Endoscopic Management of Combined Biliary and Duodenal Obstruction

Abstract

Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction of gastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combined obstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associated with surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenal metal stents. Biliary cannulation is difficult in type II bilioduodenal strictures where the duodenal stenosis is located at the level of the papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenal strictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopic ultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and efficacy of endoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories and standardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction.

Keywords: Endoscopy; Gastric outlet obstruction; Jaundice, obstructive.

Fig. 1.

Fluoroscopic image revealing successful placement of biliary and duodenal metal stents in a patient with type I bilioduodenal stenosis.

Fig. 2.

Endoscopic ultrasound-guided choledochoduodenostomy. (A) Puncture of bile duct with a 19 G needle and contrast injection, (B) placement of guidewire and initiation of stent deployment, (C) complete deployment of choledochoduodenal stent.

Fig. 3.

Endoscopic ultrasound-guided hepaticogastrostomy. (A) Puncture of intrahepatic bile duct with a 19 G needle, (B) placement of guidewire and dilatation of the tract with a catheter, (C) and (D). deployment of metal stent (note: a double pigtail plastic stent has also been placed within the metal stent).

Fig. 4.

Algorithmic approach to combined biliary and duodenal obstructions. ERCP, endoscopic retrograde cholangiopancreatography; EUS-BD, endoscopic ultrasound-guided biliary drainage.