343 Bilateral Metal Stent ERCP Through an Endoscopic Ultrasound-Guided Gastrojejunal Lumen-Apposing Stent

Abstract

INTRODUCTION: ERCP in patients with altered anatomy due to malignant obstruction is consistently a challenge. EUS-guided gastroenterostomy using lumen-apposing metal stents (LAMS) have been shown to be effective and safe for the relief of gastric and intestinal obstruction. We report a successful case of ERCP performed through a recently placed EUS-guided Gastroenterostomy in a patient with both malignant biliary and gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 64-year-old male with a history of metastatic gallbladder cancer status-post placement of an internal-external biliary drain and percutaneous cholecystostomy was admitted to our institution with nausea, vomiting, and jaundice with concern for gastric outlet obstruction and worsening biliary obstruction on CT imaging. To relieve the gastric outlet obstruction, the decision was made to perform EUS guided gastroenterostomy with a LAMS using the “double-scope method.” An ultraslim upper endoscope traversed the stricture into the second portion of the duodenum. Water filling of the intestinal lumen was achieved with this scope while a therapeutic linear echoendoscope was simultaneously passed through the mouth into the stomach and visualized the water-distended distal duodenum and proximal jejunum. EUS-guided gastroenterostomy was performed using a 15 mm electrocautery enhanced LAMS. Balloon dilation of the stent lumen up to 15 mm was performed. The patient enjoyed a regular diet that evening. On the next day, ERCP was performed. A double channel therapeutic endoscope was advanced into the duodenum through the LAMS and bilateral metal stenting of the right and left biliary systems was performed. On follow-up, patient was able to tolerate a regular diet and jaundice improved DISCUSSION: In this case, we successfully performed bilateral metal stent placement ERCP via EUS-guided gastroenterostomy to relieve gastric outlet obstruction and biliary obstruction. The diameter of the lumen apposing metallic stent was sufficient to insert a double-channel therapeutic scope, which facilitated bilateral metal stenting. Of note, care must be taken when performing endoscopic procedures through a newly created gastrenterostomy. Watch the video: http://bit.ly/2SwvkHG