Post written by Kevin D. Platt, MD, and Ryan J. Law, DO, from the Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA.

Our case describes a 59-year-old woman with metastatic ovarian cancer who presented with nausea with vomiting and jaundice secondary to a large mesenteric mass that was causing both gastric outlet and biliary obstruction. After a failed attempt at conventional ERCP, same session EUS-guided gastrojejunostomy using a LAMS and hepaticogastrostomy using a FCSEMS was performed, resulting in symptomatic improvement.

Our video suggests that same session EUS-guided gastrojejunostomy and hepaticogastrostomy is feasible for the management of combined gastric outlet and biliary obstruction in appropriately selected patients. EUS-gastrojejunostomy was performed first to minimize the risk of HGS stent dislodgement if performed in the opposite sequence. Several teaching points are demonstrated in this case. As mentioned, the EUS-gastrojejunostomy should be performed first. Secondly, consideration should be given to placement of a longer FCSEMS through the LAMS gastrojejunostomy in patients with ascites, as anecdotal evidence suggests they may be at risk for poor wound healing and delayed anastomotic dehiscence. Double-EUS-guided bypass should be considered for palliation in appropriate patients and may confer advantages over potential alternatives. Most importantly, this approach avoids the need for surgery, avoids percutaneous drains, and mitigates the risk of recurrent luminal obstruction seen with enteral stenting.

First and foremost, endoscopists should be aware that combination procedures can be considered in the same endoscopic session for select patients with biliary and luminal obstruction. In patients with ascites, endoscopists may consider placement of a co-axial self-expanding esophageal stent through the LAMS gastrojejunostomy to mitigate the risk of postprocedure leaks or anastomotic dehiscence.

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