To the Editor:
In December, the video case report by Kevin D. Platt et al1 was published online, describing the successful EUS-guided palliation of a metastatic ovarian cancer with biliary and duodenal obstruction. We agree with the authors that simultaneous creation of a double EUS bypass is feasible, and we think that this is a crucial addition to the endoscopic armamentarium in patients with a bifocal stenosis.2,3 In the current case report, the authors mention performing the EUS-guided gastrojejunostomy (EUS-GJ) first, followed by the EUS-guided hepaticogastrostomy. In our opinion, aside from preventing EUS-guided hepaticogastrostomy dislodgement after EUS-GJ, there are 2 other important reasons to perform these procedures in the described order.
Recently, we assessed the use of EUS-guided biliary drainage in the context of failed ERCP and postsurgical anatomy.4 This series included 9 patients in whom a double EUS bypass was performed. Analysis of these procedures revealed that in 6 of 9 combined procedures, significant contrast extravasation or free air surrounding the stomach was seen after successful intrahepatic biliary drainage,4 which may compromise visualization during EUS-GJ. Furthermore, in situations where biliary drainage has been performed first, additional insufflation of CO2 during EUS endoscope insertion or while placing a nasojejunal catheter in preparation for EUS-GJ will keep the transgastric tract patent. This may allow for gas to egress into the peritoneal cavity, resulting in a capnoperitoneum with the potential of significantly complicating subsequent EUS-GJ. However, the most compelling reason to perform EUS-GJ first is the fact that successful EUS-guided biliary drainage is dependent on a functioning gastrojejunal transit. If creation of an EUS-GJ is not possible, EUS-guided biliary drainage is futile and will only result in cholangitis.
In summary, we concur that the development of EUS-guided double bypass procedures has evolved as a potentially crucial step forward in the management of patients with both gastroduodenal and biliary stenosis. Furthermore, we strongly recommend that EUS-GJ be performed first, followed by EUS-guided biliary drainage, albeit for reasons other than those stated by the current authors.
Disclosure
All authors disclosed no financial relationships.
References
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