EUS-guided double drainage for synchronous malignant gastric and biliary obstruction

Malignant pancreatic, duodenal and biliary tract pathology may often present late with simultaneous malignant distal biliary obstruction (MDBO) and gastric outlet obstruction (GOO), referred to as dual obstruction with poor patient prognosis. Historically, this often results in nutritionally compromised and jaundiced patients with limited palliative drainage options. Endoscopic approaches to these obstructions in isolation, via enteral stenting (ES) and endoscopic retrograde cholangiopancreatography, have remained the mainstay of endoscopic palliative therapies to date, offering alternatives to surgical intervention. However, these are limited by requirements for repeated reinterventions and the synchronous nature of dual obstruction may preclude further therapies. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) and EUS-biliary drainage (EUS-BD) are increasingly deployed to manage these symptoms with superior outcomes to other endoscopic approaches and offer similar long-term clinical outcomes to surgical intervention. The role of combined EUS-double drainage (EUS-DD; EUS-GE and EUS-BD) in dual obstruction is becoming central in the palliative management of these patients, providing a minimally invasive, clinically efficacious and safe alternative to surgical intervention in a potentially frail patient cohort. EUS-DD is a technically demanding procedure and is limited to expert centres at present with adequate volume and sufficient auxiliary interventional/surgical support. Significant training exposure is required to develop and maintain endoscopic skillsets. Despite these limitations, EUS-DD is well positioned to become the standard of care in appropriate centres for palliation of malignant dual obstruction.