A 40-year-old man with a history of rectal cancer and abdominoperineal amputation was admitted with a complete small bowel obstruction, with no ostomy output for 3 days. Computed tomographic (CT) scan of the abdomen demonstrated massively dilated small-bowel loops ([Fig. 1]) with a high-grade obstruction at the level of the preterminal ileum due to a peritoneal implant ([Fig. 2]). Pelvic recurrence and bone and liver metastases were also observed. Conservative management for 2 weeks failed to resolve the patient’s symptoms. After detailed interdisciplinary discussion with the patient, we decided to attempt endoscopic ultrasound-guided colo-enterostomy using a lumen-apposing metal stent ([Video 1]).
Fig. 1 Computed tomographic (CT) scan of the abdomen showing dilated loops of small bowel.
Fig. 2 Peritoneal implant with complete stenosis at the level of the ileum.
Video 1 Endoscopic ultrasound-guided colo-enterostomy.
A gastroscope was used to advance to the third part of the duodenum. A guidewire was advanced to the jejunum and an 8.5-Fr nasobiliary drain was left in place. Contrast with methylene blue was infused to mark the proximal small bowel under fluoroscopy. Through the ostomy, we advanced a GF-UCT180 curved linear-array echoendoscope (Olympus) over a guidewire to the ascending colon. The most dilated loop of the small bowel with debris-filled fluid and no contrast on fluoroscopy was chosen. A 20 – × 10-mm electrocautery-enhanced lumen-apposing metal stent (Hot Axios; Boston Scientific) was deployed with a freehand technique. Abundant drainage of non-blue-stained small-bowel fluid into the colon was observed. Repeat CT scan demonstrated decompression of the small bowel and patency of the colo-enterostomy stent ([Fig. 3]).
Fig. 3 CT scan of the abdomen with colo-enterostomy between the hepatic flexure and ileum.
The patient improved symptomatically after the procedure and resumed oral feeding within 24 hours of the procedure. Antibiotics were continued for 5 days after the procedure. No immediate postoperative adverse events were noted, and the patient was subsequently discharged and followed up as an outpatient.
Only a few cases of EUS-guided colo-enterostomy have been published [1]
[2]
[3]. This new technique may be useful in palliative patients in whom surgery is not an appropriate option.
Endoscopy_UCTN_Code_TTT_1AQ_2AF
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
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