Endoscopic Double Stenting for the Management of Combined Malignant Biliary and Duodenal Obstruction

Abstract

Periampullary cancers are often diagnosed at advanced stages and can cause both biliary and duodenal obstruction. As these two obstructions reduce patients’ performance status and quality of life, appropriate management of the disease is important. Combined malignant biliary and duodenal obstruction is classified according to the location and timing of the duodenal obstruction, which also affect treatment options. Traditionally, surgical bypass (gastrojejunostomy and hepaticojejunostomy) has been performed for the treatment of unresectable periampullary cancer. However, it has recently been substituted by less invasive endoscopic procedures due to its high morbidity and mortality. Thus, endoscopic double stenting (transpapillary stenting and enteral stenting) has become the current standard of care. Limitations of transpapillary stenting include its technical difficulty and the risk of duodenal-biliary reflux. Recently, endoscopic ultrasound-guided procedures have emerged as a novel platform and have been increasingly utilized in the management of biliary and duodenal obstruction. As the prognosis of periampullary cancer has improved due to recent advances in chemotherapy, treatment strategies for biliary and duodenal obstruction are becoming more important. In this article, we review the treatment strategies for combined malignant biliary and duodenal obstruction based on the latest evidence.

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting

“…In patients with combined malignant duodenal and biliary obstruction, “double stenting” should be the standard of care practice, due to its lower invasiveness and shorter recovery time [ 104 ]. Regarding approach for biliary stenting, endoscopic retrograde cholangiopancreatography stenting might be associated with a lower AE rate compared to EUS-guided biliary drainage and should be considered the preferred approach, when feasible [ 105 ].…”

Long‐term outcomes of endoscopic double stenting using an anti‐reflux metal stent for combined malignant biliary and duodenal obstruction

“…Combined malignant biliary and duodenal obstruction is difficult to manage endoscopically. 4 Previously, endoscopic double stenting with conventional biliary covered self-expandable metal stents (SEMS) and duodenal SEMS was performed. 5 However, early biliary stent dysfunction due to duodeno-biliary reflux were difficult to manage.…”

Clinical Advances in the Diagnosis and Treatment of Biliary Tract Diseases

“…Traditionally, transpapillary biliary drainage with ERCP and duodenal stenting have been used, but the technical difficulty of transpapillary drainage and duodenobiliary reflux have been a problem. Recently, EUS-guided novel methods such as EUS-BD- and EUS-guided gastrojejunostomy (EUS-GJ) for duodenal drainage have been developed; moreover, new metal stents, such as an anti-reflux metal stent (ARMS) and lumen-apposing metal stent (LAMS), have been developed, which are expected to provide better treatment results [ 6 ].…”