Abbreviations:LAMS (lumen-apposing metal stent), SBO (small-bowel obstruction)
Small-bowel obstruction (SBO) is typically managed with gastric decompression and intravenous hydration; however, when conservative management fails, operative management is necessary.
1In cases of extrinsic compression from adhesive disease, laparotomy with lysis of adhesions is often required.
- Tanaka S.
- Yamamoto T.
- Kubota D.
- et al.
Predictive factors for surgical indication in adhesive small bowel obstruction.
Am J Surg. 2008; 196: 23-27
2Patients with high-grade obstruction who do not proceed to operative management are at risk for bowel perforation and septic shock from peritonitis.
- Hayanga A.J.
- Bass-Wilkins K.
- Bulkley G.B.
Current management of small-bowel obstruction.
Adv Surg. 2005; 39: 1-33
3However, many patients either fail operative management or are not candidates for surgery because of comorbidities.
- Foster N.M.
- McGory M.L.
- Zingmond D.S.
- et al.
Small bowel obstruction: a population-based appraisal.
J Am Coll Surg. 2006; 203: 170-176
4Endoscopic management of distal SBO is most effective in short strictures without high-grade obstruction.
- Barkan H.
- Webster S.
- Ozeran S.
Factors predicting the recurrence of adhesive small-bowel obstruction.
Am J Surg. 1995; 170: 361-365
5A nonsurgical method for treating SBO in patients unfit for surgery has the potential to improve clinical outcomes for a challenging patient population. The aim of this video (Video 1, available online at www.VideoGIE.org) was to describe the EUS-directed ileocolonic anastomosis technique in the nonoperative management of distal SBO.
- Hirai F.
- Beppu T.
- Takatsu N.
- et al.
Long-term outcome of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease.
Dig Endosc. 2014; 26: 545-551
EUS-directed ileocolonic anastomosis is performed with the patient under general anesthesia. A forward-viewing curvilinear array echoendoscope (TGF-UC180J; Olympus, Central Valley, Pa, USA) is inserted and advanced into the right colon segment, as close to the SBO transition point as possible. Under fluoroscopic guidance, we pass the echoendoscope to the proximal right colon segment, and echo is used to visualize the dilated small bowel. A lumen-apposing metal stent (LAMS) with electrocautery-enhanced tip (AXIOS-EC; Boston Scientific, Natick, Mass, USA) is advanced across the colonic wall into the target ileum. The distal flange of the LAMS is deployed under EUS guidance and the proximal end of the stent under direct endoscopic visualization. Optionally, the LAMS is then dilated with a through-the-scope balloon dilator to allow passage of the endoscope into the small bowel. Under fluoroscopy, contrast is injected to confirm placement of the LAMS across the lumina and absence of leakage.
A 65-year-old man with a history of HIV infection (CD4: 347), chronic obstructive pulmonary disease, hypertension, and anal squamous cell carcinoma who had undergone diverting colostomy, ileocecectomy with ileocolonic anastomosis, and adjuvant chemoradiation developed recurrent SBO. After an extended admission at our institution for SBO with failure of conservative treatment, the patient underwent surgical management with laparotomy and lysis of adhesions; a gastrostomy tube was placed at that time for gastric decompression. He was readmitted 3 additional times for recurrent SBO, which was managed conservatively.
He presented again with a complete SBO with no ostomy output for 1 week and increased gastrostomy tube drainage. A CT scan of the abdomen and pelvis demonstrated massively dilated small-bowel loops with a high-grade obstruction at the level of the ileocolonic anastomosis without associated mass (Fig. 1). He was started on intravenous fluids, and a nasogastric tube was placed. Blood cultures were collected and found to be positive for coagulase-negative Staphylococcus; he was started on vancomycin and cefepime. Colonoscopy was performed and demonstrated complete obliteration of the lumen at the ileocolonic anastomosis (Fig. 2). He was deemed to be a poor surgical candidate because of his prior surgeries and was referred for further management.
A forward-viewing echoendoscope was inserted into the colostomy and advanced into the right colon segment. Under fluoroscopy, the echoendoscope was positioned in the proximal transverse colon. The endosonographic view demonstrated a markedly dilated small bowel. Using a LAMS with electrocautery, we advanced a 20- × 20-mm stent across the colonic wall into the ileum (Fig. 3). Using a 20-mm through-the-scope balloon dilator, we dilated the stent to its fully expanded diameter (Fig. 4). The endoscope was advanced into the small bowel, and contrast injection confirmed excellent placement without leakage (Fig. 5).
The patient tolerated the procedure well without adverse events. Within 12 hours, his nasogastric tube was removed and he was tolerating a liquid diet; by 48 hours after the procedure he was tolerating a regular diet. There were no adverse events (Fig. 6).
In conclusion, EUS-directed ileocolonic anastomosis is a novel approach to the management of SBO. The advent of LAMSs has made bypass of a bowel obstruction possible. Further study is needed to determine optimal patient selection.
Dr Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, and Olympus America. Dr James receives research and training support by a grant from the NIH (T32DK007634). All other authors declare no relevant funding for this work. All other authors disclosed no financial relationships.
- Video 1
EUS-guided ileocolonic anastomosis for relief of complete small bowel obstruction.
- Predictive factors for surgical indication in adhesive small bowel obstruction.Am J Surg. 2008; 196: 23-27
- Current management of small-bowel obstruction.Adv Surg. 2005; 39: 1-33
- Small bowel obstruction: a population-based appraisal.J Am Coll Surg. 2006; 203: 170-176
- Factors predicting the recurrence of adhesive small-bowel obstruction.Am J Surg. 1995; 170: 361-365
- Long-term outcome of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease.Dig Endosc. 2014; 26: 545-551
Published online: June 26, 2020
© 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.
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