Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a key therapeutic tool for biliary access, but cannulation failure occurs in 5%-10% of cases. We report a 92-year-old woman with obstructive jaundice and complete distal common bile duct obstruction, in whom standard ERCP failed. A percutaneous-endoscopic rendezvous (PE-RV) approach successfully established biliary drainage via a transhepatic guidewire and stent placement. However, the patient developed pneumoperitoneum, tension pneumothorax, and subcutaneous emphysema following abrupt catheter removal. These manifestations are collectively referred to as "air leak syndrome," which encompasses the abnormal presence of air in the peritoneal cavity, pleural space, and subcutaneous tissue. Imaging showed no pneumoretroperitoneum, suggesting gas migration through an immature percutaneous tract. Urgent drainage and antibiotics led to gradual recovery. This case highlights PE-RV as a valuable salvage technique but underscores the risk of rare gas-related complications when percutaneous tract closure is premature. To minimize the risk of such complications, procedural protocols may need to incorporate delayed catheter removal or tract embolization to ensure safe outcomes. Careful catheter management, delayed removal, and interdisciplinary coordination are essential for safe outcomes.