The palliation of simultaneous biliary and duodenal obstruction in patients with advanced pancreatic cancer is a clinically and technically challenging scenario. Endoscopic procedures are a valid alternative to surgical or percutaneous transhepatic biliary drainage. The availability of self-expanding metal stents (SEMSs) and lumen-apposing metal stents (LAMS) have expanded therapeutic options. We describe a case in which biliary and duodenal obstructions were treated successfully with the combined use of SEMS and LAMS devices. Endoscopic ultrasound-guided biliary drainage with the use of new LAMS and a duodenal SEMS can be a valid option in expert hands as a palliative and minimally invasive treatment for gastric outlet and biliary obstruction

Arena, Rosario

Cifalà, Viviana

Fabbri, Carlo

Merighi, Alberto

Metelli, Flavio

Pezzoli, Alessandro

Pizzo, Elena

Simone, Loredana

Solimando, Riccardo

English

UCL Discovery

ACG CASE REPORTS JOURNALCASE REPORT | ENDOSCOPYCombined Endoscopic Stent-In-Stent Placement byLumen-Apposing Metal Stents Through Self-ExpandingMetal Stents for Simultaneous Malignant Biliary andDuodenal ObstructionFlavio Metelli, MD1, Alessandro Pezzoli, MD1, Carlo Fabbri, MD2, Elena Pizzo, PhD3, Rosario Arena, MD1, Viviana Cifalà, MD1,Loredana Simone, MD1, Riccardo Solimando, MD1, and Alberto Merighi, MD11Department of Gastroenterology and GI Endoscopy, University Hospital, Ferrara, Italy2Department of Gastroenterology and GI Endoscopy, Forli-Cesena, Italy3Department of Health Economics, University College of London, London, United KingdomABSTRACTThe palliation of simultaneous biliary and duodenal obstruction in patients with advanced pancreatic cancer is a clinically andtechnically challenging scenario. Endoscopic procedures are a valid alternative to surgical or percutaneous transhepatic biliarydrainage. The availability of self-expanding metal stents (SEMSs) and lumen-apposing metal stents (LAMS) have expandedtherapeutic options. We describe a case in which biliary and duodenal obstructions were treated successfully with the combineduse of SEMS and LAMS devices. Endoscopic ultrasound-guided biliary drainage with the use of new LAMS and a duodenal SEMScan be a valid option in expert hands as a palliative and minimally invasive treatment for gastric outlet and biliary obstruction.INTRODUCTIONSystemic chemotherapy represents the only treatment strategy for patients with advanced pancreatic cancer (PC). However, patientswith unresectable PC could present malignant biliary obstruction (MBO) and gastric outlet obstruction syndrome that impair theunderlying conditions and prevents access to chemotherapy.1Endoscopic interventions were revolutionized in 1979 by the first endoscopic biliary placement, and since then, a diverse range ofdevices for biliary drainage have been developed.1 Endoscopic retrograde cholagiopancreatography (ERCP) is still the current first-line treatment for biliary drainage, with a high success rate, low complications, and high stent patency. Themost frequent reason forERCP failure is difficult access for cannulation; this can be due to surgically altered anatomy, duodenal obstruction, or ampullaryinfiltration. For decades, percutaneous biliary drainage was considered the salvage procedure for a failed ERCP. Nowadays, en-doscopic ultrasound (EUS)-guided biliary drainage has demonstrated to be a valid alternative thanks to effective internal drainage,reduction in patients discomfort, and dramatic reduction in both short- and long-term adverse events.2–4 Recently, electrocautery-enhanced lumen-apposing metal stent (LAMS) delivery system (Hot AXIOSª; Boston Scientific, Marlborough, MA) was dem-onstrated to be an effective tool for the treatment of pancreatic fluid collections, acute cholecystitis, and distal MBO.5–7We present apatient with locally-advanced PC complicated by MBO and duodenal stenosis, who was treated with a combined endoscopic endEUS approaches as palliative treatment.CASE REPORTA79-year-old womanwas admitted to our hospital with painless jaundice. She had a history of stable oncohematological disease. Onadmission, laboratory tests showed increased total bilirubin (8.7 mg/dL) and direct bilirubin (5.2 mg/dL), associated with increasedACG Case Rep J 2021;8:e00704. doi:10.14309/crj.0000000000000704. Published online: November 23, 2021Correspondence: Alessandro Pezzoli, MD (a.pezzoli@ospfe.it).ACG Case Reports Journal / Volume 8 acgcasereports.com 1white blood cell (13.5 3 103/mL) and C-reactive protein(148.5 mg/L) Computed tomography revealed the presenceof pancreatic head neoplasm, with signs of duodenal in-filtration and biliary tract dilation (Figure 1). An ERCP wasattempted but failed because of complete duodenal stenosis.Therefore, an uncovered duodenal self-expanding metalstent (SEMS) (WallFlex Duodenal, 22 3 90 mm, BostonScientific, MA) was placed through the duodenal stenosis toresolve the obstruction. A EUS was scheduled few days laterfor tissue acquisition and biliary drainage with EUS-choledocoduodenostomy (EUS-CDS) because of pro-gressive jaundice (total bilirubin had increased up to 15mg/dL).Three days later, the EUS-CDS was performed with a linearechoendoscope (GF-UCT-180; Olympus Corp., Japan). Thedilated common bile duct was directly punctured with a 10 310 mm electrocautery-enhanced LAMS delivery system. Thedevice was inserted through the duodenal bulb into the com-mon bile duct, obtaining immediate biliary drainage (Figure 2).Radiological control showed the correct position of the LAMSthrough duodenal stent mesh (Figures 3 and 4). The procedurewas well tolerated by the patient, and the serum bilirubin levelreduced gradually to 5.5mg/dL over the next 5 days. The patientwas able to eat during the following 6 months. The patient wasdischarged 4 days later and referred to the oncologist for pal-liative chemotherapy.DISCUSSIONThe clinical management of patients with advanced PC is oftenchallenging because of the complexity of their clinical pre-sentation. MBO is a frequent complication requiring biliaryFigure 1. Computed tomography scan showing the pancreaticneoplasm.Figure 2. Endoscopic view of the lumen-apposing metal stents (HotAXIOS) in the duodenal bulb.Figure 3. Radiological control after the procedures.Figure 4. Computed tomography scan control after the procedures.ACG Case Reports Journal / Volume 8 acgcasereports.com 2Metelli et al Combined Endoscopic Stent-In-Stent Placementintervention; however, 6%–9% of patients develop a duo-denal obstruction requiring surgical or endoscopic pallia-tion.1 In the presence of duodenal stricture, ERCP is notfeasible. The most frequent option is percutaneous biliarydrainage, which has a high success rate but is associated toadverse events in more than 30% of cases and can affect thequality of life because of the presence of external drainage.2–4Currently, duodenal obstruction is generally treated withSEMSs.8 The clinical success rate of duodenal SEMS place-ment in patients affected by gastroduodenal obstruction isbetween 84% and 93%, with a technical success rate rangingbetween 93% and 97%.9,10After the placement of a duodenal stent, an ERCP can beperformed with the aim of placing a biliary stent through themesh of the duodenal stent. This is a challenging techniquebecause of the limited space for the duodenoscope inside theduodenal stent.11 The reported technical success of duodenaland biliary stent insertion in synchronous bilioduodenalstenosis ranges from 71.4% to 94.4%.12–14 EUS-guidedtransluminal drainage of obstructed bile duct can be a validoption. The use of EUS-hepaticogastrostomy (EUS-HGS) orEUS-guided choledochoduodenostomy (EUS-CDS) are 2ultrasound-guided alternatives that can be effective in case ofdistal malignant biliary stenosis.15,16 The superiority of EUS-BD over percutaneous procedures in expert centers has beenreported in recently published data.17 In particular, the use ofLAMS for EUS-BD has improved the procedure in technicalfeasibility and safety.18Our patient presented with jaundice secondary to biliarycompression and a type I duodenal obstruction according to theMutignani et al classification (type I: duodenal stenosis arepresent in the duodenal bulb or in the duodenal genu, type II:the duodenal stenosis involves the papilla, and type III: duo-denal stenosis occurs distally from the papilla, without its in-volvement).12 We treated this patient with a minimal invasiveapproach using a double stentingmethod through the duodenalbulb. A SEMSwas placed for duodenal obstruction and a LAMSfor biliary stenosis. To our knowledge, only 2 similar cases arereported in literature; in both cases, the LAMS were releasedthrough the mesh of the duodenal SEMS such as in ourpatient.19,20Our report supports the use of EUS-CDS associated to SEMSplacement in such challenging clinical scenarios. EUS biliarydrainage is a salvage therapy that should be reserved for type Iand type II bilioduodenal stenosis when ERCP is not feasiblebecause of the presence of synchronous duodenal obstruction.We believe that patients with advanced disease should betreated with minimally invasive techniques to allow access tochemotherapy and preserve the quality of live. These patientsshould be treated in referral centers where multiple compe-tences (interventional radiology, surgery, oncology, and en-doscopy) are available.DISCLOSURESAuthors contributions: F. Metelli, A. Pezzoli, and R. Arenawrote the manuscript. A. Pezzoli and C. Fabbri performed theendoscopic examinations. All authors revised the manuscriptfor intellectual content and approved the final manuscript. A.Pezzoli is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.Received December 28, 2020; Accepted June 21, 2021REFERENCES1. Shepherd HA, Royle G, Ross AP, Diba A, Arthur M, Colin-Jones D. En-doscopic biliary endoprosthesis in the palliation ofmalignant obstruction ofthe distal common bile duct: A randomized trial. Br J Surg. 1988;75:1166–8.2. Smith AC, Dowsett JF, Russell RC, Hatfield AR, Cotton PB. Randomisedtrial of endoscopic stenting versus surgical bypass inmalignant low bileductobstruction. Lancet. 1994;344(8938):1655–60.3. Téllez-Ávila FI, Herrera-MoraD,Duarte-MedranoG, et al. Biliary drainagein patients with failed ERCP: Percutaneous versus EUS-guided drainage.Surg Laparosc Endosc PercutanTech. 2018;28:183–7.4. Sportes A, Camus M, Greget M, et al. Endoscopic ultrasound-guidedhepaticogastrostomy versus percutaneous transhepatic drainage for ma-lignant biliary obstruction after failed endoscopic retrograde chol-angiopancreatography: A retrospective expertise-based study from twocenters. Therap Adv Gastroenterol. 2017;10:483–93.5. Hammad T, Khan MA, Alastal Y, Sharaiha RZ, Tyberg A, Nawras A. Ef-ficacy and safety of lumen-apposingmetal stents in EUS-guided transmuraldrainage of pancreatic fluid collections: A systematic review and meta-analysis. Paper presented at ACG 2016 Annual Scientific Meeting; October14, 2016; Las Vegas, NV.6. Lisotti A, Linguerri R, Bacchilega I, Cominardi A, Marocchi G, Fusaroli P.EUS-guided gallbladder drainage in high-risk surgical patients with acutecholecystitis-procedure outcomes and evaluation of mortality predictors.Surg Endosc. 2021.7. Kunda R, Pérez-Miranda M, Will U, et al. EUS-guided chol-edochoduodenostomy for malignant distal biliary obstruction using alumen-apposing fully covered metal stent after failed ERCP. Surg Endosc.2016;30:5002–8.8. van Hooft JE, Uitdehaag MJ, BrunoMJ, et al. Efficacy and safety of the newWallFlex enteral stent in palliative treatment of malignant gastric outletobstruction (DUOFLEX study): A prospective multicenter study. Gastro-intest Endosc. 2009;69:1059–66.9. Dormann A, Meisner S, Verin N, Wenk Lang A. Self-expanding metalstents for gastroduodenal malignancies: Systematic review of their clinicaleffectiveness. Endoscopy. 2004;36:543–50.10. van Hooft JE, UitdehaagMJ, BrunoMJ, et al. Efficacy and safety of the newWallFlex enteral stent in palliative treatment of malignant gastric outletobstruction (DUOFLEX study): A prospective multicenter study. Gastro-intest Endosc. 2009;69:1059–66.11. KhashabMA, Valeshabad AK, LeungW, et al. Multicenter experience withperformance of ERCP in patients with an indwelling duodenal stent. En-doscopy. 2014;46:252–5.12. Mutignani M, Tringali A, Shah SG, et al. Combined endoscopic stent in-sertion in malignant biliary and duodenal obstruction. Endoscopy. 2007;39:440–7.13. Maire F, Hammel P, Ponsot P, et al. Long-term outcome of biliary andduodenal stents in palliative treatment of patients with unresectable ade-nocarcinoma of the head of pancreas.Am JGastroenterol. 2006;101:735–42.14. Katsinelos P, Kountouras J, Germanidis G, et al. Sequential or simultaneousplacement of self-expandable metallic stents for palliation of malignantbiliary and duodenal obstruction due to unresectable pancreatic head car-cinoma. Surg Laparosc Endosc Percutan Tech. 2010;20:410–5.15. Rimbaş M, Larghi A. Endoscopic ultrasonography-guided techniques foraccessing and draining the biliary system and the pancreatic duct. Gastro-intest Endosc Clin N Am. 2017;27:681–705.ACG Case Reports Journal / Volume 8 acgcasereports.com 3Metelli et al Combined Endoscopic Stent-In-Stent Placement16. KhanMA,AkbarA, KhanTHS, et al. Endoscopic ultrasound-guided biliarydrainage: A systematic review and meta-analysis. Dig Dis Sci. 2016;61:684–703.17. Sharaiha RZ, Khan MA, Kamal F, et al. Efficacy and safety of EUS-guidedbiliary drainage in comparison with percutaneous biliary drainage whenERCP fails: A systematic review and meta-analysis. Gastrointest Endosc.2017;85:904–14.18. Rinninella E, Kunda R, Dollhopf M, et al. EUS-guideddrainageofpancreaticuidcollections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: A large retrospective study (with video). Gastro-intestEndosc. 2015;82(6):1039–46.19. Sportes A, Airinei G, Kamel R, Raynaud JJ, Benamouzig R. Endoscopicultrasound-guided choledochoduodenostomy with a lumen-apposing metalstent through an uncovered metal duodenal stent. Endosc Int Open. 2018;6:E1395–E1397.20. De Davide L, Bureau MA, Toliopoulos P, et al. EUS biliary drainage with alumen-apposing metal stent through a pre-existing duodenal metal stent.VideoGIE. 2019;26(4):131–2.Copyright:ª 2021 The Author(s). Published byWolters Kluwer Health, Inc. on behalf ofThe American College of Gastroenterology. This is an open access article distributedunder the terms of the Creative Commons Attribution-Non Commercial-No DerivativesLicense 4.0 (CCBY-NC-ND), where it is permissible to download and share the workprovided it is properly cited. The work cannot be changed in any way or used com-mercially without permission from the journal.ACG Case Reports Journal / Volume 8 acgcasereports.com 4Metelli et al Combined Endoscopic Stent-In-Stent Placement

Combined Endoscopic Stent-In-Stent Placement by Lumen-Apposing Metal Stents Through Self-Expanding Metal Stents for Simultaneous Malignant Biliary and Duodenal Obstruction

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Combined Endoscopic Stent-In-Stent Placement by Lumen-Apposing Metal Stents Through Self-Expanding Metal Stents for Simultaneous Malignant Biliary and Duodenal Obstruction

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