One-step endoscopic ultrasound-guided fine-needle biopsy of pancreatic mass, gastroenterostomy, and gallbladder drainage for malignant biliary and gastric outlet obstruction

A 77-year-old woman was admitted to our emergency department because of a 2-week history of vomiting, weight loss, and abdominal pain. An abdominal computed tomography (CT) scan revealed a 4-cm pancreatic mass that resulted in gastric outlet obstruction and dilation of the biliary tree and gallbladder. In a multidisciplinary meeting, it was decided to perform endoscopic ultrasound (EUS)-guided fine-needle biopsy (EUS-FNB), EUS-guided gastroenterostomy (EUS-GE), and EUS-guided gallbladder drainage (EUS-GBD) using two lumen-apposing metal stents (LAMSs). Under general anesthesia, EUS-FNB of the pancreatic mass was performed through the stomach using a 22-G needle (Acquire; Boston Scientific, Natick, Massachusetts, USA) ([Video 1]). Subsequently, a nasobiliary tube was passed through the neoplastic stricture to fill the jejunal loop with saline solution, methylene blue, and contrast medium. A 16 × 20-mm electrocautery-enhanced LAMS (Hot-Spaxus; Taewoong Medical, Gimpo-si, Korea) was passed from the stomach to the dilated jejunal loop using the freehand technique ([Fig. 1]). The proximal flange of the LAMS was deployed using the intrachannel technique. Subsequently, EUS-GBD was performed using an 8 × 20-mm electrocautery-enhanced LAMS (Hot-Spaxus; Taewoong Medical) and the freehand technique ([Fig. 2]). No adverse events were experienced by the patient. The post-procedural CT scan confirmed the accurate positioning of the two LAMSs between the stomach and jejunum, and between the stomach and gallbladder. The patient was discharged after 3 days, having successfully resumed oral feeding. In conclusion, in such cases, a one-step approach involving EUS-FNB, EUS-GE, and EUS-GBD is safe when performed by experts ([Video 1]).