World Congress of Gastroenterology

WCOG 2019


 
EUS-GUIDED CHOLEDOCHODUODENOSTOMY AND EUS-GUIDED GASTROJEJUNOSTOMY IN A PATIENT WITH COMBINED MALIGNANT BILIARY AND GASTRIC OUTLET OBSTRUCTION
GOKUL BOLLU JANAKAN 1 CHANDRASEKAR THOGULUVA SESHADRI 1 RAJA YOGESH KALAMEGAM 1 SATHIAMOORTHY SURIYANARAYANAN 1 SABARINATHAN RAMANATHAN 1 PRASAD MENTA SANJEEVARAYA 1 VIVEKSANDEEP THOGULUVA CHANDRASEKAR 2

1- MEDINDIA HOSPITALS
2- UNIVERSITY OF KANSAS SCHOOL OF MEDICINE
 
Abstract:

Endoscopic palliation is preferred to surgery in patients with combined biliary and gastric outlet obstruction due to the poor prognosis and to avoid the morbidity associated with surgery. Here we report a case with combined biliary and gastric outlet obstruction successfully managed with Endoscopic ultrasonography (EUS) guided biliary drainage followed by a EUS-guided gastrojejunostomy to palliate obstructive jaundice and vomiting respectively.

Forty-one-year-old male presented with epigastric pain, vomiting and significant loss of weight. On CT imaging a large (12 x 10 cm) heterogeneously enhancing mass lesion was noted involving the pancreatic head, 2nd and 3rd parts of the duodenum with distal bile duct obstruction and invasion of the superior mesenteric vein, portal vein and inferior vena cava. At endoscopy, an obstructing proliferative growth involving the first and second parts of the duodenum was noted biopsy from which revealed poorly differentiated adenocarcinoma.  Blood investigations showed low haemoglobin (7.8 gm/dL), elevated bilirubin and alkaline phosphatase and CA 19-9 of 36.27 U/mL. Since there was a combined biliary and gastric outlet obstruction, a EUS-guided choledochoduodenostomy (CDS) and EUS-guided gastrojejunostomy (GJ) was planned (See video). An 8 cm partially covered biliary metallic stent was deployed through the duodenal bulb under EUS guidance, following which a nasobiliary drainage catheter was placed across the obstructing growth into the jejunum under combined endoscopic and fluoroscopic guidance. After distending the jejunum with methylene blue stained saline, direct puncture of the jejunum was done using electrocautery enabled lumen apposing metallic stent (LAMS) under EUS guidance and a GJ was created. A relook endoscopy revealed fully expanded metallic stents in the posterior wall of the stomach (EUS-GJ) and in the duodenum (EUS-CDS). Following these procedures his bilirubin started decreasing and he was able to tolerate soft diet without vomiting. He was doing well at one-month follow-up.

EUS-CDS is a welcome alternative to percutaneous biliary drainage in cases of failed ERCP. Recurrent obstruction and the need for re-intervention is significantly less with EUS GJ compared to enteral stenting as the former is performed proximal to the stricture and the latter, through the stricture.

Keywords:

EUS GUIDED CHOLEDOCHODUODENOSTOMY AND GASTROJEJUNOSTOMY 

 

KEYWORDS: Combined biliary and gastric outlet obstruction, EUS-guided choledochoduodenostomy, EUS-guided gastrojejunostomy.