Endoscopic Approaches to Concomitant Malignant Biliary Obstruction and Gastric Outlet Obstruction

Anatomic Scenarios of Biliary and Duodenal Obstruction

The location of the duodenal obstruction in relation to the major papilla is the major determinant for successful endoscopic simultaneous palliation of biliary and duodenal obstruction using ERCP techniques, because duodenal obstruction can limit access to the bile duct. Mutignani et al. proposed a classification system for the three anatomic scenarios of duodenal obstruction in relation to the major papilla that determine the endoscopic approach to and technical success of combined palliation of biliary and duodenal obstruction. The classification system is as follows ( Fig. 42.1 ):

• Type I stenosis occurs at the level of the duodenal bulb or upper duodenal genu but without involvement of the papilla.

• Type II stenosis affects the second part of the duodenum with involvement of the major papilla.

• Type III stenosis involves the third part of the duodenum distal to and without involvement of the major papilla.

Of the three types of biliary-duodenal stenoses, technical difficulty in achieving successful combined biliary and duodenal palliation is least in patients with type III duodenal stenosis, whereas type I is intermediate and type II is the most technically difficult.

The approach to type I cases is to pass the duodenoscope through the duodenal stricture to the major papilla, if possible. This may require balloon dilation of the stricture to a diameter of 15 to 18 mm ( Fig. 42.2, A ) and/or passing the balloon to the third duodenum to be used as an anchor to pull the endoscope across the stricture. Once the major papilla is reached, the biliary tree is cannulated and an expandable metal biliary stent is placed ( Fig. 42.2, B ). A guidewire is then advanced through the channel of the endoscope and passed into the fourth portion of the duodenum; the duodenoscope is withdrawn into the stomach and a duodenal stent that passes through the working channel of the endoscope is deployed across the duodenal stricture as previously described ( Fig. 42.2, C ). It is usually necessary to place the proximal end of the stent into the stomach to allow enough stent coverage of the duodenal stricture because type I strictures tend to be in the proximal duodenal bulb. If the duodenoscope cannot be advanced through the stricture despite balloon dilation, a duodenal stent can be placed across the stricture. Because the luminal diameter of commercially available duodenal stents is 20 to 22 mm and duodenoscopes are approximately 11 mm, the endoscope can usually be passed through the stent during the same procedure to allow the biliary system to be accessed with placement of biliary self-expandable metal stents (SEMS). However, this may require balloon dilation of the duodenal stent. It is important that the duodenal stent be placed with the distal end positioned proximal to the level of the major papilla to allow the bile duct to be accessed ( Fig. 42.3, A and B ). The location of the major papilla can be estimated fluoroscopically in the presence of a prior biliary stent or by passing a smaller-caliber forward-viewing endoscope to the papilla and obtaining a radiographic image with the endoscope positioned at the level of the papilla for later reference. If the duodenoscope cannot be passed through the duodenal stent lumen because of inadequate stent expansion despite balloon dilation, there are three options: Option 1 is to repeat the ERCP after waiting at least 48 to 72 hours, at which time the duodenal stent is almost always fully expanded and allows passage of the duodenoscope to the second duodenum. Option 2 is percutaneous access to the biliary tree, and option 3 is EUS-guided entry into the biliary tree to palliate BO as described in the following paragraphs.

The approach to type II cases is most difficult. The second duodenum is strictured and involves the major papilla. Unless the patient has had a prior transpapillary biliary stent placed, bile duct cannulation is often not successful because the major papilla is not endoscopically identifiable due to extensive tumor infiltration. In addition, the lumen is narrowed and there is little working room between the tip of the endoscope and the major papilla. Nonetheless, one should first attempt placement of an expandable metal biliary stent. If successful, the duodenal stent is then placed across the stricture and overlies the biliary stent. If identification and/or cannulation of the major papilla cannot be achieved, then a duodenal stent is placed across the stricture. Unfortunately, the stent will invariably further impair endoscopic visualization of the major papilla. In some cases, however, the major papilla can be identified through the interstices of the duodenal stent and the bile duct accessed with placement of a biliary SEMS. If the bile duct cannot be accessed through a transpapillary approach after duodenal stent placement, then biliary access can be achieved using a percutaneous or EUS approach. Typically, in either of the two approaches the bile duct is accessed through the liver (when EUS is used, a transgastric approach is most often used). In addition, with either approach there are two options: a rendezvous (RV) approach or completion alone using a percutaneous or EUS approach. When the RV approach is used, a guidewire is passed into the biliary tree across the stricture and through the interstices of the stent into the stent lumen ( Fig. 42.4, A and B ); if the EUS approach is used, the echoendoscope is removed. A duodenoscope is advanced into the lumen of the duodenal stent and the guidewire is grasped with a snare and withdrawn into the channel of the endoscope. A biliary stent is advanced through the endoscope channel over the guidewire into the biliary tree and deployed. The distal end of the biliary stent resides within the lumen of the duodenal stent ( Fig. 42.4, C ).When the biliary stent is placed entirely using the percutaneous approach, the stent is passed antegrade and the distal end is positioned into the duodenal lumen as described earlier ( Fig. 42.5, A–C ). When the EUS approach is undertaken, the distal end of the biliary stent can reside within the biliary tree proximal to the biliary stricture and with the proximal end deployed into the gastric lumen to create a hepaticogastric anastomosis as described later. The latter EUS-guided approach is similar to the percutaneous approach in which the guidewire is passed antegrade into the duodenum across the duodenal stricture. The stent is then passed through the echoendoscope and deployed across the stricture with the distal end into the duodenum. Finally, in a recent case report, an EUS-guided approach was performed where the echoendoscope was passed into the lumen of a previously placed duodenal stent in a type II stenosis in which the papilla could not otherwise be endoscopically visualized. The bile duct opening was identified and a transpapillary biliary SEMS placed.

Type III cases are the least common and often result from pancreatic cancer that arises from the uncinate process. The tumor encases the bile duct, causing BO, and extends inferiorly, causing duodenal obstruction below the level of the major papilla. These cases are the least technically difficult because the duodenoscope can be passed to the major papilla and to the level of the stricture. In addition, it is not necessary to pass the endoscope beyond the duodenal stricture and thus balloon dilation of the stricture is not necessary. The sequence of SEMS placement (biliary stent first and then duodenal stent, or vice versa) is usually not critical when the major papilla and the proximal portion of the biliary stricture are not in close proximity ( Fig. 42.6, A–C ). However, if the proximal level of the duodenal obstruction is very close to the major papilla, it is best to place the biliary stent first because the proximal end of the duodenal stent may need to be placed across the level of the major papilla to allow adequate coverage of the duodenal stricture. Whatever sequence of stent placement is chosen, it is best to avoid placing the duodenal stent across the biliary opening so that biliary access is preserved both at the time of the initial procedure and in the future should biliary stent occlusion occur.

Clinical Scenarios

In addition to the relationship of the duodenal obstruction to the major papilla, other factors influence the endoscopic approach. These include prior surgical palliation (gastrojejunal bypass) and clinical scenarios. The most common clinical scenario is the initial development of BO followed by later onset of duodenal obstruction. Many patients with duodenal obstruction have already undergone a palliative intervention for relief of BO—endoscopic, percutaneous, or surgical. If a transpapillary stent was previously placed, then the type of stent and timing of stent placement need to be determined. For example, if a plastic biliary stent was previously placed, it is likely occluded or will become occluded and needs to be replaced. In such patients it is recommended that a metal biliary stent be placed at the time of duodenal stent placement, especially in type II patients (see Fig. 42.2 ) because the duodenal stent must cross the level of the major papilla, making subsequent biliary stent placement difficult, if not impossible, since it may not be accessible through the interstices of the duodenal stent.

Another scenario is simultaneous presentation of gastric and duodenal obstruction without prior intervention. In this scenario it is recommended that placement of a biliary SEMS be performed during the same procedure as placement of the duodenal SEMS, if possible.

An additional clinical scenario is duodenal obstruction followed by later BO. This is uncommon and could be difficult to treat endoscopically because the papilla is usually inaccessible if the duodenal stent was placed across the papilla. If the stent does not cross the papilla, the endoscope can be passed through the metal stent and ERCP performed as usual. If the stent has crossed the papilla in a type I duodenal stenosis, it may be possible to identify a normal papilla through the interstices of the stent, followed by successful cannulation of the bile duct ( Fig. 42.7 ), or to create a window within the stent at the level of the papilla using rat-tooth forceps or argon plasma coagulation. If these maneuvers fail, then either a percutaneous or EUS-guided approach to placement of a metal biliary stent is usually required, as described earlier.

Finally, when considering endoscopic management of duodenal obstruction in the patient without clinically overt BO, prophylactic placement of a biliary SEMS should be considered, especially if there is any evidence of biliary ductal dilation by noninvasive imaging or in the presence of abnormal liver function tests that cannot be explained by other processes such as medications or presence of liver metastases.

Technical Approaches

Since the first description of EUS-guided GE by Fritscher-Ravens et al. and the advent of the lumen-apposing stent, three EUS approaches have been developed for stent insertion: (1) direct EUS-GE, (2) balloon-assisted EUS-GE, and (3) EUS-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) ( Table 42.1 ). In patients with concomitant GOO and BO, we suggest performing both EUS-GE and EUS-BD in a single session.