Endoscopic ultrasound-guided ileocolostomy using a novel lumen-apposing metal stent for small-bowel obstruction with peritoneal carcinomatosis

Peritoneal carcinomatosis is a serious condition stemming primarily from advanced gastrointestinal cancers, which causes significant symptoms such as vomiting due to malignant bowel obstruction (MBO) [1] [2]. The prognosis is poor, treatments often lack evidence-based guidelines, and many interventions, including surgical options for related MBO, present challenges [3]. Herein, we present a case of endoscopic ultrasound (EUS)-guided ileocolostomy using a novel lumen-apposing metal stent (LAMS) to treat MBO associated with peritoneal carcinomatosis.

A 52-year-old woman presented to our hospital with frequent vomiting. She had undergone subtotal gastrectomy with Billroth I anastomosis 15 years previously. She had recently been diagnosed with recurrence of peritoneal carcinomatosis. An abdominal computed tomography (CT) scan revealed significant dilatation of the entire small intestine ([Fig. 1] a) and a leading stricture in the distal ileum ([Fig. 1] b). Given the patient’s wishes and her unsuitability for surgery, we first attempted to place an enteral stent using a cap-assisted colonoscope; however, even at the point of the scope’s furthest reach, 30 cm from the ileocecal valve, the ileal stricture could not be accessed.

Fig. 1 Images from the initial computed tomography scan showing: a significant dilatation of the entire small intestine, accompanied by minimal ascites; b a pronounced stricture (yellow arrow) resulting from the recurrence of peritoneal dissemination in the distal ileum.

After this unsuccessful attempt, we opted to perform a transluminal EUS-guided ileocolostomy ([Video 1]). Using a linear echoendoscope (EG-580UT; Fujifilm Medical Systems, Tokyo, Japan), we identified significant dilatation of the ileum. The distal ileum in the pelvic cavity was then punctured from the sigmoid colon using a standard 19-gauge needle (EZ Shot3; Olympus Medical, Tokyo, Japan). Following needle puncture, contrast agent was injected to visualize the distal ileum fluoroscopically. Subsequently, a guidewire was placed and coiled in the distal ileum. Finally, a novel LAMS with an electrocautery-enhanced tip (Niti-S HOT SPAXUS; Taewoong Medical, Gyeonggi-do, South Korea) was inserted and deployed across the ileocolic tract. Upon successful deployment, a substantial volume of liquid fecal material flowed into the sigmoid colon via the LAMS.

Endoscopic ultrasound (EUS)-guided ileocolostomy using a novel lumen-apposing metal stent (LAMS) to treat malignant bowel obstruction.Video 1

Following the intervention, the patientʼs symptoms improved notably, and there were no immediate or delayed adverse events. A subsequent CT scan verified appropriate positioning of the LAMS, connecting the distal ileum and sigmoid colon ([Fig. 2]). EUS-guided ileocolostomy using this novel LAMS is a viable alternative to surgery for the management of MBO.

Fig. 2 Images from the subsequent computed tomography scan 2 weeks after the endoscopic ultrasound-guided ileocolostomy showing the correctly positioned lumen-apposing metal stent, which has decompressed the entire small intestine.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Bellavance EC, Alexander Jr HR. Palliative interventions in patients with peritoneal metastases and malignant bowel obstruction. J Clin Oncol 2012; 30: 4290-4291
• 2 Ferguson HJ, Ferguson CI, Speakman J. et al. Management of intestinal obstruction in advanced malignancy. Ann Med Surg (Lond) 2015; 4: 264-270
• 3 Santangelo ML, Grifasi C, Criscitiello C. et al. Bowel obstruction and peritoneal carcinomatosis in the elderly. A systematic review. Aging Clin Exp Res 2017; 29: 73-78

Publication History

Article published online:
23 January 2024