Long-term palliation of combined malignant gastric outlet and biliary obstruction by using sequentially enteral stents and EUS-guided antegrade biliary and lumen-apposing gastrojejunal stents.

For unresectable advanced gastric malignancies causing malignant gastric outlet obstruction(GOO) and malignant biliary obstruction(MBO), traditional treatment methods include surgical gastrojejunostomy and hepatojejunostomy. However, surgical treatment is associated with many complications and prolonged recovery. We report a case of a 56-year-old male patient who complained of nausea and vomiting after meals for one month. Esophagogastroduodenoscopy(EGD) revealed a malignant gastric tumor, pyloric obstruction, and gastric retention. Abdominal CT revealed multiple liver metastases and distant lymph nodes metastases. Two duodenal stents were placed within two months to relieve the malignant GOO. Five months later, rapid tumor progression led torecurrent malignant GOO and involvement of the duodenum, resulting in MBO. Since endoscopic retrograde cholangiopancreatography(ERCP) was not feasible, we relieved the MBO through endoscopic ultrasound guided antegrade stenting (EUS-AS). One week later, GOO was treated with endoscopic ultrasound guided gastroenterostomy (EUS-GE). During the 6-month follow-up period, the patient experienced no recurrence of obstructive jaundice or gastric retention, and the treatment was effective. Endoscopic stent placement can relieve malignant double obstruction,with minimal complications and rapid recovery. Endoscopic interventions are repeatable and provide immediate and reliable clinical benefit.