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 2nd 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.
