Single session endoscopic ultrasound‐guided double bypass (hepaticogastrostomy and gastrojejunostomy) for concomitant duodenal and biliary obstruction: A case series

Abstract

Background Concomitant malignant biliary and gastric outlet obstruction can be difficult to manage endoscopically with traditional endoscopic retrograde cholangiopancreatography (ERCP) and luminal stenting. Endoscopic ultrasound (EUS)‐guided hepaticogastrostomy (HG) and gastrojejunostomy (GJ) are novel techniques that can relieve both obstructions in a single session. This study aims to describe the outcomes of combined, single session EUS‐HG and EUS‐GJ. Methods This is a two‐center retrospective study of consecutive patients who underwent same session EUS‐HG and EUS‐GJ. The primary outcome was technical success. Secondary outcomes included adverse events (AE), reduction in total serum bilirubin, length of hospital stay (LOS), and re‐intervention rates. Results A total of 23 patients underwent EUS‐HG and EUS‐GJ (12 males, mean age 66.4 years). Twenty‐one were performed for malignant obstruction. Technical success was 100% and 95.6% for HG and GJ, respectively. All patients subsequently tolerated a soft diet and 72.7% (16/22) of patients had a 50% reduction in bilirubin post‐procedure. The median LOS for the 17 patients who were not discharged home immediately following the procedure was 2 (range 1‐20) days. There were five AEs (2 mild, 3 moderate). Only three patients required reintervention (interventional radiology‐guided biliary drainage, stent exchange for a benign biliary stricture, and placement of a second stent through an occluded distal common bile duct stent) over a median follow‐up of 78 days. One patient with pancreatic cancer underwent successful tumor resection. Conclusion Single session EUS‐guided double bypass (HG and GJ) is technically feasible and safe when conducted by experienced endosonographers. Larger, comparative studies are needed.

Combined endoscopic mAnagement of BiliaRy and gastrIc OutLET obstruction (CABRIOLET Study): A multicenter retrospective analysis

“…EUS has revolutionized the endoscopic management of simultaneous biliary and GOO. However, limited non‐comparative series have mainly evaluated either individual procedures or single specific combinations in double obstruction 9–12 . Our study offers some insight on the risk of dysfunction of different combinations used in the management of double obstruction in three tertiary referral centers.…”

“…The rate of AEs was 21% (no severe or fatal AE), whilst 13% required biliary re-interventions. 12 A recent meta-analysis suggested that EUS-CDS reduced the risk of reinterventions compared to EUS-HGS. 31 However, our findings suggest that choledochoduodenostomy drainage might be compromised in the context of a double obstruction.…”

“…Despite this potential interplay, the combined management of double obstruction has not been deeply analyzed, with only a small series describing specific combinations. 9 , 10 , 11 , 12 …”

“…Despite this potential interplay, the combined management of double obstruction has not been deeply analyzed, with only a small series describing specific combinations. [9][10][11][12] The aim of this study was to analyze and compare the outcomes of different procedure combinations aimed at treating double obstruction.…”

Endoscopic palliation of malignant biliary obstruction

“…In this study, the endoscopist preferred HGS over CDS to decrease the risk of bleeding, stent misdeployment and potential making pancreatic surgical resection more difficult[ 67 , 97 ]. Of note, a study of 23 patients with concomitant duodenal and biliary obstruction undergoing single session EUS-HGS and gastrojejunostomy found that one patient with pancreatic cancer underwent successful pancreaticoduodenectomy 168 days post-biliary drainage and the fistula remained in situ with no complications[ 98 ]. On the other hand, in a large multicenter study comparing HGS ( n = 24 ) to CDS ( n = 23), the authors preferred CDS as it takes advantage of the anatomical proximity between the duodenal bulb and extrahepatic duct, by which puncture can be easier with shorter procedure times and less guidewire manipulation[ 85 ].…”