V-13. Sequential Endoscopic Management of Dual Malignant Obstruction: Overtube-Assisted ERCP Prior to Esophageal Stenting

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ID: 325938
2026
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Ranked #188 of 453 articles by views in diseases of the esophagus : official journal of the international society for diseases of the esophagus

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Abstract
Abstract Topic Esophageal Cancer: Other Background Advanced esophageal cancer may rarely present with concomitant malignant biliary obstruction due to metastatic lymphadenopathy. Endoscopic management is technically challenging when luminal narrowing prevents passage of a side-viewing duodenoscope. Furthermore, esophageal stent placement prior to biliary drainage may compromise subsequent access to the papilla. We describe a sequential endoscopic strategy utilizing overtube-assisted ERCP prior to esophageal stent deployment. Methods A 51-year-old man with advanced distal esophageal carcinoma involving the esophagogastric junction presented with progressive dysphagia and obstructive jaundice. Laboratory evaluation demonstrated leukocytosis and direct hyperbilirubinemia consistent with cholangitis. Contrast-enhanced imaging revealed distal common bile duct obstruction secondary to extensive metastatic lymphadenopathy, with intrahepatic and extrahepatic bile duct dilatation. Forward-viewing endoscopy confirmed a tight circumferential malignant stricture at the EG junction. Although the forward-viewing endoscope was able to traverse the lesion, the side-viewing duodenoscope could not be advanced across the stricture. An overtube was positioned under forward-viewing endoscopic guidance beyond the EG junction. The duodenoscope was subsequently advanced through the overtube, enabling successful biliary cannulation. Double-guidewire–assisted sphincterotomy was performed, followed by deployment of a self-expandable metal stent in the common bile duct. After securing biliary drainage, a self-expandable esophageal stent was placed for dysphagia relief. Results Immediate bile drainage was achieved. Clinical resolution of cholangitis occurred with progressive improvement in bilirubin and cholestatic markers. The patient’s dysphagia improved following esophageal stenting. Conclusion In patients with advanced esophageal cancer complicated by malignant biliary obstruction, overtube-assisted ERCP prior to esophageal stent placement provides a feasible and strategic approach to secure biliary access. This sequential technique may prevent loss of endoscopic access and optimize outcomes in complex dual malignant obstruction. Video Description This video demonstrates a sequential overtube-assisted ERCP followed by esophageal self-expandable metal stent deployment in a patient with advanced distal esophageal cancer complicated by malignant biliary obstruction. Due to severe luminal narrowing at the esophagogastric junction, standard duodenoscope advancement was unsuccessful. An overtube was introduced under forward-viewing endoscopic guidance to facilitate safe passage of the side-viewing duodenoscope. Double-guidewire-assisted sphincterotomy was performed, followed by successful placement of a fully covered biliary self-expandable metal stent. Subsequently, an esophageal stent was deployed to relieve dysphagia. This case highlights a practical endoscopic strategy for managing synchronous malignant esophageal obstruction and biliary obstruction in advanced disease. The video emphasizes technical considerations, stepwise problem-solving, and safe endoscopic palliation in complex anatomical situations. This approach may serve as a useful reference for endoscopists managing challenging combined esophageal and biliary malignancies.
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Authors Natcha Boontanagon, Thita Intralawan, Noppawat Samankatiwat
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Journal diseases of the esophagus : official journal of the international society for diseases of the esophagus
Year 2026
DOI
10.1093/dote/doag077.413
URL
https://academic.oup.com/dote/article-pdf/39/Supplement_1/doag077.413/70760939/doag077.413.pdf
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