Ampullary tumor infiltrating into duodenum

Gastric outlet obstruction had resulted in this 70 year old gentleman due to his ampullary tumor infiltrating into his duodenum. He had earlier undergone stenting of the common bile duct for obstructive jaundice. First a plastic stent followed a few weeks later by a self expanding metallic stent. Unfortunately, only a couple of weeks later he developed symptoms of gastric outflow obstruction. The tumor had invaded the duodenal wall. On endoscopy, the previously placed metallic biliary stent was seen (A: red arrow) with the tumor tissue obstructing the duodenal lumen at the junction of bulb and descending duodenum (A: green arrow). It was decided to place a 22mm x 90mm self expanding metallic stent. The stent assembly was manoeuvred across the strictured area under flouroscopic guidance followed by contrast injection to confirm luminal patency beyond the strictured segment (B: red arrows). The stent was then deployed (C: green arrow. This is a classic picture of a patient with gastric outflow obstruction: a stent being placed on the right, stomach full of fluid due to obstruction on the left and the  obstructed duodenal lumen in top middle). The stent was deployed successfully (D). The final image showing the fully deployed stent (E: green arrow) with the previously placed metallic (E: red arrow) and plastic (E: yellow arrow) biliary stents.