SINGLE-SESSION EUS-GUIDED GASTRO-JEJUNOSTOMY AND CHOLEDOCHO-DUODENOSTOMY TO TREAT DUAL STENT DYSFUNCTION IN CONCURRENT MALIGNANT GASTRIC OUTLET AND BILIARY OBSTRUCTION

Gastric Outlet Obstruction (GOO) usually occurs late in pancreatic cancer, typically associated with biliary obstruction. Combined duodenal and biliary self-expandable metal stents (SEMS) are not always effective whereas surgery often carries prohibitive risks

A 49 year-old female with pancreatic cancer developed GOO and jaundice four months after biliary SEMS placement at ERCP. A stricture in the 2^nd duodenum was successfully bridged with a duodenal SEMS. The duodenal SEMS, however failed to expand. Forced-balloon expansion of the duodenal SEMS was ruled out. EUS-guided gastrojejunostomy (EUS-GJ) and choledocho-duodenostomy (CDS) were performed in the same session. The unexpanded SEMS was cannulated with a guidewire. A 7F nasobiliary drainage catheter was passed through a therapeutic upper endoscope across the stricture into the jejunum. The gastroscope was exchanged for a linear EUS-scope. The proximal jejunal loops were distended with contrast and methylene-blue injected through the catheter. EUS-guided free-hand insertion of a 15 × 10-mm cautery-enabled LAMS into the proximal jejunum was performed, despite some difficulty with tenting of the jejunum caused by low-volume ascites. The LAMS was deployed and endoscopy confirmed proper placement. The prior transpapillary biliary SEMS was readily identified under EUS from the bulb. The CBD was punctured with a 19G needle, and over-the-wire dilation of the tract was peformed prior to SEMS insertion from the duodenum into the CBD. No complications ensued. The patient recovered oral tolerance, cleared jaundiced and was transferred to hospice care.

Double endoscopic bypass under EUS-guidance can offer single-session, minimally invasive palliation to patients with concurrent gastric outlet and biliary obstruction where luminal SEMS placement is either technically or clinically (early and late dysfunction) failed.