LAMS to the SEMS Rescue!

We present the case of an 80-year-old woman with gastric outlet obstruction syndrome due to colorectal cancer metastasis in the distal duodenum. A 9-cm luminal uncovered self-expandable metal stent (SEMS) (Wallstent®, Boston Scientific, Marlborough, MA, USA) was inserted, with the proximal flange located in D2. The obstructive symptoms resolved but the patient was admitted a week later due to jaundice (total bilirubin 4.07 mg/dL, direct 2.84 mg/dL). Abdominal computerized tomography revealed marked dilation of the common bile duct (CBD) up to the level of the papilla (Fig. 1). An endoscopic retrograde cholangiopancreatography (ERCP) was scheduled. Anticipating difficulties in accessing the duodenal papilla, an endoscopic ultrasoundguided biliary drainage (EUS-BD) was also planned in advance. As suspected, the metal mesh in the duodenum hindered duodenoscope progression, precluding any attempt at biliary cannulation. Since the duodenal bulb was free, we decided to perform a choledochoduodenostomy using a 6 × 8 mm lumen-apposing metal stent (LAMS) (Hot AXIOS®, Boston Scientific, Marlborough, MA, USA). A therapeutic echoendoscope was advanced to the duodenal bulb and a 19-gauge needle was used to puncture the dilated CBD and aspirate bile. A 0.035-inch guidewire was then inserted into the CBD and the LAMS was deployed following the manufacturer’s instructions (Fig. 2). After the procedure, jaundice resolved and the patient was able to resume the palliative chemotherapy prescribed, with no recurrence of obstructive symptoms or jaundice in 4 months of follow-up. Figure 3 shows a predischarge gastroduodenography, revealing patency of the duodenal stents and oral contrast opacifying the biliary tree through the LAMS. This case highlights biliary obstruction as an uncommon adverse effect of endoscopic SEMS placement. We attributed jaundice to the procedure and not to malig-