Ryan Law, DO, from Northwestern University, Feinberg School of Medicine, in Chicago, Illinois, USA presents this video case “Cholecystoduodenostomy and duodenal stenting for relief of biliary and gastric outlet obstruction.”
Our case describes the placement of a lumen-apposing stent into the gallbladder followed by placement of an uncovered metal duodenal stent for palliation in a 60-year-old man with biliary obstruction and gastric outlet obstruction secondary to widely metastatic pancreatic adenocarcinoma. Initially, a forward-viewing echoendoscope was used to puncture the gallbladder and allow placement of the lumen-apposing stent for creation of the cholecystoduodenostomy for biliary drainage. Next, a standard endoscope and biliary accessories were used to cannulate the duodenal stricture alongside the lumen apposing stent and place a self-expandable metal duodenal stent. The patient had clinical improvement with normalization of his liver tests and was able to tolerate a soft diet.
The clinical situation described above is not at all uncommon in patients with advanced pancreas cancer. Endoscopic biliary drainage via ERCP can be challenging in the setting of a concurrent gastric outlet obstruction (i.e. inability to pass the duodenoscope, difficulty finding the papillary orifice), often resulting in the need for advanced intervention (i.e. biliary rendezvous) or percutaneous biliary drainage. The lumen-apposing stent has provided a new avenue for endoscopic drainage in scenarios such as this. However, placement of a lumen-apposing stent into the duodenum may occupy the intestinal lumen leading to difficulty in placement of a duodenal stent. Our case demonstrates a successful solution to the clinical challenge encountered in this patient.
This technique may be successful in patients with similar concurrent biliary and gastric outlet obstruction. It should be noted that cystic duct patency is necessary to ensure the cholecystoduodenostomy will provide durable biliary drainage.
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