Pancreatic and duodenal masses can result in both biliary and duodenal obstruction that makes their treatment challenging. In this video we present an 84-year-old man with a mass causing biliary and duodenal obstruction manifested as anorexia, weight loss, and jaundice. He was not a surgical candidate and so endoscopic management was pursued. To relieve his biliary obstruction, endoscopic retrograde cholangiopancreatography was first attempted but was not successful because the papilla could not be accessed. In addition, a wire was unable to pass the papilla for an EUS-guided rendezvous procedure. We then created an endoscopic choledochoduodenostomy under EUS and fluoroscopic guidance, using a lumen-apposing metal stent. To avoid sump syndrome, we placed a double-pigtail plastic stent within the metal stent. To treat the luminal stenosis, enteral stent placement was attempted; however, our wire was unable to pass the stricture in the duodenum. Instead, we created an endoscopic gastrojejunostomy by directly using an electrocautery-enhanced lumen-apposing metal stent without initial needle or wire access. The patient did well, was comfortable, had a bowel movement the next morning, and wanted to eat. He was advanced to clears and discharged from the hospital.
Supplementary Material
Video 1. For patients with duodenal and biliary obstruction, who are poor surgical candidates, single-session endoscopic choledochoduodenostomy and gastrojejunostomy is a viable management strategy
Figure 1.
A duodenal obstruction engulfing the papilla A, did not allow successful endoscopic retrograde cholangiopancreatography, EUS-guided rendezvous procedure, and enteral stent placement. B, Endoscopic choledochoduodenostomy was successfully completed to relieve the biliary obstruction. Arrow points to the lumen apposing stent; arrowheads point to a plastic pigtail stent. C, An endoscopic gastrojejunostomy was successfully completed to treat the duodenal obstruction. Arrows point to the electrocautery-enhanced lumen-apposing metal stent.
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Supplementary Materials
Video 1. For patients with duodenal and biliary obstruction, who are poor surgical candidates, single-session endoscopic choledochoduodenostomy and gastrojejunostomy is a viable management strategy