Endoscopic management of combined malignant biliary and gastric outlet obstruction

Abstract

Patients with periampullary cancer or gastric cancer often develop malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), and combined MBO and GOO is not rare in these patients. Combined MBO and GOO is classified by its location and sequence, and treatment strategy can be affected by this classification. Historically, palliative surgery, hepaticojejunostomy and gastrojejunostomy were carried out, but the current standard treatment is combined transpapillary stent and duodenal stent placement. Although a high technical success rate is reported, the procedure can be technically difficult and duodenobiliary reflux with subsequent cholangitis is common after double stenting. Recent development of endoscopic ultrasound (EUS)-guided procedures enables the management of MBO as well as GOO under EUS guidance. EUS-guided biliary drainage is now increasingly reported as an alternative to percutaneous transhepatic biliary drainage in failed endoscopic retrograde cholangiopancreatography (ERCP), and GOO is one of the major reasons for failed ERCP. In addition to EUS-guided biliary drainage, the feasibility of EUS-guided double-balloon-occluded gastrojejunostomy bypass for MBO was recently reported, and EUS-guided double stenting can potentially become the treatment of choice in the future. However, as each procedure has its advantages and disadvantages, treatment strategy should be selected based on the type of obstruction and the prognosis and performance status of the patient.

Moving away from the tumor zone: A work in progress

“…This thought‐provoking and timely review by Nakai et al . coincides with the rapid progress made in interventional endoscopy in the past decade adapting EUS‐guided interventions.…”

“…In this issue of the Journal, Nakai et al . propose an algorithmic endoscopic approach for the treatment of patients presenting with combined MBO and GOO adapting cutting‐edge techniques, some of which are still in evolution.…”

Covered duodenal self‐expandable metal stents prolong biliary stent patency in double stenting: The largest series of bilioduodenal obstruction

“…Strictures were sorted into three groups according to the location of the duodenal stricture in relation to the papilla: Duodenal stenosis was located before and without involvement of the papilla (type I), duodenal stenosis involved the papilla (type II), and duodenal stenosis was located distal to and without involvement of the papilla (type III). The patients were also divided into three groups according to the timing of the obstruction: biliary obstruction before duodenal obstruction (group 1), biliary obstruction and duodenal obstruction occurring concurrently (group 2), and biliary obstruction after duodenal obstruction (group 3) (Table S1) . The presence of ascites/liver metastasis/peritoneal dissemination was evaluated according to computed tomography before double SEMS placement.…”

Successful treatment for infected biloma after endoscopic ultrasound-guided hepaticogastrostomy using double stent placement technique

“…is now a well established procedure [1] . However, EUS-guided biliary drainage (EUS-BD) procedures have possibility of several adverse events such as stent migration or bile leakage.…”