A 50-year-old male was admitted to the hospital complaining of right upper quadrant pain and vomiting. Initial abdominal computed tomography (CT) showed a stomach mass in the pylorus, narrowing the lumen, and multiple enlarged perigastric lymph nodes (LNs). Based on the CT image, advanced gastric cancer was diagnosed as stage IIIB. The patient was not a candidate for surgery because of the advanced stage of his stomach cancer. Therefore, a self-expandable, uncovered type pyloric stent (18 mm × 10 cm; Bona stent, Sci-Tech Inc., Seoul, Korea) was placed successfully for palliative treatment. After the procedure, the patient was able to tolerate a low residue diet without vomiting and showed a normal total bilirubin level. Five days after placement of the stent, the patient was referred for management of an elevated total bilirubin level (6.6 mg/dL) and jaundice. Ultrasonography showed diffuse dilatation of intrahepatic ducts from the proximal common bile duct (not shown here). Percutaneous biliary drainage (PTBD) was performed via the left lateral segmental duct under ultrasonographic guidance. A tubogram revealed blockage of the common bile duct, which was interpreted to indicate acute extrahepatic duct compression by the expanded pyloric stent and multiple enlarged perigastric LNs (Fig. 1A). Six days after PTBD, we placed a biliary stent (10 mm × 7 cm; Hercules, S&G Biotech, Seongnam, Korea) in the common bile duct. Follow-up tubogram after the biliary stent insertion revealed good passage of contrast media via the biliary stent into the duodenum (Fig. 1B), and the total bilirubin level decreased to 1.38 mg/dL and remained normal for 118 days.

A 76-year-old female was referred to our hospital with complaints of abdominal discomfort and recurrent vomiting. Gastroduodenal endoscopy revealed advanced carcinoma in the second and third portion of the duodenum. We placed an uncovered duodenal stent (20 mm × 14 cm; Hanaro stent, SolcoIntermed, Seoul, Korea) for palliation. After duodenal stent placement, the patient tolerated a soft diet and the total bilirubin level was within normal ranges. Six days after duodenal stent placement, the patient was referred again because the total bilirubin levels had rapidly increased (5.1 mg/dL). CT showed diffuse dilatation of extra- and intra-hepatic ducts (not shown here). PTBD was performed via the right posterior segmental duct and a tubogram showed complete obstruction at the Ampulla of Vater with dilatation of the biliary tree (Fig. 2A). Acute biliary obstruction was assumed to result from compression of Ampulla of Vater by expansion of the duodenal stent and displaced duodenal cancer. To manage the obstruction, a biliary stent (10 mm × 7 cm; Hercules stent, S&G Biotech, Seongnam, Korea) was placed through the mesh of the duodenal stent after pre-stent balloon dilatation with a 6 mm × 4 cm balloon. A follow-up tubogram, 3 days after placement, of the biliary stent showed good passage of contrast media into the duodenum and jejunum through the biliary and duodenal stents (Fig. 2B). Five days later, the total bilirubin level was also normalized (0.8 mg/dL). The patient was monitored for 135 days and remained asymptomatic through that time.