Challenges and Innovative Solutions in Double Endoscopic Derivations: A Case Report and Endoscopic Management

Introduction Endoscopic ultrasound-guided choledocoduodenostomy (CD-EUS) and gastrojejunostomy (GY-EUS) are effective for treating double stenosis (duodenal and biliary) in patients with unresectable pancreatic neoplasms.

Case Report A 65-year-old woman with extensive jejunal resection presented with double obstruction (duodenal and biliary) due to an unresectable pancreatic neoplasm. In one session, a double endoscopic derivation was performed using the "free-hand" technique: GY-EUS with a 20x10 mm lumen-apposing metal stent (LAMS) after jejunal loop distension with irrigation via a nasobiliary catheter, and CD-EUS with a 6x8 mm LAMS with a double pigtail coaxial 7F-3 cm. The patient was discharged with normalized cholestasis and good oral tolerance.

Four weeks later, she was readmitted with vomiting, fever, abdominal pain, cholestasis, and elevated C-reactive protein. A CT scan revealed misplacement of the GY-EUS stent in the colon (type IV). Biliary duct cleaning, replacement of the double pigtail, and removal of the GY-EUS stent were performed. A gastrocolonic fistula was closed using the endoloop technique with clips. Following this, the duodenal stenosis was treated with a 22 mm x 120 mm non-covered duodenal stent. The patient was discharged with clinical improvement and good oral tolerance.

Conclusion Type IV misplacement of GY-EUS is rare but may occur in patients with rapid intestinal transit post-resection. Endoscopic management of obstructive complications of CD-EUS and GY-EUS, including duodenal stents, is effective.

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Artikel online veröffentlicht:
27. März 2025