Overview
Definition:
The rendezvous technique is a minimally invasive approach used to extract bile duct stones when conventional endoscopic or percutaneous methods are not feasible or have failed
It involves a coordinated effort between an endoscopist and a surgeon performing a percutaneous procedure to allow for stone removal via a common channel, typically accessed through either the duodenum or the liver
This technique aims to avoid open surgery and its associated morbidity.
Epidemiology:
Choledocholithiasis, the presence of gallstones in the common bile duct, occurs in approximately 10-20% of patients undergoing cholecystectomy for symptomatic cholelithiasis
The incidence of bile duct stones requiring complex management strategies like the rendezvous technique is considerably lower, often associated with challenging anatomy, prior surgery, or failed prior interventions
Advanced age and co-morbidities are also contributing factors.
Clinical Significance:
Bile duct stones can lead to significant complications including cholangitis (infection of the bile ducts), biliary obstruction causing jaundice, and pancreatitis
Accurate and effective stone clearance is crucial for preventing these life-threatening conditions
The rendezvous technique offers a valuable alternative when standard methods are insufficient, preserving organ function and reducing patient recovery time compared to open surgery.
Indications
Indications For Rendezvous:
Failure of standard ERCP stone clearance due to difficult anatomy (e.g., altered anatomy post-gastric surgery, impacted stones, benign biliary strictures)
Inability to access the papilla of Vater for ERCP
Failed or incomplete percutaneous transhepatic biliary drainage (PTBD) stone removal
Need for combined approach when one modality alone is insufficient
Situations where a large or impacted stone cannot be cleared by ERCP alone
Patients with high surgical risk where open surgery is contraindicated.
Contraindications:
Active cholangitis requiring immediate drainage and sepsis control (may be a relative contraindication or require staged approach)
Uncorrected coagulopathy
Severe pancreatitis that precludes instrumentation
Known or suspected bile duct malignancy that requires definitive surgical resection rather than mere stone removal
Inability to establish a safe percutaneous tract
Lack of multidisciplinary team expertise.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination focusing on symptoms of biliary obstruction, cholangitis, or pancreatitis
Comprehensive review of previous investigations and procedures
Assessment of comorbidities and anesthetic risk
Evaluation of nutritional status.
Imaging Studies:
Abdominal ultrasound to confirm gallstones and bile duct dilation
MRI/MRCP (Magnetic Resonance Cholangiopancreatography) to delineate the biliary anatomy, stone burden, location, and any associated strictures or pathology
CT scan may be used for better visualization of anatomical variations or surrounding structures
ERCP if previously attempted, to review findings.
Laboratory Tests:
Complete blood count (CBC) to assess for leukocytosis
Liver function tests (LFTs) including bilirubin, alkaline phosphatase, AST, ALT, and GGT to assess degree of cholestasis and liver injury
Coagulation profile (PT/INR, aPTT) to assess hemostatic capability
Serum amylase and lipase to rule out pancreatitis.
Antibiotic Prophylaxis:
Broad-spectrum intravenous antibiotics should be initiated prior to the procedure, typically covering Gram-negative organisms and Enterococcus
Common regimens include ceftriaxone with metronidazole, or ciprofloxacin
Prophylaxis is continued post-procedure as indicated, especially if cholangitis was present or suspected.
Procedure Steps
Two Team Approach:
The procedure requires close collaboration between an interventional radiologist (performing the percutaneous access) and a gastroenterologist/endoscopist (performing the duodenal access).
Percutaneous Access:
Under image guidance (ultrasound and fluoroscopy), a percutaneous tract is established into the biliary tree, typically in the right upper quadrant, targeting an intrahepatic duct
A guidewire is advanced through the bile duct towards the duodenum
A small caliber drainage catheter or sheath may be placed initially.
Endoscopic Access And Rendezvous:
Simultaneously, the endoscopist performs ERCP, cannulating the common bile duct
A guidewire is advanced from the endoscopic side, aiming to meet the guidewire from the percutaneous tract within the bile duct
Once both guidewires are in place and visualized fluoroscopically, one of the wires is snared and exteriorized through the opposite access route (e.g., the percutaneous tract).
Stone Extraction:
With both access routes established and a shared lumen created, various stone removal techniques can be employed
This may include: Stone extraction with a balloon catheter
Mechanical lithotripsy using a Dormia basket or a specialized lithotripter passed through the working channel created by the two wires
Large stones may be fragmented by electrohydraulic lithotripsy (EHL) or laser lithotripsy
A nasobiliary tube or drainage catheter is usually placed for drainage and to facilitate subsequent stone clearance or stent placement.
Final Checks:
Post-procedure cholangiography is performed to confirm complete stone clearance, assess for any residual filling defects, evaluate for bile leaks, and assess the patency of the biliary tree
Any identified strictures may be stented endoscopically or percutaneously.
Postoperative Care
Monitoring:
Close monitoring of vital signs, abdominal pain, and signs of bleeding or infection
Serial assessment of LFTs to evaluate resolution of cholestasis
Monitoring for complications such as pancreatitis, cholangitis, or bile leak.
Pain Management:
Adequate analgesia is provided, typically with intravenous patient-controlled analgesia (PCA) or oral analgesics as pain subsides.
Hydration And Nutrition:
Intravenous fluid resuscitation is maintained until adequate oral intake is tolerated
Nutritional support may be required, especially if there is significant jaundice or malabsorption.
Antibiotics:
Postoperative antibiotics are continued based on the patient's clinical status and any intraoperative findings
Prophylaxis is typically continued for 24-48 hours unless signs of infection are present.
Drain Management:
Percutaneous drains are managed according to protocol, with output monitored
They are usually removed once drainage is minimal and the patient is clinically stable
Nasobiliary tubes are typically removed after a few days once patency is confirmed and drainage is satisfactory.
Complications
Early Complications:
Bleeding from percutaneous tract or papilla
Pancreatitis secondary to ERCP
Cholangitis if stone clearance is incomplete or tract becomes infected
Bile leak (biloma or external biliary fistula)
Injury to adjacent organs (bowel, blood vessels)
Pneumothorax or hemothorax (rare, with hepatic lobe approach)
Sepsis.
Late Complications:
Biliary stricture formation at the access site or due to prior instrumentation
Recurrent choledocholithiasis
Persistent biliary fistula
Cholangitis due to retained stones or strictures
Liver abscess formation.
Prevention Strategies:
Meticulous technique by experienced operators
Careful selection of access sites and angles
Use of appropriate caliber instruments
Adequate imaging guidance throughout the procedure
Prompt recognition and management of early complications
Judicious use of antibiotics
Careful selection of patients and timing of intervention.
Key Points
Exam Focus:
The rendezvous technique is a salvage procedure for complex bile duct stone removal, requiring a combined endoscopic and percutaneous approach
Key success factors include excellent radiologic-endoscopic teamwork and mastery of both ERCP and percutaneous biliary access techniques
DNB/NEET SS questions may focus on indications, contraindications, steps of the procedure, and potential complications.
Clinical Pearls:
Always consider the patient's anatomy and prior surgical history when planning the approach
A successful rendezvous hinges on establishing secure and parallel guidewires in the common bile duct for a shared lumen
Be prepared for variations in stone burden and ductal anatomy, which may necessitate lithotripsy or stenting
Communication is paramount between the interventional radiologist and the endoscopist.
Common Mistakes:
Attempting a rendezvous technique without adequate expertise or multidisciplinary support
Inadequate preoperative imaging leading to surprises during the procedure
Poor communication between teams leading to misaligned guidewires or conflicting interventions
Failure to adequately assess for retained stones or strictures post-procedure
Premature removal of percutaneous drains without ensuring biliary continuity.