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. 1b). 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). 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.