“THE DOUBLE TROUBLE”: SEQUENTIAL SAME-SESSION, EUS-GUIDED TREATMENT OF DUODENAL AND BILIARY STENOSIS

Background and aim:

Patients with peri-ampullary malignancies may present concomitantly with both Gastric Outlet Obstruction (GOO) and biliary obstruction. Standard access to the biliary tree with ERCP may fail due to malignant luminal compromise. With the recent advent of interventional EUS and dedicated devices like Lumen Opposing Metal Stent (LAMS), EUS-guided management of both GOO and biliary obstruction is now possible.

Material and methods:

This is a case of a 74 years old woman with locally advanced cancer of the pancreatic head. The cancer was infiltrating the duodenum, superior mesenteric vessels, and distal common bile duct. An attempt to place a duodenal metal stent to overcome the duodenal stenosis failed in another facility. The patient presented with jaundice and vomiting due to GOO. She was scheduled for same-session, EUS-guided gastroenterostomy (GE) and choledocho-duodenostomy (CD).

Results:

Under general anesthesia a 0.0035 inch guidewire was inserted through the duodenal stenosis and a 20 mm balloon dilator was inserted over the wire, across the obstruction, and inflated with contrast fluid. A linear echoendoscope was used to locate the balloon and, under X-ray assistance, a jejunal loop was directly accessed with a 15 mm diameter electrocautery enhanced (ECE) LAMS, avoiding multiple accessory exchanges. With the same instrument, from the duodenal bulb, a dilated (17 mm) CBD was accessed with an 8 mm ECE-LAMS with immediate biliary decompression. At the end of the procedures, contrastography revealed no leak of contrast fluid.

Conclusions:

Double bypass confers the advantage for both luminal and biliary patency as food and bile are diverted away from the site of obstruction. Furthermore, this procedure can solve a “double problem” in a single-session/single operator fashion. Studies comparing this novel concept to existing techniques are warranted.