COMBINED ENDOSCOPIC STENTING FOR CONCOMITANT BILIARY AND DUODENAL MALIGNANT STRICTURES: DATA FROM A SERIES IN A SINGLE REFERRAL CENTER

Aims Endoluminal stent placement is a simple and safe alternative to surgical by-pass in gastric outlet obstruction (GOO) due to advanced gastro-duodenal and bilio-pancreatic cancer. In either biliary or gastro-duodenal malignant obstruction, double biliary and duodenal stenting placement is needed.

Aim of the study was to evaluate the efficacy of combined stenting, in one or two times, in biliary and gastro-duodenal obstruction.

Methods From February 2007 to August 2019, we collected data on self-expanding metal stent (SEMS) placement in malignant GOO, even in association to biliary stent placement for biliary obstruction. We evaluated technical success of combined stenting and early (< 24h) or late (>24h) complications.

Results A total of 122 patients (61.5%M) was treated with SEMS for GOO. 64/122 (52.5%) patients (36M) had also biliary involvement and needed biliary drainage: 59/64 (92.2%) were treated with biliary stent, 5/64 (7.8%) underwent Lumen-Apposing Metal Stent (LAMS) EUS-guided placement, using Hot-Axios (Boston Scientific). Among patients with concomitant biliary and duodenal malignant strictures, 38/64 (59.4%) underwent double stenting in the same procedure. Conversely in 26/64 (40.6%) patients, biliary and duodenal stents were placed in two times; usually biliary obstruction occurred early and was treated before the onset of symptomatic duodenal obstruction.

Duodenal SEMS were successfully placed in all patients. Technical success of double stenting was achieved in 63/64 patients (98.4%).

We observed 11/64 (17.2%) complications: 2 intra-procedural (1 deployment of LAMS, 1 iatrogenic duodenal perforation), 2 early (1 pancreatitis, 1 bleeding) and 7 late (2 outlet obstruction due to duodenal ingrowth and 5 cholangitis, due to biliary ingrowth or plugs).

Conclusions In a referral center for bilio-pancreatic diseases, the impact of bilio-duodenal malignant stricture is significant. Combined stenting of biliary and duodenal obstruction is an effective and minimally invasive procedure, alternative to surgery, with low complication rate, thus becoming the standard of palliative care in these patients.