Subsequent ileal stent placement for synchronous small-bowel obstruction through endoscopic ultrasound-guided ileocolostomy with a lumen-apposing metal stent

Peritoneal carcinomatosis is a severe complication of advanced gastrointestinal cancer, often leading to malignant bowel obstructions (MBOs) at multiple synchronous or metachronous points, with distressing symptoms such as frequent vomiting [1] [2]. Surgical management of MBO presents significant challenges in these patients [3]. Here, we report a case of stepwise endoscopic management of MBO using endoscopic ultrasound (EUS)-guided ileocolostomy with a lumen-apposing metal stent (LAMS), followed by metal stent placement through the LAMS for synchronous small-bowel obstruction.

A 64-year-old woman with locally advanced pancreatic cancer with multiple metastases presented with persistent vomiting owing to peritoneal carcinomatosis. Abdominal computed tomography (CT) scanning revealed marked small-bowel dilatation ([Fig. 1] a), with distal ileal obstruction ([Fig. 1] b). Given her unsuitability for surgery, an initial attempt at enteral stent placement via colonoscopy was made but was unsuccessful owing to limited advancement of the scope. Subsequently, EUS-guided ileocolostomy ([Video 1]) was performed using an electrocautery-enhanced LAMS (Niti-S HOT SPAXUS; Taewoong Medical, Gyeonggi-do, Korea) and the free-hand technique. Upon successful deployment, a substantial volume of liquid fecal material drained into the sigmoid colon through the LAMS.

Fig. 1 Initial computed tomography images showing: a marked dilatation of the entire small intestine, accompanied by mild ascites; b a distinct stricture (yellow arrow) in the distal ileum, likely due to recurrent peritoneal carcinomatosis.

Stepwise endoscopic ultrasound-guided ileocolostomy is performed using a lumen-apposing metal stent (LAMS), followed by small-bowel stent placement through the LAMS.Video 1

The patient was readmitted 1 month later with abdominal distension and frequent vomiting. A follow-up CT showed progression of the peritoneal carcinomatosis, with synchronous small-bowel obstruction in the mid ileum ([Fig. 2] a). Colonoscopy was performed ([Video 1]), and access through the LAMS allowed identification of a distal ileal obstruction. After the obstruction had been cannulated and contrast injected to delineate the occluded segment, a guidewire was placed. Subsequently, a 6-cm uncovered self-expandable metal stent (Niti-S duodenal stent; Taewoong Medical) was successfully deployed ([Fig. 2] b), leading to clinical improvement, and the patient was discharged from hospital.

Fig. 2 Images of colonoscopic small-bowel stenting for synchronous ileal obstructions showing: a on follow-up computed tomography scan, progression of peritoneal carcinomatosis with synchronous small-bowel obstruction (yellow arrow) in the mid ileum; b on colonoscopy, a successfully deployed 6-cm uncovered self-expandable metal stent.

This case highlights a novel, minimally invasive, stepwise endoscopic approach for multifocal MBO, demonstrating the feasibility of EUS-guided ileocolostomy with a LAMS to facilitate subsequent interventions, including stent placement, for synchronous or metachronous small-bowel obstructions.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Bellavance EC, Alexander 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:
13 June 2025