Post written by William F. Abel, MD, from Carilion Clinic, Virginia Tech, Roanoke, Virginia, USA.

Concomitant gastric outlet and biliary obstruction presents a unique challenge, as severe underlying illness often limits surgical treatment options. Our study details an observational experience to both relieve the gastric outlet obstruction and allow for biliary stenting as well as anticipated future exchange using EUS-directed transduodenal ERCP.

Complex problems can be an excellent inspiration for creative solutions. In principle, a lumen-apposing metal stent (LAMS) traversed by a therapeutic endoscope has already been demonstrated with the EUS-directed transgastric ERCP procedure.

The difference in our population is that the fistula maintained by the LAMS is meant to remain in place for an extended period, as it offers a therapeutic benefit in and of itself. In addition, many of these patients had obstructive etiologies such as malignancy or chronic pancreatitis that were not expected to resolve and would thus require repeated ERCPs with stent exchange using the LAMS as a conduit to reach the papilla.

Our retrospective study showed excellent results with 100% technical and clinical success. The EUS-directed transduodenal ERCP procedure provides an elegant solution to concomitant obstruction in patients with retained biliary metal stents or anticipated future needs for stent exchange. With the LAMS remaining patent and intact for well over 1 year in multiple patients, this adds to the literature regarding the longevity and durability of these stents.

A, Artist’s representation of antegrade EUS-guided gastroduodenostomy. Notably, water insufflation is just proximal to the ligament of Treitz. B, Fluoroscopic view of EUS-directed transduodenal ERCP in progress, with the lumen-apposing metal stent indicated by an arrow.

Read the full article online.

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