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

Abstract

Figures

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.

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.

Full text

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.

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.

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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