This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and Sutab. Greetings, my name is Myunghoon Kim and I will be sharing a case titled Three Little Lambs in One Patient. These are all the authors and corresponding disclosures. This is a 79-year-old gentleman with multiple comorbidities including stroke on clopidogrel with known pancreatic head adenocarcinoma who is status post biliary stem placement for decompression. He presented to us with worsening abdominal pain. CT imaging showed acute choicestitis with worsening intrahepatic ductal dilation. The patient was deemed a poor surgical candidate and our GI team was consulted for consideration of EUS guided drainage of the gallbladder. Here in the CT abdomen pelvis, we can see the significant gallbladder distension with pericolocystic stranding, worsening intrahepatic biliary ductal dilation and unchanged biliary stem position. ERCP was challenging due to external compression on the duodenum but it showed diffused biliary ductal dilation so the previously placed biliary stem was replaced with a new 10 millimeter by 6 centimeter self-expanding metal stem and a common bile duct with appropriate drainage. EUS guided cholecystogastrostomy was created using a 15 by 10 millimeter LAMs to drain the gallbladder. This was placed in the pre-pyloric stomach as opposed to the duodenum due to stenosis of the area likely due to progressive cancer. We utilized endoscopic ultrasound and confirmed visualization of the gallbladder. Using fluoroscopy, we injected contrast through the LAMs which demonstrated cystic duct obstruction. Here we demonstrate the LAMs in appropriate position with bilious output. The patient tolerated the procedure and was subsequently discharged with improvement of symptoms. Two months post cystic gastrostomy, the patient presented again with worsening abdominal pain. CT findings during this presentation showed new severe dilation of the main pancreatic duct in the neck, body, and tail of the pancreas. This corona view demonstrates multiple findings. For one, there is the gallbladder containing the previously placed LAMs with the double pictoplastic stents in place. There is also the metal stent within the common bile duct. And most importantly, there is the severe dilation of the main pancreatic duct in the neck, body, and tail of the pancreas. Surgical oncology and GI were both consulted for further management. Due to his poor surgical candidacy, the multidisciplinary decision was to attempt trans-papillary drainage. While there was no evidence of gastric outlet obstruction, the traditional ERCP duodenoscope could no longer traverse the now severely extrinsically stenosed duodenum. Due to the patient's symptoms and a challenging anatomy, the plan was to pursue placement of a pancreatic gastrostomy using LAMs into the pancreatic duct for palliative purposes. First, we used EOS and color doppler imaging to identify any interposed vessels. After the doppler did not identify concerning vessels, we punctured the pancreatic duct via electrocautery device, and a 10 by 10 millimeter luminoposing metal stent was deployed through the working channel. Here, we see the full LAMs deployment into the pancreatic duct. This endoscopic view shows the proximal end of the LAMs with subsequent gush of clear liquid with opaque white debris into the stomach. A through the scope dilator was used to dilate the duct up to 10 millimeters. A temp was made via fluoroscopy to advance a guide wire into the native ampulla, but it was unsuccessful due to the pancreatic malignancy. Contrast was injected, which demonstrated the dilated pancreatic duct. After exchanging to an XP scope, we immediately perform a transgastric pancreatoscopy and visualize the pancreatic ductal lumen. On the left, we see the duct towards the pancreatic tail, and on the right, we visualize the duct towards the pancreatic head. We attempted to bypass the orifice of obstruction with the guide wire via direct endoscopy, but it was unsuccessful. Therefore, we subsequently placed a 5 French by 6 centimeter single pictoplastic stent in the LAMs and secured it onto the LAMs itself to prevent subsequent pancreatic ductal trauma. Patient had no complications with immediate symptomatic pain relief and was discharged several days later. One month later, the patient presented back into the hospital with new nausea, vomiting, and abdominal distension. Here in the CT abdomen pelvis, we demonstrate the acute gastric outlet obstruction with markedly fluid-filled distension of the stomach to the level of the pylorus and first portion of the duodenum. Also of note, the pancreatic gastrostomy LAMs led to successful decompression of the pancreas with interval decrease in pancreatic ductal dilation to 1 centimeter. Decision was made to perform EGD for re-evaluation of the previous pancreatic gastrostomy and for consideration of creating a gastrojejunostomy with LAMs for decompression for the gastric outlet obstruction. In this endoscopic view, the prior pancreatic gastrostomy LAMs with plastic stent was carefully removed. And then we left behind the double pictoplastic stent to where the second LAMs was placed with good effect. Next, a new LAMs was deployed to create a gastrojejunostomy bypassing the gastric outlet obstruction caused by the patient's known pancreatic head adenocarcinoma. A through-the-scope dilator was then used to dilate the lumen. Another month later, patient presented for his outpatient follow-up appointment. At that time, he had well-controlled abdominal pain without significant nausea. He continued to follow with palliative care until he eventually passed away peacefully and pain-free. We demonstrated a unique case of a patient receiving pancreatic gastrostomy for decompression of the pancreatic duct and palliation of his pain. He ultimately underwent placement of three little LAMs to palliate several pancreatic biliary and luminal obstructions. Lumen-opposing metal stents continue to provide new avenues for treatment and palliation, including the possibility of pancreatic gastrostomy as described in this case.

pancreatic adenocarcinoma

LAMs procedure

biliary duct dilation

palliative care

gastrojejunostomy