| Caso do mês - janeiro 2024 | Case of the month - january 2024

Everything, everywhere, all at once!

Joana Revés¹, Bárbara Morão¹, Catarina Fidalgo¹, Luísa Glória¹, Rui Loureiro^1
1 Serviço de Gastrenterologia, Hospital Beatriz Ângelo, Loures, Portugal

Description

A 69-year-old previously healthy woman presented to the emergency department with a one-week history of dark urine, nausea, pale stools, back pain, and early satiety with bloating and vomiting. Physical examination revealed jaundice without abdominal pain. Blood tests demonstrated significantly elevated bilirubin levels (total 7.6mg/dL, conjugated 5.8mg/dL) and abnormal liver enzymes. Imaging revealed a pancreatic head neoplasm, with duodenum invasion and involvement of the gastro-duodenal artery, with multiple liver metastases, staged as a cT2N1M1 (Figure 1). After multidisciplinary discussion, palliative chemotherapy was recommended due to the irresectable nature of the lesion preceded by biliary drainage.

                                                                                         Figure 1. Common bile duct dilation upstream to the pancreatic head neoplasia

An initial attempt of an ERCP was hindered by a duodenal stricture due to neoplastic infiltration that limited the access to the papilla. A subsequent evaluation was proposed using endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) and due to the worsening of the gastric outlet obstructive symptoms, a combined EUS-guided digestive palliation was proposed. A linear echoendoscope was used, with identification of the common bile duct (CBD) with significant dilation (15mm) where an EUS-choledocoduodenostomy (EUS-CD) was performed using a lumen-apposing metal stent (LAMS) of 6x8mm with an electrocautery delivery system (Figure 2). 

Figure 2. Endoscopic ultrasound choledocoduodenostomy – EUS-CD (a. endoscopic ultrasound placement of the cautery-enhanced LAMS; b. endoscopic view of the LAMS)

To prevent LAMS's biliary wall compression, a coaxial double-pigtail plastic stent 4cmx7Fr was placed. Then, a 10Fr nasobiliary catheter was placed in the jejunum immediately distal to the stenosis and just beyond the ligament of Treitz. A mixture of methylene blue and diluted contrast was administered to distend the small bowel loop. An EUS-gastroenterostomy (EUS-GE) was performed using a cautery-enhanced LAMS of 20x10mm. Successful passage of the methylene blue from the jejunal loop to the gastric lumen was seen. The post-procedural recovery was uneventful, with a decline in bilirubin levels and resumption of diet (Figure 3).

Figure 3. Radiological view of both EUS-CD and EUS-GE the day after the procedure (a. EUS-CD; b. EUS-GE).

Discussion

This complex EUS-guided approach targeting both biliary and digestive obstructions is seldomly reported in the literature.^1-4 Traditionally, failed ERCP biliary drainage cases resorted to percutaneous transhepatic biliary drainage (PTBD), associated with more frequent adverse events and reduced quality of life. Different EUS-BD approaches have emerged in this setting, including rendezvous (limited to cases where the papilla can be reached), antegrade stenting (through transhepatic internal stenting with limited technical success), or the preferable transluminal approaches (hepaticogastrostomy–EUS-HG or EUS-CD).⁵ EUS-HG and EUS-CD seem to have comparable success rates and adverse events, with EUS-CD demonstrating superiority in procedure time and recurrent biliary obstruction but potentially interfering with future surgical interventions.^5,6 Malignant gastric outlet obstruction was historically managed with a surgical gastrojejunostomy (associated with high morbidity) or placement of an enteral stent (limited by recurrent obstruction). The emergence of EUS-GE with larger stents (LAMS 20mm) offers a minimally invasive and effective alternative. This method, when conducted by a skilled endoscopist, proves beneficial for patients expected to live more than 3 months and without ascites. Notably, it stands as a promising option, particularly for those scheduled for EUS-BD.5 While guidelines advocate EUS-BD post unsuccessful ERCP and EUS-GE as an alternative to enteral stenting or surgery, there are no current recommendations for a combined approach.⁷ This case underscores therapeutic EUS's advantage in handling intricate dual obstructions.

REFERENCES
1. Qatomah A, Nawawi A, Bessissow A, Barkun J, Miller C, Chen YI. Endoscopic ultrasound-guided gastrojejunostomy and choledochoduodenostomy with lumen-apposing metal stents: an efficient approach to double endoscopic bypass. Endoscopy. Dec 2022;54(S 02):E886-e887. doi:10.1055/a-1851-4857
2. Abidi WM, Thompson CC. Endoscopic choledochoduodenostomy and gastrojejunostomy in the treatment of biliary and duodenal obstruction. Gastrointest Endosc. Jun 2016;83(6):1287 doi:10.1016/j.gie.2015.11.045
3. Mangiavillano B, Auriemma F, Paduano D, Lamonaca L, Repici A. Gastrojejunostomy in a patient with previous choledochoduodenostomy and duodenal stent with transcholedocical approach. Endoscopy. Dec 2022;54(S 02):E847-e848. doi:10.1055/a-1838-3985
4. Kongkam P, Luangsukrerk T, Harinwan K, et al. Combination of endoscopic-ultrasound guided choledochoduodenostomy and gastrojejunostomy resolving combined distal biliary and duodenal obstruction. Endoscopy. Sep 2021;53(9):E355-e356. doi:10.1055/a-1294-9399
5. Canakis A, Baron TH. Therapeutic Endoscopic Ultrasound: Current Indications and Future Perspectives. GE Port J Gastroenterol. Sep 2023;30(Suppl 1):4-18. doi:10.1159/000529089
6. Yamazaki H, Yamashita Y, Shimokawa T, Minaga K, Ogura T, Kitano M. Endoscopic ultrasound-guided hepaticogastrostomy versus choledochoduodenostomy for malignant biliary obstruction: A meta-analysis. DEN Open. Apr 2024;4(1):e274. doi:10.1002/deo2.274
7. van der Merwe SW, van Wanrooij RLJ, Bronswijk M, et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. Feb 2022;54(2):185-205. doi:10.1055/a-1717-1391