The EUS-guided rendezvous technique（EUS-RV）is a useful salvage method for cases in which biliary cannulation during ERCP is difficult. However, the procedure has not been standardized, and technical approaches vary among institutions. Although adverse events such as bile leakage and bleeding have been reported, detailed analyses remain limited. At our institution, puncture of the intrahepatic bile duct (B2/B3) from the stomach is the first-line approach, whereas puncture of the common bile duct from the second portion of the duodenum (D2 position) is selected when intrahepatic bile duct dilation is insufficient. This study evaluated the outcomes and adverse events associated with EUS-RV performed at our institution.

A total of 106 EUS-RV procedures were performed at our institution between November 2018 and October 2025. The puncture route, technical success rate, time to biliary cannulation, and adverse events were retrospectively analyzed. Technical success was defined as successful bile duct cannulation. Cannulation time was defined as the interval from ERCP failure to successful cannulation with EUS-RV. Adverse events were defined as those directly attributed to the EUS-RV procedure.

The median age was 77 years, and 54 patients were male. Primary diseases included common bile duct stones (n=44), intrahepatic stones (n=3), pancreatic cancer (n=29), distal cholangiocarcinoma (n=10), hilar cholangiocarcinoma (n=6), ampullary cancer (n=3), and others (n=11). Puncture routes were B2/B3 in 60 cases, the D2 position in 44 cases, and the D1 position (push position at the duodenal bulb) in 2 cases. The technical success rate was 82.1% (n=87/106). Causes of technical failure included insufficient bile duct dilation (n=7), inability of the guidewire to pass through the papilla or biliary stricture (n=11), and failure of the duodenoscope to reach the papilla after guidewire placement (n=1). The mean cannulation time was 29 minutes. EUS-RV related adverse events occurred in 5 cases (4.7%), consisting of bile leakage (n=2) and intraductal bleeding (n=3). Bile leakage occurred in one case punctured from the D1 position and in another case punctured from the duodenal bulb with stretch position. Bleeding events were attributed to B3 puncture. All adverse events improved with conservative management, and no additional interventions were required.

Adverse events related to EUS-RV occurred in 4.7%. Puncture from the duodenal bulb may increase the risk of bile leakage and should be avoided when possible. Technical refinements and representative adverse event cases from our experience will be presented with video.