
==== Front
Endosc Ultrasound
Endosc Ultrasound
EUSJ
Endoscopic Ultrasound
2303-9027
2226-7190
Lippincott Williams & Wilkins

EUSJ_240076
10.1097/eus.0000000000000075
00009
3
Images and Videos
Double EUS-guided bypass for gastric outlet and biliary tract malignant obstruction: A standardized one-step approach (with videos)
de Oliveira Victor Lira victorlira.oliveira@gmail.com
1
dos Santos Marcos Eduardo Lera marcoslera@gmail.com
1
Boghossian Mateus Bond matbogho@gmail.com
1
de Freitas Júnior João Remí junior_de_freitas@hotmail.com
1
Lemos Pires Pereira Maria Luíza 2 ∗
Turiani Carolina Vaz carolinaturiani@gmail.com
3
de Moura Eduardo Guimarães Hourneaux eduardoghdemoura@gmail.com
1
1 Gastrointestinal Endoscopy Unit—Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil
2 Gastrointestinal Surgery Unit—Hospital dos Servidores do Estado de Pernambuco, Recife, PE, Brazil
3 Gastrointestinal Surgery Unit—Associação Beneficência Portuguesa de São Paulo, SP, Brazil.
∗ Address for correspondence: Av. Conselheiro Rosa e Silva, s/n—Espinheiro, Recife, PE 52020-020, Brazil. E-mail: marialuizalemosp@gmail.com (M.L. Lemos Pires Pereira).
Jul-Aug 2024
20 8 2024
13 4 271272
13 12 2023
27 5 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc on behalf of Scholar Media Publishing.
2024
Wolters Kluwer on behalf of Scholar Media Publishing.
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

OPEN-ACCESSTRUE
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pmcVarious malignant conditions, including gastric cancer, periampullary neoplasms, and pancreatobiliary tumors, can result in concurrent biliary tract and gastric outlet obstruction (GOO). Nowadays, less invasive approaches such as duodenal stenting and transpapillary drainage via endoscopic retrograde cholangiopancreatography are preferred over surgical treatment.[1,2]

EUS–guided therapies, specifically EUS-guided gastroenterostomy (EUS-GE) and EUS-guided biliary drainage (EUS-BD), are valuable alternatives. They offer higher success rates and fewer stent-related issues, particularly in challenging cases where traditional methods may exhibit decreased efficacy.[3,4]

Two video-documented cases showcase combined EUS-guided bypass procedures for gastric outlet obstruction (GOO) and biliary tract obstruction, illustrating the basic principles of the technique (Videos 1 and 2).

A 64-year-old woman presented with jaundice, weight loss, abdominal discomfort, and vomiting over 2 months. Laboratory tests showed elevated bilirubin and anemia without infectious signs. Further examinations, including esophagogastroduodenoscopy and abdominal CT scan, revealed duodenal deformation and a pancreatic head mass measuring 6 × 5 × 4 cm, involving the celiac trunk. EUS-guided biopsies confirmed pancreatic ductal adenocarcinoma. Due to the challenging duodenal stenosis, a successful combined EUS-guided gastroenterostomy (EUS-GE) and choledocoduodenostomy was performed [Figure 1]. The patient was discharged on day 3, transitioning from a liquid to a soft diet at home. At the 30-day follow-up, she showed resolution of symptoms.

Figure 1 Intraprocedural images. A, Fluoroscopic confirmation of EUS-gastroenterostomy LAMS positioning with contrast injection. B, Endoscopic view of EUS-guided cholecystogastrostomy LAMS with satisfactory bile outflow. LAMS: Lumen-apposing metal stent.

In the second case, a 59-year-old woman, previously treated for metastatic breast cancer, developed GOO and jaundice 6 years later. Abdominal magnetic resonance imaging revealed infiltrative tissue in the common bile duct and duodenum, leading to dilation of the stomach and biliary tract [Figure 2]. A double EUS-guided bypass, combining EUS-GE and cholecystogastric EUS-guided anastomosis, was performed due to a more favorable gallbladder disposition [Figure 3]. Postprocedure, she transitioned to a soft diet and was discharged on day 7. At the 90-day follow-up, she maintained a soft diet without obstructive symptoms.

Figure 2 Preprocedural MRI. A, Gastric distention and dilation of intrahepatic bile ducts. B, Dilation of main pancreatic duct. MRI: Magnetic resonance imaging.

Figure 3 Postprocedural CT scan. A, Tomographic imaging EUS-guided cholecystogastrostomy with LAMS in adequate position. B, Tomographic imaging of EUS-guided gastroenterostomy with LAMS in adequate position. CT: Computed tomography; LAMS: Lumen-apposing metal stent.

Combined EUS-guided biliary drainage (EUS-BD) and EUS-guided gastroenterostomy (EUS-GE) in a single session is an advanced approach for symptom relief in palliative patients with advanced oncologic diseases, and the initial performance of EUS-BD does not seem to increase the risks for subsequent EUS-GE. The advent of cautery-enhanced lumen-apposing metal stent (LAMS) streamlines the procedure and enhances reproducibility, allowing a safe freehand approach with high success rates when basic principles of therapeutic echoendoscopy and EUS-guided drainages are followed.

Declaration of Patient Consent

Informed consent was obtained from all individual participants included in the study, following the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Source of Funding

None

Ethical Approval

All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and in compliance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Conflict of Interest

EGHM and MELS receives sponsorship for consultancy from Boston Scientific and Olympus. All the other authors declare no conflicts of interest.

Author Contributions

All authors contributed to the study conception and design. VLO, MELS, MBB, JRFJ, and EGHM performed material preparation, data collection, and analysis. The draft of the manuscript was written by VLO, MLLPP, and CVT, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Published online: 20 August 2024
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