Double stenting with EUS‐CDS using a new anti‐reflux metal stent for combined malignant biliary and duodenal obstruction

A 79 year-old woman with advanced pancreatic cancer was hospitalized due to the tumor ingrowth of uncovered duodenal self-expandable metal stent (SEMS) and the outward migration of biliary SEMS (Fig. 1). The migrated biliary SEMS was removed and an endoscopic naso-biliary drainage (ENBD) tube was inserted. Endoscopic ultrasound guided-hepaticogastrostomy (EUS-HGS) was attempted, but failed because of insufficient dilation of the biliary branch even by injecting the saline from ENBD tube. Therefore, we tried to perform double stenting combined with EUS-guided choledochoduodenostomy (EUS-CDS) using a new anti-reflux metal stent (ARMS). By performing conventional EUS-CDS procedure, a laser-cut biliary SEMS with anti-reflux valve (Kawasumi Duckbill biliary stent, 10mm x 6cm; Kawasumi Laboratories, Japan) was deployed (Video 1).