Percutaneous-Endoscopic Rendezvous Technique for Treatment of Malignant Biliary Obstruction in a Gastric Cancer Patient after Billroth II Gastrectomy

Lianda Siregar1,2(*), Imelda Maria Loho1,2, Agus Sudiro Waspodo1, Hendro Saulata1, Viharsyah Aulia Akbar1, Rahmanandhika Swadari1

1 Department of Gastroenterology and Hepatology, “Dharmais” Hospital, Indonesian National Cancer Center, Jakarta, Indonesi;
2 Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

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Correspondence to: Lianda Siregar, Department of Gastroenterology and Hepatology, “Dharmais” Hospital, Indonesian National Cancer Center, Jakarta, Indonesia.
Telephone: +62-21-5681570, ext. 2335
Email: liandadr_siregar@yahoo.com

Received: Apirl 6, 2021
Revised: May 15, 2021
Accepted: May 17, 2021
Published online: October 21, 2021


Gastric cancer is the fifth most commonly diagnosed cancer in the world, with a peak incidence rate at 60 years of age and men affected more than women. Obstructive jaundice is a rare symptom associated with gastric cancer, with a prevalence rate of 2.3%. Management of obstructive jaundice through endoscopic retrograde cholangiopancreatography (ERCP) may be challenging in patients with an altered anatomy, such as a previous history of having undergone a Billroth II. As such, rendezvous techniques of ERCP and percutaneous transhepatic biliary drainage (PTBD) that enter one location through two access points can be used to alleviate the complexities of altered anatomy due to previous abdominal surgery of which ERCP alone was technically difficult and often unsuccessful in problematic conditions. In this case report we present a case of a male with a previous history of a rendezvous technique with ERCP and PTBD, following a Billroth II gastrectomy, and successful stent implantation without any complication.

Key words: Percutaneous-endoscopic rendezvous technique; Endoscopic retrograde cholangiopancreatography; Billroth II procedure; Bile duct obstruction; Gastric cancer

© 2021 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Siregar L, Loho IM, Waspodo AS, Saulata H, Akbar VA, Swadari R. Percutaneous-Endoscopic Rendezvous Technique for Treatment of Malignant Biliary Obstruction in a Gastric Cancer Patient after Billroth II Gastrectomy. Journal of Gastroenterology and Hepatology Research 2021; 10(5): 3596-3598 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/3127


Gastric cancer is the fifth most commonly diagnosed cancer in the world with a peak incidence rate at 60 years of age and men affected more often than women. Gastric cancer causes 783,000 deaths each year, making it the third most fatal cancer among males[1]. Patients with gastric cancer would have symptoms and signs such as epigastric pain, hematemesis, melena, weight loss, anorexia, and nausea. Vomiting may occur if there is an obstruction, while dysphagia may occur if the tumor is located in the cardia. Symptoms of obstructive jaundice in gastric cancer were not commonly found and thus was a rare complication[2].

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for the management of obstructive jaundice in gastrointestinal tumor due to its minimally invasive nature[3]. However, performing ERCP in patients with surgically altered anatomy, such as post Billroth-II gastrectomy, is more challenging, particularly as it relates to the insertion to the afferent loop and the cannulation procedure. In order to address these difficulties, the rendezvous technique, which combines the endoscopic and percutaneous techniques to reach one location through two access points, was used[4].

Here we present a case where we used the rendezvous technique with ERCP and percutaneous transhepatic biliary drainage (PTBD) to implant a stent in a patient with altered anatomy due to a previous history of Billroth-II gastrectomy. 

Case summary

A 73-year-old male presented to the outpatient clinic of our department with a primary complaint of yellowish eyes for two weeks, accompanied by additional symptoms of nausea and vomiting. He had a history of gastric adenocarcinoma with poor differentiation, three years prior to admission and underwent a Billroth-II gastrectomy, followed by six cycles of chemotherapy with docetaxel and carboplatin. The patient did not present for follow-up during the last year and finally came to our clinic with yellowish eyes and skin. Other past medical history was unremarkable.

On physical examination, the patient had obvious jaundice with scleral icterus. Other physical findings were unremarkable. On blood test, his total bilirubin level was 22,88 mg/dL with direct bilirubin 22,12 mg/dL. Other laboratory findings were as follows: hemoglobin 12,5 g/dL, white blood cells 9,44 103/µL, ALT 46 U/L, AST 79 U/L ALP 359 U/L, GGT 269 U/L, albumin 3,4 g/dL, CA 72-4: 30,24 U/mL. Abdominal CT revealed multiple peripancreatic and periduodenal mesenteric lymph nodes enlargement attached to the head of the pancreas and the common bile duct, (CBD) causing dilation of common bile duct (CBD), as well as right and left hepatic ducts (Figure 1). No residual mass in the perianastomotic region was detected. 

ERCP was attempted but the afferent limb and the ampulla could not be reached with the conventional side-viewing duodenoscope. Therefore, the percutaneous-endoscopic rendezvous technique was performed. An 80cm long 0,035-inch hydrophilic guidewire (Cook Medical) was inserted into the jejunum using a left-lobe approach under fluoroscopic guidance with the patient supine (Figure 2A). The endoscope was then inserted orally by the operator to reach the biliary orifice. However, endoscope insertion was difficult due to looping, therefore abdominal pressure placed by the hand of an assistant was applied. The distal tip of the guidewire was grasped with a snare and passed through the working channel of the duodenoscope (Figure 2B). Retrograde cannulation was achieved over the guidewire and a 10 Fr, 11-cm plastic stent was successfully implanted (Figure 2C and 2D). The patient was discharged without any complication.

Figure 1 Abdominal CT showed dilated right intrahepatic duct (blue arrow), as well as enlarged lymph nodes (yellow arrow) which obstructed the CBD.

Figure 2 A guidewire was introduced from the left hepatic bile duct to jejunum B. The distal tip of the guidewire was grasped with a snare. C and D. Successful stent implantation in CBD.


Obstructive jaundice in gastric cancer is a rare complication, with the incidence of jaundice associated with gastric cancer reported to be only 2,3%[5]. In some cases, ERCP may be challenging as sometimes, the endoscope cannot reach the ampulla of Vater due to gastric outlet obstruction by the tumor, or due to surgically altered anatomy[6], such as Billroth I, Billroth II, and Roux-en-Y[7]. The difficulties to guide the endoscope into the loop is caused by the presence of anastomosis angulations, adhesions, excessive length, Braun entero-entero-anastomosis, and distorted anatomy at the duodeno-jejunal angle[8,9]. Patients with surgically altered anatomy have lower ERCP success rates compared with patients having normal anatomy[10]. Altered anatomy is found in patients with congenital anomalies, duodenal stenosis, large periampullary diverticula, and also diversionary surgery, of which Billroth II partial gastrectomy is the most common[8]. In a study by Cheng et al it was shown that the success rate of ERCP in patients with a prior history of Billroth II gastrectomy varies from 68 % to 92 %[11].

Stent implantation through the rendezvous technique of PTBD and ERCP is a minimally invasive treatment procedure for obstructive jaundice. The indications for this procedure must meet the indications for both PTBD and ERCP[3]. Ying et al study showed that the indication for both PTBD and ERCP was obstructive jaundice, high serum bilirubin level, dilated bile duct above the stricture, no ascites around the puncture site, normal coagulation function, inability to enter the common bile duct due to distortion of the ampulla, or an inability to pass a guide wire across the lesion during the initial ERCP[3]

The key to a successful rendezvous technique lies at advancing the PTBD guidewire across the ampulla of Vater to guide the endoscope[3]. A rendezvous technique after percutaneous transhepatic biliary drainage (PTBD), which requires a dilated intrahepatic duct, can facilitate the cannulation[12]. If the intrahepatic duct is not dilated, the safety performance of the percutaneous transhepatic rendezvous technique can be challenging. A double-balloon enteroscopy (DBE), single-balloon enteroscopy (SBE), and rotational or spiral enteroscopy (SE) is the device - assisted endoscope that can increase ERCP success rate in patients with surgically altered anatomy. Krutsri et al study reported a DBE insertion success rate of 90%-100% in Billroth II gastrectomy[12].

An understanding of the different types of postoperative reconstruction anatomy is important to determine the easiest way to access the afferent limb and also to select the most appropriate endoscopic technique[3]. By understanding postoperative reconstruction anatomy and the correct procedure, we can minimize postoperative complications. However, ERCP failure can increase the risk of acute pancreatitis due to the procedure. The occurrence rate of post-ERCP pancreatitis has been reported to be 7.3-17%, even when methods for difficult bile duct cases were used. Therefore, further caution is needed to minimize ERCP failure and to avoid further complication[13].


In this case, we succeeded in performing a rendezvous technique with both ERCP and PTBD guided by guidewire into the ampulla of Vater and implanting the stent in a patient that underwent previous Billroth II gastrectomy. In conclusion, the rendezvous technique can be used for unsuccessful ERCP and management of biliary obstruction. 


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