Endoscopic ultrasound-guided gastrojejunostomy and choledochoduodenostomy with lumen-apposing metal stents: an efficient approach to double endoscopic bypass
Bibliographic record
Abstract
Concomitant malignant gastric outlet and biliary obstruction is a morbid complication of pancreatic cancer [ 1 ]. Double endoscopic bypass with endoscopic ultrasound-guided gastroenterostomy (EUS-GE) and an EUS-guided choledochoduodenostomy or hepatogastrostomy is a promising but technically challenging modality in gastric outlet and biliary obstruction [ 2 ]. The advent of dedicated biliary lumen-apposing metal stents (LAMS) [ 3 ] has the potential to greatly facilitate double endoscopic bypass and enhance its adoptability [ 2 ]. An 80-year-old woman with stage IV pancreatic cancer presented with gastric outlet and biliary obstruction secondary to tumor progression. An endoscopic retrograde cholangiopancreatography was unsuccessful owing to the inability to reach the papilla. Following informed consent, we proceeded with a double endoscopic bypass ([ Video 1 ]). Video 1 Endoscopic ultrasound-guided gastrojejunostomy and choledochoduodenostomy with lumen-apposing metal stents: an efficient approach to double endoscopic bypass. Quality: mobile 360 480 720 Download A therapeutic gastroscope was advanced to the level of the obstruction in the duodenum. A 0.035-mm wire was inserted up to the jejunum followed by a 7-Fr nasobiliary drain to the ligament of Treitz ([ Fig. 1 a ]). Saline combined with contrast and methylene blue was injected into small bowel (400 ml) ([ Fig. 1 b ]). The echoendoscope was then inserted and the distended small bowel located under endoscopic ultrasound (EUS). A 15 × 10-mm lumen-apposing metal stent (LAMS) (Axios; Boston Scientific, Marlborough, Massachusetts, USA) was then inserted directly using cautery assistance and deployed successfully forming the gastroenterostomy ([ Fig. 1 c ]). The echoendoscope was then advanced to the bulb of duodenum to locate the dilated common bile duct measuring 12.5 mm in diameter ([ Fig. 2 a ]). A 6 × 8-mm biliary LAMS was then inserted using cautery assistance and deployed to establish the choledochoduodenostomy ([ Fig. 2 b ]). The total procedure time was 36 minutes. The patient’s bilirubin decreased as expected and her diet advanced. The patient was discharged from hospital 7 days after the double endoscopic bypass. Fig. 1 a Fluoroscopy images for nasobiliary drain in the small bowel. b Endoscopic ultrasound (EUS) image shows dilated small bowel following infusion. c EUS image shows insertion of lumen-apposing metal stent in the small bowel. Fig. 2 a Endoscopic ultrasound (EUS) image shows dilated common bile duct (CBD) measured at 12.5 mm. b EUS image shows insertion of lumen-apposing metal stent in the CBD. Double endoscopic bypass is potentially the ideal modality for relieving gastric outlet and biliary obstruction. Our case demonstrates the ease with which this procedure can be performed using LAMS for both obstructions. Larger studies will be needed to ascertain the efficacy and safety of double endoscopic bypass using LAMS in malignant gastric outlet and biliary obstruction. Fig. 3 Successful double endoscopic bypass with endoscopic ultrasound-guided gastroenterostomy and choledochoduodenostomy. Endoscopy_UCTN_Code_TTT_1AS_2AB Endoscopy E-Videos https://eref.thieme.de/e-videos Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos Publication History Article published online: 24 June 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.001 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.002 |
| Bibliometrics | 0.003 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.003 |
| Open science | 0.001 | 0.003 |
| Research integrity | 0.004 | 0.004 |
| Insufficient payload (model declined to judge) | 0.003 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".