Endoscopic Approaches to Concomitant Malignant Biliary Obstruction and Gastric Outlet Obstruction

Biliary obstruction (BO) and gastric outlet obstruction (GOO) are common complications of pancreatic cancer. Reestablishing both biliary and luminal patency are of upmost importance for successful management or palliation of these patients. Endoscopic retrograde cholangiopancreatography (ERCP) is often challenging in cases of malignant biliary obstruction, especially when associated with GOO. In this chapter, we will discuss the endoscopic management of concomitant malignant BO and GOO, including novel EUS-guided interventions. We will describe the importance of proper anatomic understanding and classification GOO, which largely determines the most appropriate endoscopic approach. Optimal stent selection, timing, and order of biliary and enteral stent insertion and advanced techniques, such as performing ERCP through an existing enteral stent, will also be discussed. Finally, we will review the techniques and the existing literature for EUS-guided gastroenterostomy in GOO and EUS-guided biliary drainage.