# Troubleshooting of Endoscopic Ultrasound‐guided Rendezvous Using a Nasobiliary Drainage Tube

## TL;DR

A new method using a nasobiliary drainage tube helps overcome challenges in a complex endoscopic procedure for bile duct stones.

## Contribution

The paper introduces a novel troubleshooting method using a nasobiliary drainage tube in endoscopic ultrasound-guided rendezvous.

## Key findings

- A nasobiliary drainage tube (NBD) was successfully used to guide bile duct cannulation in a patient with a large periampullary diverticulum.
- The NBD helped maintain guidewire position during a complicated endoscopic procedure involving gastroptosis.
- The method proved effective in cases where traditional techniques failed due to anatomical challenges.

## Abstract

Endoscopic ultrasound‐guided rendezvous (EUS‐RV) is an alternative technique for patients in whom selective bile duct cannulation (SBDC) has failed during endoscopic retrograde cholangiopancreatography (ERCP). However, EUS‐RV has several challenging steps. Herein, we present a method for troubleshooting the EUS‐RV using a nasobiliary drainage tube (NBD) in a patient with a large periampullary diverticulum (PAD) and severe gastroptosis. An 80‐year‐old woman presented with nausea. Contrast‐enhanced computed tomography revealed a common bile duct (CBD) stone. Although ERCP was performed twice, the ampulla of Vater (AV) could not be identified due to the large PAD. Therefore, EUS‐RV was performed. The CBD was punctured from the descending part of the duodenum. Although a guidewire was advanced through the AV, the PAD hindered guidewire insertion to the anal side of the duodenum. During the switch to duodenoscopy, the guidewire was withdrawn due to gastroptosis. A subsequent attempt to puncture the CBD through the duodenal bulb resulted in guidewire entrapment. To manage the prolonged procedure, a 5‐French NBD was temporarily placed in the CBD. An NBD was subsequently inserted into the duodenum via the PAD using esophagogastroduodenoscopy under fluoroscopic guidance after 1 week. After switching to duodenoscopy, SBDC was successful along the NBD that was not withdrawn, and the stone was removed. NBD use in EUS‐RV may be effective in difficult cases of guidewire manipulation into the distal duodenum due to PAD and guidewire maintenance due to gastroptosis. Further, NBD is a readily available device, making its use convenient.