Failed Endoscopic Ultrasound-Guided Hepaticogastrostomy: Do Not Give Up-Endoscopic Ultrasound-Guided Rendezvous-Hepaticogastrostomy Can Rescue You.

Background and Aims:EUS-guided hepaticogastrostomy (EUS-HG) is increasingly used to achieve internal biliary drainage in patients with altered anatomy or inaccessible papillae. However, failure may occur secondary to nondilated intrahepatic ducts that preclude guidewire passage, or the inability to dilate fibrotic tracts or advance a stent, especially in patients with cirrhosis. This video demonstrates the use of rendezvous techniques to rescue failed EUS-HG and enable successful internal drainage. Methods:Five patients who failed conventional EUS-HG underwent rescue with 1 of 3 techniques: EUS-to-interventional radiology (IR) rendezvous using an IR-inflated target balloon (n = 3), IR-to-IR rendezvous using dual percutaneous access and transhepatic puncture through a snare (n = 1), and endoscopic rendezvous using oral wire retrieval and retrograde dilation (n = 1). Fully covered metal stents were deployed in all cases. Results:Technical success was achieved in all 5 patients. One patient did not achieve complete clinical resolution because of persistent hepaticojejunostomy dehiscence. No adverse events occurred during or after the procedure. The median follow-up was 28 months. Conclusions:EUS-guided rendezvous-hepaticogastrostomy offers an effective and safe solution for salvaging failed EUS-HG. These techniques should be considered before defaulting to long-term percutaneous biliary drainage.