Electronic reprint for personal use Multicenter experience with performance of ERCP in patients with an indwelling duodenal stent Authors Mouen A. Khashab 1 , Ali Kord Valeshabad 1 , Wesley Leung 2 , Joel Camilo 3 , Norio Fukami 3 , Frederick Shieh 4 , David Diehl 4 , Rajeev Attam 5 , Frank P. Vleggaar 6 , Payal Saxena 1 , Martin Freeman 5 , Anthony Kalloo 1 , Peter D. Siersema 6 , Stuart Sherman 2 Institutions Institutions are listed at the end of article. submitted 21. July 2013 accepted after revision 29. October 2013 Bibliography DOI http://dx.doi.org/ 10.1055/s-0033-1359214 Published online: 2014 Endoscopy © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Mouen A. Khashab, MD Johns Hopkins Hospital 1800 Orleans St, Suite 7125 B Baltimore MD 21205 USA Fax: +1-443-287-1960 mkhasha1@jhmi.edu Case report/series Introduction ! Endoscopic retrograde cholangiopancreatogra- phy (ERCP) is the technique most commonly em- ployed for palliation of biliary obstruction [1]. Pa- tients with gastric outlet obstruction (GOO) re- sulting from intrinsic or extrinsic tumor compres- sion and/or infiltration of the duodenum present a particular challenge during ERCP, especially in the presence of a duodenal self-expandable metal stent (SEMS) [2]. The location of the duodenal obstruction in rela- tion to the major papilla is of foremost impor- tance in determining the success of simultaneous endoscopic palliation of biliary and duodenal ob- struction, since the duodenal obstruction can lim- it access to the biliary orifice [3]. Type I stenosis occurs at the level of the duodenal bulb or upper duodenal genu without involving the major pa- pilla. Type II stenosis affects the second part of the duodenum and involves the papilla. Type III stenosis involves the third part of the duodenum distal to the papilla and does not involve it [3]. ERCP is least challenging in patients with type III duodenal stenosis, while type I is intermediate and type II is the most technically difficult [2]. There is a dearth of literature describing or guid- ing endoscopists in the management of biliary ob- struction in these difficult-to-treat patients [2]. The aim of this study was to describe a multicen- ter experience of performing ERCP in patients with biliary obstruction and a papilla obscured by a preexisting duodenal stent. Patients and methods ! This study was carried out as a retrospective co- hort study at one European and five US tertiary centers. The endoscopy and/or hospital claims da- tabases were searched for patients who under- went duodenal SEMS placement for treatment of GOO between November 2000 and November 2012. Adult men or women with duodenal stents obscuring the papilla and who required biliary stenting subsequent to duodenal stenting (during the same or a later session) were included in the study ( ● " Fig. 1). Patients with surgically altered anatomy, duodenal stents not obscuring the pa- pilla, or preexisting biliary stents were excluded. The study was approved by the Institutional Re- view Board for Human Research and complied Khashab Mouen A et al. Multicenter experience with performance of ERCP in patients with an indwelling duodenal stent … Endoscopy Endoscopic retrograde cholangiopancreatogra- phy (ERCP) in patients with a preexisting duode- nal stent covering the papilla is particularly chal- lenging. The aim of this study was to describe a multicenter experience of performing ERCP in pa- tients with biliary obstruction in whom the papil- la was obscured by a preexisting duodenal stent. A total of 38 patients with preexisting duodenal stents obscuring the papilla underwent ERCP. Endoscopic biliary cannulation was successful in 13 patients (34.2 %). In 12 of these 13 patients (92.3%), endoscopic therapy was performed dur- ing the same procedure and achieved clinical suc- cess with relief of jaundice in all cases (100 %). The most commonly utilized procedure in patients in whom ERCP failed was EUS-guided biliary drain- age (EGBD; n = 13 /22, 59.1 %), followed by percu- taneous transhepatic biliary drainage (n = 9 /22, 40.9 %). Three patients in whom ERCP failed either did not consent to further intervention or were transferred to other centers. Thus, ERCP was tech- nically challenging in our cohort of patients with preexisting duodenal stents, but was nonetheless successful in about one third of cases. Overall, when performed by experts, endoscopic biliary drainage (via ERCP or EGBD) can be successfully achieved in the majority of patients with indwel- ling duodenal stents.