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Endoscopic ultrasound-guided colonic anastomosis: pushing the boundaries
Lumen-apposing metal stents (LAMS) have pushed the boundaries of interventional EUS beyond drainage of pancreatic fluid collections. EUS-guided gastroenterostomy (EUS-GE) using LAMS is now an accepted treatment modality for malignant gastric outlet obstruction (GOO) at many institutions. EUS-GE has multiple advantages over enteral stenting, including decreased risk of recurrent GOO due to stent occlusion. EUS-GE entails formation of an anastomosis between the stomach and a small bowel segment distal to the site of obstruction, usually the distal duodenum or proximal jejunum.
EUS-guided anastomosis formation has also been described at other sites, such as duodenojejunostomy (EUS-DJ) and jejunojejunostomy (EUS-JJ). EUS-DJ can be utilized in patients with malignant distal duodenal or proximal jejunal obstruction when EUS-GE is not possible, or for facilitation of subsequent endoscopic retrograde cholangiopancreatography (ERCP) in patients with difficult surgical anatomy and in whom standard ERCP has failed. EUS-JJ can be employed to treat afferent or efferent loop obstructions in patients with surgically altered anatomy (e. g., after pancreaticoduodenectomy).
Despite the multiple routes and access points for EUS-guided anastomosis creation described above, interventional endosonographers have predominantly avoided the colon. This is likely multifactorial, but reasons include fear of fecal leakage, perforation, and peritonitis.
The colon is probably an easier target for EUS-guided anastomosis than is the jejunum, simply because of its larger lumen. The cecum/ascending colon and transverse colon are in proximity to the duodenum and stomach, respectively. Sooklal and Kumar reported a case of a 43-year-old man with inoperable malignant small bowel obstruction (SBO) in the mid-ileum . A percutaneous venting tube was not possible due to peritoneal carcinomatosis. EUS-guided duodenocolostomy (EUS-DC) was performed between the second duodenum and the cecum after initially advancing a colonoscope to the cecum and filling it with fluid. Nausea and vomiting resolved and the patient was able to tolerate comfort food by mouth. Mir and colleagues reported the case of a 72-year-old woman with inoperable metastatic cancer and history of colonic stent placement, who presented with malignant SBO . An echoendoscope was advanced transanally and an ileocolonic anastomosis was created using a LAMS between the sigmoid colon and ileum, allowing resumption of tube feeding. No adverse events occurred in either of these two cases, and both patients ended up under hospice care due to their end-stage malignant disease.
These two cases highlight the feasibility of EUS-guided enterocolonic (EUS-EC) anastomoses using LAMS. We recently encountered a 64-year-old man with a history of appendiceal cancer treated with surgical resection and ileocolonic anastomosis. He later presented with metastasis and symptomatic multilevel SBO in the distal duodenum, jejunum, and ileocolonic anastomosis. Symptoms included abdominal pain, distention, intolerance to oral intake, nausea, and vomiting. The patient desired to consume comfort food orally and refused a decompression percutaneous endoscopic gastrostomy (PEG) tube. An EUS-guided approach was discussed with the patient and the multidisciplinary team. EUS-DC and EUS-guided gastrocolostomy (EUS-GC) were deliberated as options to bypass and relieve symptoms of multilevel SBO. Potential risks of perforation, fecal peritonitis, diarrhea, and malnutrition were discussed. Colonoscopy was performed using an adult colonoscope after the colon was cleansed with multiple enemas. About 500 mL of fluid (saline, contrast, and methylene blue) was infused in the right colon. The colonoscope was withdrawn and a linear echoendoscope was advanced transorally. The intention was to target a right colonic loop to minimize the risk of diarrhea. A well-distended and fluid-filled transverse colon loop in proximity to the gastric wall was located sonographically and radiographically. This was punctured with a 19-gauge needle under EUS guidance with aspiration of blue-tinged fluid confirming colonic access. A 15 mm × 15 mm LAMS (Hot Axios; Boston Scientific, Marlborough, Massachusetts, USA) was then placed under EUS guidance using the freehand technique, forming a gastrocolostomy ([Fig. 1]; [Video 1]). The procedure was completed without any adverse events. The patient was placed on a twice-daily proton pump inhibitor (PPI) and started on a liquid diet and total parenteral nutrition (TPN). All obstructive symptoms resolved and he was discharged home on a full liquid diet 9 days after the procedure. At 6 weeks after the procedure, he reported eating semisolid food without nausea, vomiting, or diarrhea. He had discontinued his TPN at his own discretion and has been able to maintain his weight.
Video 1 Endoscopic ultrasound-guided gastrocolostomy procedure.
The three cases discussed above illustrate scenarios where EUS-guided gastrojejunostomy (EUS-GJ) or enteral stenting are not feasible options to alleviate symptoms of complex SBO, necessitating an EUS-EC or EUS-GC approach to bypass the obstruction and allow some degree of oral intake. These cases suggest the feasibility and safety of both approaches, recognizing the colon as a possible target organ for EUS-guided anastomoses in highly selected cases. Below are salient discussion points relevant to this emerging field.
26 November 2020 (online)
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