Table 1.

Classification based on location of malignant stricture in concurrent malignant biliary obstruction (MBO) and gastric outlet obstruction (MGOO) and treatment suggestions. Modified from [14].

Treatment Suggestion	Description	Classification
♦Transpapillary stenting (ERCP) is possible if the scope can pass the duodenal obstruction or the duodenal stent ♦EUS-guided antegrade (AG) stent placement is preferred over EUS-guided transmural stenting ♦Duodenal stenting/EUS-GEA	GOO occurs at the level of the duodenal bulb or upper duodenal genu, but without involvement of the papilla	Type 1
♦Double stenting is technically possible by adding a duodenal stent if an indwelling biliary stent is present ♦ In cases with the ampulla overlapped by a duodenal stent, there are some techniques for biliary access: ○ In cases with an indwelling duodenal stent, biliary access can be achieved by the rendezvous technique, either EUS or PTBD-guidance ○ Simultaneous double stenting with the temporary plastic biliary stent placement technique ♦Placement of a duodenal stent followed by a transpapillary biliary stent through the duodenal stent (to enable future reinterventions for biliary stent occlusion) ♦EUS-CDS and EUS-GEA ♦EUS-HGS and duodenal stenting/EUS-GEA	GOO affects the second part of the duodenum, with involvement of the papilla.	Type 2
♦Transpapillary stenting including both ERCP and EUS-guided antegrade stenting is possible but prone to duodenobiliary reflux ♦EUS-CDS and duodenal stenting/EUS-GEA ♦EUS-HGS and duodenal stenting/EUS-GEA	GOO involves the third part of the duodenum, distal to and without involvement of the papilla.	Type 3

MBO = malignant biliary obstruction; ERCP = endoscopic retrograde cholangiopancreatography; MGOO = malignant gastric outlet obstruction; EUS-CDS = endoscopic ultrasound choledocoduodenostomy; PTBD = percutaneous transhepatic biliary drainage; EUS-HGS = endoscopic ultrasound hepaticogastrostomy.