Concomitant malignant gastric outlet ambilary obstruction is difficult to manage using traditional endoscopic stinting. Double endoscopic bypass is a promising modality. Main limitation, technically taxing and difficult. The following demonstrate the ease of double endoscopic bypass using lumen opposing metallic stint for both EOS choledochordadenostomy and EOS gastrogygenostomy. Eight-year-old female with metastatic pancreatic cancer presents with jaundice and symptoms of gastric outlet obstruction. Initial laboratory testing revealed cholestasis. CT showed malignant duodenal infiltration with common bile duct dilatation. ERCP was unsuccessful due to the inability to reach the papilla. Following informed consent, proceeded to endoscopic double bypass. The following describes the technique of endoscopic double bypass, including EOS guided gastrogygenostomy with nasobiliary catheter assistance and EOS guided choledochordadenostomy with a dedicated biliary lumen opposing metallic stint. At first, a therapeutic scope was inserted and a wire was advanced across the point of obstruction into the small bowel. The fluoroscopy image confirmed the presence of the wire in the small bowel. After the insertion of the wire using therapeutic scope, a nasobiliary drain was inserted over the guide wire across the point of obstruction into the small bowel. Fluoroscopy image following the insertion of nasobiliary drain confirming its presence in the small bowel. Using the nasobiliary drain, the small bowel was infused with a mixture of 400 ml of normal selene, methylene blue, and contrast. Under EOS guidance, a 15 mm lumen opposing metallic stint was then inserted freehand with catheter assistance followed by successful stint deployment. endoscopic image showing gastrogyneostomy with a flow of methylene blue into the lumen of the stomach from the small bowel. We then turned our attention to performing EOS choledicodydenostomy. The endoscope was advanced to the duodenal bulb and the common bile duct located via EOS. The bile duct measured 12 millimeter in diameter. Under EOS guidance, a 6 millimeter lumen opposing metallic stent was then inserted freehand with cuttery assistance followed by successful stent deployment. The distal flange was then deployed and the stent was then pulled back snug against the bile duct wall, followed by deployment of the proximal flange of the stent. A focus of the endoscopic image showing the choledicodydenostomy with the flow of the bile into the lumen of the duodenum. Fluoroscopy image showing both gastrogyneostomy and choledicodydenostomy stents in place. Total procedure time 36 minutes. The patient tolerated the procedure very well. The bilirubin normalized expectantly. The patient was discharged from the hospital tolerating an oral diet six days post procedure. The use of dedicated biliary and traditional lumen opposing metallic stent can greatly facilitate endoscopic double bypass, thereby enhancing the adaptability of this otherwise challenging procedure. Double endoscopic bypass is potentially the ideal modality in revealing the biliary and gastric outlet obstruction. Performing both EOS gastrogyneostomy and EOS choledicodydenostomy during the same session is feasible, however it's technically challenging. Our case demonstrates the ease at which double endoscopic bypass can be performed using lumen opposing metallic stent for both obstructions. Larger studies will be needed to ascertain the efficacy and safety of double endoscopic bypass using lumen opposing metallic stent in malignant gastric outlet obstruction and biliary obstruction.

malignant gastric outlet obstruction

biliary obstruction

metastatic pancreatic cancer

double endoscopic bypass

lumen opposing metallic stint