much from this pioneering experience. Recent times have seen a closer cooperation between the two approaches and this has led to encouraging results. The biliary tree can be accessed either retrogradely by the endoscopic transpapillary route or antegradely by the ultrasonography-guided percutaneous transhepatic route. The combination of these two techniques to facilitate internal drainage and achieve biliary decompression constitutes the rendezvous maneuver  . This method can be utilised in the management of benign distal strictures or malignant strictures that are inoperable and where the retrograde approach has failed ,, . In this procedure the radiologist passes a guidewire through the external percutaneous transhepatic drain into the duodenum, and over which the endoscopist accesses the bile duct. Subsequent endoprosthesis insertion and internal drainage can then be successfully achieved. We describe here four patients who underwent the rendezvous maneuver successfully.
Patients and Methods
All four patients included for this procedure had failed internal drainage by endoscopic retrograde cholangiopancreatography (ERCP) and had subsequently been initiated on percutaneous transhepatic drainage (PTD). External drainage had been initiated in the referring hospital for failure of stent insertion into the biliary ducts or for failure of papilla cannulation. All patients had previous abdominal ultrasonography and computed axial tomography (CAT) scanning. Investigations had revealed obstructive jaundice with biliary strictures surgery and were referred to the endoscopy in all the patients. They were considered unfit for department for relief of the biliary obstruction by palliative internal drainage and thereby improve the quality of life.
The combined radiological and endoscopic procedure was performed under fluoroscopic screening. The actual size of the endoprosthesis was determined by the site(s) of the obstruction. Once free and satisfactory internal drainage was achieved. then the percutaneous transhepatic catheter was removed. The effect on jaundice was termed successful when there was one-third or more decrease in the serum bilirubin from the initial value within one week of the procedure. A description of the individual patients and their respective procedures are described below.
Patient # 1
A 54 years old gentleman was referred to our department from another hospital with severe obstructive jaundice. Investigations had revealed that he had a tumor at the bifurcation of the common hepatic duct. He was considered inoperable and subsequently initiated upon external drainage but this only partially relieved the obstruction. He subsequently underwent the rendezvous maneuver which involved dilating both the stenosed left and right hepatic ducts over the guidewire and inserting two 10cms 7 French endoprostheses, one each into the left and right hepatic ducts. The endoprosthesis in the left hepatic duct (LHD) was introduced through the external drain but the one in the right hepatic duct (RHD) required the rendezvous technique for insertion [Figure 1].
Patient # 2
An 80 years old lady was referred to the endoscopy department with obstructive jaundice. She had been diagnosed to have an extensive malignant stricture at the porta-hepatis involving both hepatic ducts and another stricture in the distal common bile duct (CBD). She had an indwelling 6.3 French catheter in the RHD, inserted percutaneously under ultrasound guidance in the referring hospital. Inadequacy of drainage and failure of initial ERCP to bypass the stricture was the reason for referral to our unit. She underwent the rendezvous maneuver during which it was found that the positioning of the external drain was located in the proximal part of the dilated biliary tree and was therefore not ideal. A long 12cms 10 French plastic stent was inserted past the stricture and this achieved satisfactory drainage.
Patient # 3
An 80 years old man with hepatocellular carcinoma was referred to the gastroenterology department for the management of obstructive jaundice that persisted after the insertion of an external drain in the RHD. Investigations had revealed a large tumor obstructing both the hepatic ducts with significant remnant dilatation of the biliary radicles. An ERCP was attempted for endoprosthesis insertion but was unsuccessful. Subsequently a 10cms 7 French plastic stent was inserted into the LHD with the aid of the rendezvous maneuver. An attempt to drain the right side was unsuccessful as the RHD was completely obstructed by the tumor. However, since there was effective internal drainage through the LHD, further attempts at right-sided stenting were not made.
Patient # 4
A 40 years old gentleman was referred from another hospital after undergoing open cholecystectomy following which he had developed obstructive jaundice. Subsequent surgical exploration had revealed a stone impacted above a distal CBD stricture. Intra-operative manipulation was unsuccessful in dislodging the stone and the obstruction persisted. Three subsequent attempts at ERCP in the same hospital had revealed a tight stricture in the distal CBD but had been unsuccessful in getting past the obstruction. A T-tube cholangiogram had showed a retained stone above the stricture. Following this, in our hospital, with the aid of the combined approach utilising the T-tube, a dilator balloon was used to dilate the stricture and extract the stone from the biliary ducts.
In the next step, a 10 French I0cms plastic stent was inserted beside the T-tube after inserting another guidewire into the proximal biliary tree, and another 7 French one inserted over an external guidewire and both were left in-situ for bougie of the stricture [Figure 2]. A week later, only the 10 French intrabiliary stent was left in-situ and the other stent was removed. Two months thereon, the 10 French stent was also removed and the patient did well on subsequent follow-up after one year.
All of the above described patients underwent a complete diagnostic work-up including an ERCP with an attempt at internal drainage; a trial of external drainage that failed; and subsequently the rendezvous maneuver. All four patients tolerated the procedure well without any complications during and after the procedure. Drainage was achieved in one endoscopic setting since the external drain had been left in-situ from the previous attempt at percutaneous drainage. Symptomatic improvement in the form of decreased itching, jaundice and an improvement in the general condition were accompanied by significant reductions in the biochemical parameters of biliary obstruction. Long-term follow up of the patients was not possible since three of them were referred back to their original hospital and the fourth patient who did have a follow-up till one year after the combined procedure, did well subsequently.
The prognosis of patients with malignant jaundice continues to be poor. The majority of patients with malignant biliary obstruction are inoperable at presentation  . This subgroup of patients is the one that is usually referred for biliary drainage to offer palliation, and improve the quality of life. Sonography-guided antegrade percutaneous transhepatic route and retrograde endoscopic transpapillary route are both acceptable methods with similar success-rates ,, . Traditionally. The antegrade method has been assumed to be the technically simpler of the two. A recent study has contended this view by demonstrating a significantly lower 30-day mortality, higher biliary drainage rates and lower rate of early complications for the retrograde endoscopic route  . Furthermore, internal drainage is compounded by the problem of drain blockage and the need for continuos leaving in-situ of the percutaneous external drain. The involvement of the endoscopist by way of performing ERCP helps in overcoming these problems. ERCP offers a high diagnostic value and the probability of relieving the jaundice in the same session. Drainage of the bile by the papillary routes leads to a relief of jaundice in about a reported 75-95% of patients, whereas early complications arise in less than 20% of cases. Mortality rates form an encouragingly low 1-3 %,,
External drainage through the percutaneous route also offers another means of relieving the obstruction. Variation in patient selection and the techniques adopted have made the evaluation of comparative data between these two approaches, difficult to interpret. However, an increasing number of authors are now advocating the initial trial of ERCP as the method to adopt in the drainage of the obstructed biliary tree ,, .
In the present study, all patients had failed both approaches and subsequently required the combined method. With this technique, endoprosthesis insertion was achieved with satisfactory internal biliary drainage in all four patients. The size of the endoprostheses in the first and third patient was based on the smaller size of the endoscope available during the procedure and therefore the smaller size of the stents. Although fragmentation could have been attempted in patient No. 4, but it would not have achieved fragment retrieval since the stricture was too tight to get past and moreover, the stricture still needed dilatation and subsequent bougie by stent. Benign post-operative biliary strictures have been shown to require stent placement for several months even after endoscopic dilatation 
Incomplete drainage as was seen in patient No. 3 is another significant issue that has been addressed in the past. Although symptomatic improvement in the pruritus and jaundice may be achieved, along with a lower incidence of complicating cholangitis; nevertheless some residual symptoms from the undrained lobes and the complications of cholangitis and sepsis leading to a higher early mortality remains 
In patient No. 4 we utilised the available T-tube inserted during surgery to make the intubation of the CBD possible, dilate the stricture and thereby retrieve the stone. Stenting of the biliary tree was also possible through the same route to achieve long term bougie of the stricture. This method, in our opinion, is to be considered in all patients having an in-situ T-tube in order to make the ERCP easy and quick.
While endoscopic biliary drainage or stenting is feasible in most cases, it is important to carefully select patients that are most likely to benefit from this form of treatment. It is usually easy to stent the strictured CBD, but an obstruction involving the bifurcation of the common hepatic duct and its branches can be problematic. In the scenario where bilateral ductal or hilar involvement is evident, then both the hepatic ducts should be selectively stented to avoid the complication of partial drainage , Other problems including anatomical aberrations posed by previous surgery like gastric resection or Billroth II re-anastomosis, papillary stenosis or drainage into a diverticulum makes accessibility to the ampulla very difficult  . All of these potential difficulties can be overcome, provided a guidewire can be fed into the duodenum and from thereon taken up by the endoscopist. This is the essence of the Rendezvous Maneuver. The success of this technique in relieving the obstruction ranges between 80-100% depending upon the underlying pathology , . It is a useful adjunct to standard endoscopic treatment of malignant jaundice and should be able to increase successful biliary drainage towards the 100% mark. This procedure serves as not only an anatomical rendezvous for endoprosthesis insertion, but also lays the ground for further future rendezvous' between interventional radiology and therapeutic endoscopy.
|1||Dowsett JF, Vaira D, Hatfield ARW, Cairns SR, Polydorou A, et al. Endoscopic biliary therapy using the combined percutaneous and endoscopic technique. Gastroenterology 1989;96:1180-6.|
|2||Leese T, Neoptolemos JP. Carr-Locke DL. Successes, failures, early complications and their management following endoscopic sphincterotomy - results in 394 consecutive cases from a single centre. Br J Surg 1985:,72:215-9.|
|3||Hatfield ARW, Murray RS, Lennard-Jones JE. Periampullary diverticula and common duct calculi - a combined transhepatic and endoscopic technique for difficult cases. Gut 1982;23:A889.|
|4||Robertson DAP, Hacking CN, Birch S, Ayres R, Shepherd H, Wright R. Experience with a combined percutaneous and endoscopic approach to stent insertion in malignant obstructive jaundice. The Lancet 1987:2:1449-52.|
|5||Speer AG, Cotton PB, Russell RCG, Mason RR, Hatfield ARW, Leung JW et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987;2:57.|
|6||Shlansky - Goldberg RD, Ginsberg GG, Cope C. Percutaneous puncture of the common biliary duct as a rendezvous procedure to cross a difficult obstruction. J Vase Interv Radiol 1995;6:943-6.|
|7||Mueller PR, Ferruci JT, Teplick SK, et al. Biliary stent endoprosthesis: analysis of complications in 113 patients. Radiology 1985;156:637-9.|
|8||Soehendra N, Binmoeller KF, Grimm H. Endoscopic therapy for biliary obstruction. World J Surg 1992;16:1066-73.|
|9||Klempa I, Arnold W. Palliative surgical and endoscopic therapy of malignant bile duct occlusion. Chirurg 1994;65: 836-48.|
|10||Hagenmuller F. Results of endoscopic bilioduodenal drainage in malignant bile duct stenoses. In: Classen M, Geenan J, Kawai K. eds. Non-surgical biliary drainage. Berlin: Springer-Verlag, 1984:93-104.|
|11||Huibregtse K. endoscopic insertion of stents through malignant and benign biliary strictures. In: Recent advances in Diagnostic and Therapeutic Endoscopy. MurKostverloren, Aalsmeer 1984;57-63.|
|12||Soehendra N. H. Joachim Burhenne Lecture. Common areas of interest between interventional biliary radiology and endoscopy. AJR Am J Roentgenol 1995;164:547-51.|
|13||Stanley J, Gobien RP, Cunningham J, et al. Biliary decompression: an institutional comparison of percutaneous and endoscopic methods. Radiology 1986;158:195-7.|
|14||Davids PHP, Rauws EAJ, Coene PPLO, Tytgat GN. Huibregtte K. Endoscopic stenting for post-operative biliary strictures. Gastrointest Endosc 1992:38:12-18.|
|15||Deviere J, Baize M, de Toeuf J. Cremmer M. Long-term follow-up of patients with hilar malignant stricture treated by endoscopic internal biliary drainage. Gastrointest Endosc 1988;34:95-101.|
|16||Ducreux M, Liguory C, Lefebvre JF, et al. Management of malignant hilar biliary obstruction by endoscopy: results and prognostic factors. Dig Dis Sci 1992;37:778-83.|