Combined EUSFNB, ERCP, EUSGJ for gastric and biliary obstruction from pancreatic cancer and post-sleeve gastrectomy anatomy. Authors, Brenton G. Davis, Max L. Goldman, and Christopher M. Hamersky. No disclosures. Background. An 83-year-old male with a history of pancreatic head cyst and surgical sleeve gastrectomy presented with acute abdominal pain, nausea, and vomiting while admitted for observation after a fall. On cross-sectional imaging, he was noted to have a 6-centimeter pancreatic head slash uncinate mass that was scheduled for an outpatient EUSFNB in four weeks after discharge. Prior to his procedure, he represented with both a malignant gastric outlet and distal biliary obstruction, which was amenable to intervention. He then underwent combined EUSFNB, ERCP with stent, and EUSGJ without complication. Upon starting the procedure, a large amount of food was encountered within the stomach. To get beyond this, a wire was passed under fluoroscopy and a balloon was inflated and used to trace along the greater curvature to get through the component of the food bolus. The balloon was then deflated and the wire was removed. After removal of the wire, the scope was then advanced through the pylorus to the D2-D3 obstruction that was unable to be passed endoscopically. After visualizing the ampulla, EUS was conducted. There was a 3.3 by 3.2-centimeter pancreatic mass that was then biopsied using an FNB needle. Preliminary path was facetious for adenocarcinoma. After F and B, Bile duct was cannulated and a colline geogram showed a distal stricture, likely related to malignancy. To address this stricture, we then performed a sphincterotomy prior to placement of a 10 by 60 fully covered self-expanding metal stent. After placement of the stent, biliary decompression was confirmed by drainage of bile. The placement of the stent was confirmed fluoroscopically. After placement of the biliary stent, we then placed a wire into the distal limb of the jejunum, and over this wire we threaded a nasobiliary catheter so that the distal limb of the jejunum could be insufflated with water prior to EUSGJ. Wire placement was confirmed fluoroscopically. Contrast was then injected to then again confirm that the wire was in the distal jejunum prior to finding a window for EUSGJ. After insertion of the nasobiliary catheter over the wire, the duodenoscope was then removed and the linear echoendoscope was then advanced into the stomach. To reconfirm window, EUS was performed while the jejunal limb was being insufflated. After confirming the overlying vessels, a 15x10 cautery-enhanced lumen-opposing metal stent was then placed. The distal flange was deployed without issue and approximated. The proximal flange was also deployed without issue with drainage of contents. The stent was then dilated with a 15mm through-the-scope balloon. After removing the balloon and the wire, an EGD scope was used to confirm that efferent and afferent limb were both patent. The stent was easily traversable with the upper endoscopy scope. The procedure was then terminated without issue. Clinical Implications The average lifespan of a U.S. adult is longer, obesity is common, and the prevalence of cancer is increasing. Given this, we likely may see more patients with a history of obesity surgery and complications related to advanced cancers that may need multiple endoscopic interventions. Combining diagnosis with EUSF and B, and treatment of malignant obstructions with ERCP and EUSGJ if needed, may help delay the time between diagnosis and resolution of symptoms while also reducing total number of procedures and need for anesthesia. In conclusion, as our population ages, as our cancer rates increase, and as the rates of obesity and bariatric surgery also increase within the U.S., we likely will need to start bundling procedures such as EUSF and B, ERCP, and EUSGJ to not only give standard of care but to hopefully reduce time to diagnosis, resolution of symptoms, and the need for multiple procedures with sedation. Also, we hope that the bundling of these procedures lead to decreased length of hospitalization, decreased health care costs, and an overall increase in quality of life. Thank you.

pancreatic cancer

endoscopic procedures

gastrojejunostomy

malignant obstruction

healthcare optimization