Duodenal stenting following PTBS for periampullary tumor with gastric outlet obstruction

This 74 year old lady had previously undergone percutaneous transhepatic biliary stenting (PTBS) due to a metastatic periampullary tumor which had also infiltrated into the duodenum (A3 & B: white arrows) causing gastric outlet obstruction (don't forget to check for a succession splash in any patient with jaundice, kids). Once the biliary drainage had been taken care of, we moved to free the route out the stomach. The pyloric opening was narrowed and we dilated it using a TTS balloon (A1 &A2). Following this, we advanced our duodenal stent assembly across the bulb and descending duodenum (B & C1 : black arrows). The stent (20mm x 130mm) was then carefully unsheathed (C1 to C5: white arrows show the stent being deployed. Red arrows shows the "waist" forming right about the middle of the stent at the site of maximal luminal infiltration by the tumor).

Stenting a malignant duodenal stricture

This 70 year old gentleman had previously undergone placement of a metallic biliary stent last year for an ampullary tumor. He was subsequently lost to follow up and had only now presented with gastric outlet obstructive symptoms. A swallowed contrast study (A) clearly showed the problem. The previously placed stent was outlined (A: white arrows) along with the intrahepatic biliary channel (A: green arrows). The stricture was also seen as a thin structured segment in the second part of the duodenum (A: red arrow). On endoscopy, the affected area was seen with almost complete luminal obstruction (B: white arrow). We placed a biliary cannulation catheter across the stricture followed by contrast injection which outlined the extent of the stricture (C: red arrowheads) and the unaffected bowel segment beyond the stricture (C: blue arrow). The biliary stent was also seen (C: white arrowheads). A guidewire was then placed across the stricture (D: white arrows) followed by a stent assembly (E: black arrows). A 12 cm long stent of 20 mm diameter was then deployed (F1 & F2 : black arrows show the stent assembly. White arrowheads show the deployed portion of the stent . Red arrowheads show the distal  and middle radiographic markers of the stent. F3: Fully deployed stent. Stent outlined with white arrowheads. Red arrowheads showing the radiographic stent markers. Blue arrow showing the previously injected contrast in the lumen of the distal portion of the stent. G1 & G2: The stent as seen by the endoscope: white arrows. Compare with B).

Gastric outlet obstruction secondary to duodenal ulcer induced stricture

This patient was a 65 year old lady who had developed duodenal luminal stenosis after healing of a large duodenal ulcer. On endoscopy, the duodenal lumen was reduced to a pinhole just beyond the bulb (A: white arrow). We were using an Olympus dual channel scope. We decided to use a straight ERCP cannula to try and go through the stricture (B) but even that couldn't go through. We were however able to get a guidewire across the stricture after engaging it with the cannula (C: white arrows). This was followed by dilatation of the strictured track with graduated dilatation catheters (D1, D2 & D3: white arrows). A stent assembly was then placed across the stricture (E: white arrows) and an uncovered self expanding metallic stent of 20mm diameter and 130mm length was deployed (F1 & F2: white arrows. Red arrows show the "waist" of the stent due to the strictured area. G1, G2 & G3: the stent going through expansion).