EUS-directed transduodenal ERCP in concomitant gastric outlet and biliary obstruction

Background and Aims: Patients with concomitant gastric outlet obstruction (GOO) and biliary obstruction often have limited management options, particularly in the setting of severe debility. We detail the use of EUS-guided gastroduodenal placement of a lumen-apposing metal stent (LAMS) as a conduit for transduodenal ERCP: EUS-directed transduodenal ERCP. Methods: Nine patients who developed GOO with indwelling biliary metal stents or with anticipated biliary stent placement were retrospectively included. Results: A 20 mm × 10 mm LAMS was deployed for creation of gastroduodenostomy in all patients. ERCP was performed via the gastroduodenal LAMS with resolution of jaundice in 100% of patients. GOO score improved to 3 in all patients. Conclusions: This study demonstrates excellent outcomes (resolution of jaundice and GOO) in all chronically ill, poor surgical candidates. Placement of a LAMS allowed for both treatment of GOO and ERCP access for present and future stent exchange.