The Role of Therapeutic Endoscopic Ultrasound in Management of Malignant Double Obstruction (Biliary and Gastric Outlet): A Comprehensive Review with Clinical Scenarios

Abstract

Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life.

Keywords: EUS-guided antegrade stenting; EUS-guided biliary drainage; EUS-guided choledochoduodenostomy; EUS-guided gallbladder drainage; EUS-guided gastroenterostomy; EUS-guided hepaticogastrostomy; double obstruction; gastric outlet obstruction; malignant biliary obstruction.

Figure 1

Endoscopic Ultrasound-Guided Choledochoduodenostomy (EUS-CDS). (A) EUS view of the distal flange of electrocautery-enhanced Lumen-Apposing Metal Stent (ec-LAMS) released into the common bile duct. (B) Fluoroscopy view of EUS-CDS with aereobilia confirming the correct placement. (C) Endoscopic view of the proximal flange of ec-LAMS correctly deployed into the duodenal bulb lumen. The copyright of the image belongs to the authors.

Figure 2

Endoscopic Ultrasound-Guided-Hepaticogastrostomy (EUS-HGS) with partially covered metal stent (PC-SEMS). The copyright of the image belongs to the authors.

Figure 3

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE). Fluoroscopic view of EUS-GE with contrast medium flow through the Lumen-Apposing Metal Stent (LAMS) lumen from the jejunum to the stomach. The copyright of the image belongs to the authors.

Figure 4

Management of malignant double obstruction (MBO). PTBD, percutaneous transhepatic biliary drainage. EUS-GBD, endoscopic ultrasound-guided gallbladder drainage. EUS-CDS, Endoscopic Ultrasound-Guided Choledochoduodenostomy. TP-SEMS, Transpapillary Self-Expandable Metal Stent. EUS-GE, Endoscopic Ultrasound Gastroenterostomy. EUS-HGS, Endoscopic Ultrasound-Guided Hepaticogastrostomy. Type 1, type 2, and type 3 duodenal stenosis according to Mutignani M et al. classification [83]. The copyright of the image belongs to the authors.

Figure 5

Biliary drainage strategies according to duodenal stenosis type and oncological status of the patient, considering EUS-GE the main treatment for gastric outlet obstruction. EUS-HGS, Endoscopic Ultrasound-Guided Hepaticogastrostomy. EUS-AS, Endoscopic Ultrasound-Guided Antegrade Stenting. ERCP-TP-SEMS, Endoscopic Retrograde Cholangiopancreatography Transpapillary Self-Expandable Metal Stent. EUS-CDS, Endoscopic Ultrasound-Guided Choledochoduodenostomy. EUS-GBD, endoscopic ultrasound-guided gallbladder drainage. The copyright of the image belongs to the authors.

Figure 6

Fluoroscopic image of a patient presenting with malignant double obstruction (biliary and gastric outlet) wherein Endoscopic Ultrasound-Guided Choledochoduodenostomy (EUS-CDS) and Endoscopic Ultrasound-Guided Gastroenterostomy (EUS-GE) have been performed (permission has been taken from Dr. Jayanta Samanta for the publication of this image). The copyright of the image belongs to the authors.

Figure 7

Schematic representation of ascending cholangitis/cholecystitis risk in patients with distal malignant biliary obstruction combined with type I or type II duodenal stenosis (according to Mutignani M et al. Classification [83]), treated by endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and Endoscopic Ultrasound-Guided Choledochoduodenostomy (EUS-CDS). The copyright of the image belongs to the authors.

Figure 8

Figure illustration of the procedure Endoscopic Ultrasound-Guided Hepaticogastrostomy (EUS-HGS) with Endoscopic Ultrasound-Guided Gastroenterostomy (EUS-GE). A patient was diagnosed with metastatic gallbladder carcinoma and presented with jaundice. (a) Fluoroscopic image showing a metal self-expandable metal stent (SEMS) with coaxial double pigtail plastic stent in situ. The intrahepatic biliary radicle (left ductal system) was punctured with a 19-G Endoscopic Ultrasound Fine Needle Biopsy (EUS-FNB) needle; (b) following duct puncture, a cholangiogram was performed, and a guidewire was passed and coiled in the ductal system; (c) after adequate positioning of the guidewire, the tract was dilated with 6 French cystotomes; (d) placement of a partially covered SEMS (PC-SEMS), completing EUS-HGS procedure; (e) patient presented with symptoms of gastric outlet obstruction after 3 months; he was planned for EUS-GE; fluoroscopic image shows EUS-HGS PC-SEMS and biliary SEMS (with coaxial plastic stent) in situ. A nasojejunal (NJ) tube has been passed across the duodenal obstruction with the distal end in the first jejunal loop; (f) linear echoendoscope introduced and jejunal loops filled with contrast through NJ tube for delineation; (g) EUS-GE performed using 20 × 10 mm Lumen-Apposing Metal Stent (LAMS) using the free-hand technique; and (h) final fluoroscopic images showing all the stents (EUS-HGS stent, EUS-GE stent, and prior placed biliary SEMS with coaxial plastic stent) (permission has been taken from Dr. Jayanta Samanta for the publication of this image). The copyright of the image belongs to the authors.