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Endoscopic ultrasound (EUS)-guided double bypass (EUS-DB) is a novel technique in the management of concomitant biliary and gastric outlet obstruction [1–3]. It involves the creation of both an EUS-guided gastroenterostomy and a hepatogastrostomy. We describe the first reported case in the literature (with video) of EUS-DB performed in collaboration with interventional radiology. A 54-year-old man with known 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 as a result of tumor tissue ingrowth. A decision was made to proceed to EUS-DB to optimize nutritional status, biliary drainage, and patient comfort (▶Video1). A guidewire was introduced 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 PTBDwire and advanced across the enteral stent to the ligament of Treitz, where the balloon was inflated under fluoroscopy (▶Fig. 1 a). Overall, 500mL of both saline and contrast was then injected percutaneously to dilate the small-bowel segment proximally to the balloon. EUS-guided puncture of the balloon was performed transgastrically with a 19-gauge needle (▶Fig. 1 b). Bursting of the balloon confirmed successful puncture in the desired jejunal segment. A 0.035-inch guidewire was then advanced through the needle, 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 4mm dilating balloon. A lumen-apposing metal stent (15×10mm) was then deployed under EUS guidance (▶Fig. 1 c). Contrast injection confirmed a patent gastroenterostomy. Attention was then shifted to the hepatogastrostomy. Under EUS guidance, a dilated hepatic segment III left intrahepatic bile duct was visualized. A transgastric E-Videos

A novel collaborative approach to endoscopic double bypass in concomitant gastric outlet and biliary obstruction