Long-term palliation of combined malignant gastric outlet and biliary obstruction by using sequentially enteral stents and EUS-guided antegrade biliary and lumen-apposing gastrojejunal stents

Abstract

For unresectable advanced gastric malignancies causing malignant gastric outlet obstruction(GOO) and malignant biliary obstruction(MBO), traditional treatment methods include surgical gastrojejunostomy and hepatojejunostomy. However, surgical treatment is associated with many complications and prolonged recovery. We report a case of a 56-year-old male patient who complained of nausea and vomiting after meals for one month. Esophagogastroduodenoscopy(EGD) revealed a malignant gastric tumor, pyloric obstruction, and gastric retention. Abdominal CT revealed multiple liver metastases and distant lymph nodes metastases. Two duodenal stents were placed within two months to relieve the malignant GOO. Five months later, rapid tumor progression led torecurrent malignant GOO and involvement of the duodenum, resulting in MBO. Since endoscopic retrograde cholangiopancreatography(ERCP) was not feasible, we relieved the MBO through endoscopic ultrasound guided antegrade stenting (EUS-AS). One week later, GOO was treated with endoscopic ultrasound guided gastroenterostomy (EUS-GE). During the 6-month follow-up period, the patient experienced no recurrence of obstructive jaundice or gastric retention, and the treatment was effective. Endoscopic stent placement can relieve malignant double obstruction,with minimal complications and rapid recovery. Endoscopic interventions are repeatable and provide immediate and reliable clinical benefit.

PLAIN LANGUAGE SUMMARY

The purpose of this article is to report a rare case of relieving malignant double obstruction(biliary and gastric outlet obstruction) by placing four metal stents through gastroduodenoscopy and endoscopic ultrasound guided interventions. This case demonstrates that minimally endoscopic treatment, with a flexible and stepwise therapeutic strategy, can prolong survival and improve quality of life in patients with advanced malignancies.

HIGHLIGHTS

1. Endoscopic treatment is repeatable. When enteral stenting is ineffective, an additional duodenal stent can be placed or endoscopic ultrasound guided gastroenterostomy (EUS-GE) can be used.

2. Endoscopic treatment is minimally invasive, allows for rapid recovery, and is well-tolerated by patients, even without anesthesia.

3. Endoscopic ultrasound guided biliary drainage (EUS-BD) can also relieve obstructive jaundice when endoscopic retrograde cholangiopancreatography (ERCP) treatment is not feasible. The optimal treatment strategy should be selected according to the specific clinical situation.

1. Introduction

In cases of advanced gastric malignancies, gastric outlet obstruction(GOO) and malignant biliary obstruction(MBO) may occur. Malignant GOO can cause symptoms such as nausea, vomiting, abdominal pain, and weight loss, leading to severe malnutrition. Malignant biliary obstruction may result in obstructive jaundice and liver dysfunction. These conditions are often diagnosed at an advanced stage, thus limiting treatment options. Advances in endoscopic techniques have enabled minimally invasive management of these obstructions with lower complication rates than traditional surgical bypass procedures [1,2]. Traditional endoscopic treatment for malignant double obstruction involves endoscopic retrograde cholangiopancreatography (ERCP) combined with enteral stent placement, which often faces technical challenges and frequently requires multiple interventions [3]. Endoscopic ultrasound(EUS) guided interventions have emerged as important alternative therapeutic options [4–7]. The primary goals of treatment in malignant double obstruction are to relieve symptoms, improve quality of life, and enable continuation of systemic therapy such as chemotherapy. In this case report, we describe a patient with unresectable gastric cancer who developed both malignant GOO and MBO and was successfully treated using a stepwise minimally invasive endoscopic strategy involving four metal stents.

2. Case presentation

A 56-year-old male patient presented with nausea and vomiting after meals for one month. Esophagogastroduodenoscopy (EGD) revealed gastric adenocarcinoma, pyloric obstruction, and gastric retention (Figure 1). Abdominal CT demonstrated multiple distant lymph nodes metastasis and intrahepatic metastases, rendering the patient unsuitable for surgical treatment. To relieve GOO, an 18 × 80 mm uncovered self-expanding metal stent (Micro-Tech (Nanjing), Nanjing, China)was placed under fluoroscopic and endoscopic guidance (Figure 2).

Figure 1.

The esophagogastroduodenoscopy revealed gastric adenocarcinoma and malignant gastric outlet obstruction.

Figure 2.

An 18 × 80 mm uncovered self-expanding metal stent was placed under fluoroscopic visualization to relieve malignant gastric outlet obstruction.

Two months later, the patient developed recurrent symptoms of GOO despite onging chemotherapy. Therefore, a 22x90mm uncovered self-expanding metal stent was inserted within the original stent to relieve the obstruction, and the patient was subsequently able to eat soft diet (Figure 3).

Figure 3.

A 22x90mm uncovered self-expanding metal stent was placed in the original stent to relieve the pyloric obstructio.

After five months of regular chemotherapy, the patient was readmitted with jaundice and vomiting. Laboratory tests showed obstructive jaundice and severe anemia, with a total bilirubin level of 212.8 μmol/L and hemoglobin of 67 g/L. Coagulation, electrolyte, and creatinine levels were normal. Abdominal CT revealed biliary obstruction and dilation of the proximal common bile duct.At this time, EGD confirmed recurrent pyloric outflow obstruction. The duodenoscope was unable to pass through the narrowed segment, making ERCP impossible.Because urgent biliary drainage was required, endoscopic ultrasound-guided biliary drainage was performed. Under fluoroscopic and endoscopic ultrasound guidance, a 10 × 80 mm uncovered self-expanding metallic biliary stent was placed via the dilated left hepatic duct in an antegrade approach (Figure 4). The stent was located within the common bile duct, crossing the narrowed segment.

Figure 4.

Under fluoroscopic and endoscopic ultrasound guidance, a 10 × 80 mm uncovered self-expanding metallic biliary stent was placed via the dilated left hepatic duct.

One week later, the patient’s total bilirubin level returned to normal.To reduce the frequency of endoscopic treatments, EUS-GE was considered for the patient. A 15 mm × 10 mm stent and electrocautery-enhanced delivery system was deployed using EUS and fluoroscopic guidance (Figure 5). The patient resumed a liquid diet on the second day after the procedure. During the six-month follow-up period, no recurrence of gastric outlet or biliary obstruction was observed.

Figure 5.

A 15 mm × 10 mm stent and electrocautery-enhanced delivery system was deployed using fluoroscopic guidance.

3. Discussion

For unresectable malignant gastrointestinal tumors with concurrent biliary and gastric outlet obstruction, referral to a high-level endoscopy center can be considered. If possible, palliative placement of duodenal and biliary stents can be performed. Compared to surgical gastrojejunostomy and hepatojejunostomy, endoscopic treatment has a higher clinical success rate, shorter operation time, lower cost, and repeatability, making it suitable for palliative patients. This minimally invasive endoscopic treatment method helps patients begin chemotherapy as early as possible.

Patients with malignant GOO have a median survival of only 2 to 10 months, posing a significant challenge for physicians in choosing treatment options. Enteral stenting has proven to be a minimally invasive and effective method for treating malignant GOO, with a lower complication rate and shorter hospital stay, making it particularly suitable for patients who are not candidates for surgery [8]. However, over time, the growth of malignant tumor tissue can lead to stent blockage, resulting in a high luminal obstruction rate. One clinical study indicated that over half of the patients (59%) experienced recurrent moderate GOO after a median treatment duration of 28 days [9]. This case also followed a similar pattern.The patient experienced recurrent obstruction within two months after the initial duodenal stent placement. At this time, the patient was severely malnourished. Considering the patient’s tumor progression rate and survival time, and also for future ERCP procedures,we still used intestinal stent placement. Until five months later, the patient developed both malignant GOO and MBO.

There are many options for endoscopic procedures of malignant double obstruction disease. Different therapeutic combinations have significantly different outcomes.Vanella et al evaluated different combinations in a multicenter retrospective analysis,suggested that EUS-based approaches, particularly EUS-GE combined with biliary drainage techniques such as HGS, may provide more durable outcomes.However, limited sample size in each subgroup still poses challenges to selecting the optimal endoscopic treatment [10]. Endoscopic ultrasound-guided gastrojejunostomy was first reported by Khashab et al. [11]. EUS-GE combines the minimally invasive nature of endoscopic surgery with the lasting effectiveness of gastrojejunostomy [12–14]. According to two meta-analyses, EUS-GE achieved a technical success rate and a clinical success rate of 90% [15,16],which is comparable to the treatment effects of surgical procedures [17]. Therefore, after relieving the obstructive jaundice, we decisively chose EUS-GE for the patient. This treatment proved to be very effective.

Endoscopic ultrasound-guided biliary drainage techniques, including hepatogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS)[18,19], and antegrade stenting (EUS-AS) [20], have high technical and clinical success rates [21,22], and are particularly safe when ERCP is not feasible [23,24]. EUS-CDS showed reduced effectiveness and high risk in the context of GOO, especially when combined with ES. EUS-HGS carries a relatively high risk of stent migration [25].

Endoscopic treatment of bile duct and duodenal stricture is safe and effective, but its efficacy depends on the relationship between the location of the duodenal stricture and the ampulla of Vater.For distal MBO and Type I GOO,balloon dilation of the narrowed portion of the duodenum is usually required to allow the duodenoscope to pass through. Subsequent placement of self-expanding metal stents into the intestine and bile duct can then be performed [26,27]. Although ERCP is still the standard minimally invasive treatment for bile duct and duodenal strictures [28], in our case, two stents had been placed in the duodenum for dilation, and the duodenoscope was still unable to pass through the stricture to approach the papilla, ERCP was not feasible.Abdominal CT showed dilation of the left hepatic duct and proximal common bile duct. Endoscopic ultrasound guided antegrade stenting was decisively used to successfully pass the guidewire through the narrowed segment of the distal common bile duct and through the duodenal papilla to place a biliary metal stent in the common bile duct to relieve the obstruction.Endoscopic ultrasound guided biliary drainage requires a highly skilled endoscopist to perform,and complications include stent migration, reflux cholangitis, and biliary dysfunction [29].

It is noteworthy that EUS-guided gastroenterostomy might theoretically have been considered at the time of the initial gastric outlet obstruction. However, enteral stenting remains a widely used first-line palliative treatment due to its technical simplicity, rapid symptom relief, and broad availability. In our patient, enteral stenting initially provided satisfactory clinical improvement and enabled continuation of chemotherapy. With subsequent tumor progression leading to recurrent obstruction and concomitant malignant biliary obstruction, EUS-guided interventions became a more appropriate strategy. This case therefore illustrates how endoscopic techniques can be applied sequentially and flexibly according to disease evolution and clinical needs. Our case highlights the value of flexible and multidisciplinary endoscopic strategies in the palliative management of complex malignant obstruction.

4. Conclusions/learning points

In summary, endoscopic techniques play a critical role in management of complications such as malignant GOO and MBO in patients with unresectable gastrointestinal malignancies. Techniques including enteral stenting, EUS-GE, and EUS-BD can be used alone or in combination, and can be applied single or repeatedly, ultimately significantly improving the quality of life for patients through minimally invasive treatment. This case illustrates the importance of individualized and stepwise endoscopic management for patients with advanced malignancies. Different endoscopic techniques may play complementary roles and can be applied sequentially according to disease progression, anatomical conditions, the patient’s personal wishes,and therapeutic feasibility.

Author contributions

All coauthors of this paper participated in the research. Ye Han conceived and wrote the initial draft, while also collecting clinical case information and conducting a literature review. Jintao Guo and Siyu Sun completed the key steps of the endoscopic procedure. Siyu Sun supervised and rigorously reviewed the entire process of writing the paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Statement of compliance

We confirm that this manuscript adheres to the CARE checklist for case reports, and a completed checklist is provided as supplementary material.

Data availability statement

The data supporting the findings of this study are not publicly available due to patient privacy and ethical restrictions but are available from the corresponding author upon reasonable request.