Coaxial transstent bypass to treat simultaneous malignant biliary and duodenal obstruction.

tion of the mass during endoscopy revealed welldifferentiated adenocarcinoma of the pancreas. Because of the patient’s advanced disease. cachexia, and abnormal clotting, she was not a candidate for surgical palliation. The interventional radiology service was consultedto relieve both the biliary and the gastric outlet obstructions percutaneously. The initial plan was to place a percutaneous biliary drain. After correction of the coagulation abnormalities. a two-step approach was used for biliaiy access. First, a segment II bile duct was punctured with a 22-gauge needle, using sonographic guidance and a left-sided approach. Percutaneous transhepatic cholangiographyshowed a stricture in a long segment of the common bile duct. Duct acces.s for drainage was achieved through a segment ifi left-sided mute. Cannulation through the area of obstruction was achieved. A 10-French biiajy drainage catheter with a locking pigtail was placed in the third portion ofthe duodenum. The patient then underwent percutaneous gastrostomy. Uneventful placement of three T-tack fasteners was followed by creation of gastric access using a sheath and wire. The wire was placed through the pylorus; however, numerous attempts to traverse the malignant duodenal stricture were unsuccessful (Fig. IB). The patient tolerated the