EUS trans-mural approach can be technically challenging or unfeasible in patients with distal malignant biliary obstruction (DMBO) and <12 mm common bile ducts (CBD) after ERCP failure [1-2]. Similarly, intrahepatic route requires ≥5mm intrahepatic duct (IHBD) dilatation and ≥2.5cm hepatic parenchymal distance to safely create a novel direct access from stomach [3]. EUS-guided rendezvous (EUS-RV) has emerged as an alternative approach in this scenario. However, it require technically challenging steps like biliary puncture using a 19G needle, guidewire manipulation, EUS scope withdrawal and duodenoscope re-insertion, guidewire grasping\traction inside the accessory channel and finally biliary cannulation (BC) using the EUS-placed guidewire by the “along-the-wire” and the “over-the-wire” methods. 

This single-center retrospective study aimed to evaluate the feasibility, safety, and efficacy of EUS-RV in patients with <12mm CBD and DMBO. Patients were enrolled between January 2020 and May 2025, and followed for at least 6 months follow-up. Over a total number of 2838 ERCP performed in our center, approximately one third (1082) were executed for malignant obstruction. Of this subgroup, a DMBO was reported in 785 cases and 91 patients presented a CBD<12mm. We finally registered all the 12 EUS-RV cases after failed conventional ERCP with standard or advanced cannulation techniques. Technical success, clinical success and adverse events (AEs) were analyzed. All procedures were performed under general anesthesia, using standard linear echoendoscope and ERCP equipment.

12 patients were included in this analysis. Access was performed from the bulb to the CBD or from stomach to IHBD (S2 or S3) in 8 and 3 cases, respectively. One case require approach by the main pancreatic duct due to the impossibility of a valid biliary EUS window. Mean CBD diameter was 9.8 mm (range: 7,5-11,5 mm). Wire shearing was never reported. A 10-mm snare was adopted to catch the wire through the duodenoscope. A second operator was systematically located at patient head to collect and facilitate the correct sliding of the 450-mm 0.035inch hydrophilic guidewire. The wire was inadvertently detached, broke or lost during traction in 41,6% of the cases. In this scenario, BC was performed “along-the-wire” using a standard sphincterotome following the way of the rendezvous wire. In the remained 58,4% of the cases, the “over-the-wire” BC technique was used. A tubular metal stent was deployed in all the cases. Procedural time was 89,81±29,04 minutes, confirming the high technical complexity of the procedure that require multiple steps. EUS-RV technical success was achieved in all the cases. Clinical success, defined as successful biliary drainage and jaundice resolution, was obtained in 100% of cases. No AEs were reported.

EUS-RV demonstrated favorable efficacy in patients with <12mm CBD diameter and DMBO when conventional ERCP failed as showed in this single-center retrospective analysis. In this context, EUS-RV constitutes a valid first-line treatment with comparable effectiveness and no AEs, although it necessitates multiple procedural steps that increase technical complexity and procedural time. The lack of dedicated devices necessitated standard ERCP accessories, which may have impacted procedural efficiency and outcomes, particularly wire loss. It can inadvertently occur during scope exchange, guidewire manipulation, or other EUS-RV steps, representing a critical passage that may compromise procedural success. "Along-the-wire" BC represents a useful trick in high-skilled endoscopists facilitating deep papillary access.