A332 FIRST REPORTED EUS-GUIDED DOUBLE BYPASS PERFORMED IN COLLABORATION WITH INTERVENTIONAL RADIOLOGY

Endoscopic ultrasound-guided double bypass (EUS-DB) is a novel technique in the management of concomitant biliary and gastric outlet obstruction. It involves the creation of both an EUS-guided gastroenterostomy and hepatogastrostomy To describe the first reported case in the literature (with video) of EUS-DB performed in collaboration with interventional radiology (IR) A 54-year old male known for locally advanced pancreatic cancer was referred for recurrent cholangitis and gastric outlet obstruction despite previous duodenal stenting and transhepatic percutaneous biliary drainage (PTBD). Endoscopy confirmed complete obstruction of the duodenal stent due to tumor tissue ingrowth. A decision was made to proceed to EUS-DB to optimize nutritional status, biliary drainage, and patient comfort IR introduced a guidewire through the PTBD traversing the enteral stent and advanced to the jejunum. A 20 mm dilating balloon with an overlapping snare attached was then introduced over the PTBD wire and advanced across the enteral stent to the ligament of Treitz where the balloon was inflated under fluoroscopy. Overall, 500 ml of both saline and contrast was then injected percutaneously to dilate the small bowel segment proximal to the balloon. EUS-guided puncture of the balloon was performed transgastrically with a 19-gauge needle. Bursting of the balloon confirmed successful puncture in the desired jejunal segment. An 0.035-inch guidewire was then advanced through the needle and grasped with the snare and pulled through the percutaneous access thereby creating wire tension on both ends of the wire. Track dilation was performed with a 4 mm dilating balloon. A Lumen-apposing metal stent (15 x 10 mm) was then deployed under EUS guidance. Contrast injection confirmed a patent gastroenterostomy. Attention was then shifted to the HGS. Under EUS a dilated hepatic segment III left intrahepatic bile duct was visualized. A transgastric puncture of the duct was performed with a 19-gauge needle, followed by the advancement of an 0.035-inch guidewire into the common bile duct. The HGS track was then dilated using a 4mm dilating balloon followed by successful deployment of a 10 x 80 mm partially covered self-expanding metal stent. A full stent diet was initiated 48 hours post procedure with excellent tolerance. PTBD was removed 3 days later with the bilirubin having decreased by more than 50 % at the 1-week follow-up We describe the first reported EUS-guided double bypass performed in collaboration with IR. Combining endoscopic and interventional radiology techniques may enhance the safety and ease of this novel approach. Further studies; however, will be needed to validate this technique None

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