Lumen-apposing metal stent gastrojejunostomy for biliary drainage of an obstructive biliodigestive anastomosis

A 68-year-old woman with pancreatic adenocarcinoma was referred to our department with jaundice and poor general condition. Surgical exploration 2 years previously had revealed an unresectable pancreatic head tumor and a biliodigestive anastomosis had been created. At presentation, the patient was receiving third-line chemotherapy and had locally advanced disease and peritoneal carcinomatosis. A computed tomography scan showed progressive disease, with obstruction of the biliodigestive anastomosis and consequent dilatation.

As the established endoscopic and surgical interventions were limited, the patient underwent transgastric endoscopic ultrasound-guided placement of a lumen-apposing metal stent (LAMS) into the afferent jejunal loop ([Fig. 1 a]). The correct positioning of the needle in the biliodigestive anastomosis was verified with contrast-enhanced radiography ([Fig. 1 b]). Thereafter, the LAMS was implanted under fluoroscopic guidance. Because of the duodenal obstruction, two plastic pigtail stents (10 Fr, 11-cm long) were placed through the LAMS to avoid obstruction and to secure the access before an uncovered self-expandable metal stent (SEMS) was positioned in the pars decendens duodeni ([Fig. 2 a]). Neither stent interfered with the other and they were successfully located beside each other in the antrum ([Fig. 2]; [Video 1]).

Fig. 1 Appearance before the procedure showing: a on endoscopic ultrasonography, the biliodigestive anastomosis (BDA), dilated common bile duct (CBD), and afferent loop; b on fluoroscopy, the distribution of the contrast agent within the dilated BDA and CBD caused by a malignant stenosis of the afferent loop. 

Fig. 2 Final position of the stents on: a gastroscopic image showing the duodenal and biliodigestive anastomosis (BDA) self-expandable metal stents (SEMSs) and the two plastic pigtail stents (*) that were passed through the lumen-apposing metal stent to secure the access and outflow in case there was pressure from the duodenal SEMS; b fluoroscopic overview.

Video 1 Lumen-apposing metal stent gastrojejunostomy is performed for biliary drainage of an obstructive biliodigestive anastomosis.

After the intervention, the patient’s cholestatic parameters decreased substantially and, following her discharge, chemotherapy was initially readministered in the outpatient setting. However, 2 months later, the patient's general condition deteriorated and, after receiving best-supportive care, she died 2 months later.

This case report demonstrates an alternative route for biliary drainage in palliative patients with cholestasis caused by stenosis of a malignant biliodigestive anastomosis.

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Competing interests

The authors declare that they have no conflict of interest.

Publication History

Article published online:
19 December 2022