Double Endoscopic Bypass: A Durable Solution to Pair With Improving Systemic Therapy for Metastatic Cancer

CASE REPORT An 81-year-old woman presented with vomiting and pruritus secondary to gastric outlet and biliary obstruction, with previous transverse colon adenocarcinoma resection 3 years prior. Positron emission tomography noted a 7-cm duodenal lesion with inoperable metastatic disease (Figure 1), precluding conventional biliary access. Endoscopic ultrasound-guided gastrojejunostomy (Figure 2) and choledochogastrostomy, using lumen-apposing metal stents (Boston Scientific AXIOS - 15 × 10 mm and 10 × 10 mm), was completed. Oral intake and bilirubin improved from 114 to 6 (ref 0–20 mcmol/L). Her tumor was mismatch repair-deficient metastatic colorectal cancer, prompting initiation of pembrolizumab. Symptoms resolved and six-month imaging showed complete tumor resolution (Figure 3). Maintenance pembrolizumab continues and the stents will remain in situ while asymptomatic.Figure 1.: Positron emission tomography imaging on admission showing a 7-cm duodenal lesion with features of metastatic disease.Figure 2.: Endoscopic ultrasound-guided gastrojejunostomy - fluoroscopic view of guidewire and AXIOS stent.Figure 3.: Cross sectional computed tomography imaging following treatment with pembrolizumab, showing complete resolution of tumor burden.Historically, lumen-apposing metal stents placement in malignant gastric outlet and biliary obstruction has been palliative.1 Advances in systemic therapies mean patients previously considered untreatable may now outlive their stents. Endoscopic bypass offers a less invasive alternative to surgery, with less morbidity, longer lasting patency compared with conventional biliary and enteral stenting, and the ability to remove the stents.2,3 This case illustrates the increasing role for interventional endoscopic ultrasound4 to manage these patients. This approach, while minimally invasive, carries potential risk, including bleeding, stent migration, and buried stent syndrome.5 Longer term use and outcomes with these stents warrants further studies. DISCLOSURES Author contributions: N. Parkash, O. McKay, A. Strickland, and D. Croagh: Conception and design; drafting of the article; critical revision of the article for important intellectual content; final approval of the article. N. Parkash is the article guarantor. Financial disclosure: None to report. We have received ethics approval for this project through Monash Health Ethics: ERM reference number QA/118695/MonH-2025-481176(v1). Monash Health reference number: RES-25-0000332Q. Informed consent was obtained for this case report.