Endoscopic “double stenting” has been the standard palliative therapy for patients with malignant gastric outlet obstruction (GOO) and coexisting malignant biliary obstruction (MBO). Duodenal stent placement with overlap of the ampulla is often unavoidable in patients whose GOO is at, or near, the biliary orifice. In this video (Video 1, available online at www.VideoGIE.org), we describe a novel case in which a lumen-apposing metal stent (LAMS) was used for the management of GOO but without overlapping the concomitantly placed biliary stent.
A 59-year-old man with newly diagnosed metastatic pancreatic cancer was referred for endoscopic treatment of GOO and MBO. Endoscopy revealed a severe type I stricture (Fig. 1A). This was traversed with the duodenoscope after gradual dilation of the stricture to 18 mm (Figs. 1B and 1C). Prior indwelling plastic biliary stents were successfully removed. ERCP revealed a distal MBO, which was adequately treated with placement of an uncovered metal biliary stent (10 mm × 60 mm) (Fig. 1D). The short malignant duodenal stricture was noted to be immediately proximal to the ampulla; therefore, placement of a conventional tubular duodenal stent would have inevitably overlapped the biliary stent. A LAMS (10 mm × 15 mm) was used instead, with successful restoration of luminal patency and without hindering the biliary stent (Figs. 1E and 1F). The patient was able to advance his diet and remained asymptomatic at a follow-up visit 3 weeks after the intervention.
Figure 1.
A, Endoscopic view of malignant gastric outlet obstruction. B, C, Endoscopic balloon dilation of duodenal stricture under endoscopic (B) and fluoroscopic (C) guidance. D, Endoscopic placement of uncovered self-expandable metal stent across the malignant distal biliary stricture. E, F, Endoscopic (E) and fluoroscopic (F) images of lumen-apposing stent (arrows) immediately proximal to the distal end of the newly placed biliary stent.
Recent studies have alluded to the safety and efficacy of LAMSs for the management of short benign GI strictures. In this case, the LAMS allowed successful treatment of a short malignant duodenal stricture without overlapping the biliary stent, potentially facilitating future biliary re-intervention if indicated. Future studies are needed to evaluate the potential role of LAMSs for the management of short malignant GI strictures.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
Footnotes
Written transcript of the video audio is available online at www.VideoGIE.org.
Supplementary data
Placement of a lumen-apposing metal stent for a short malignant duodenal stricture.
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Supplementary Materials
Placement of a lumen-apposing metal stent for a short malignant duodenal stricture.