EUS-guided ileal-ascending colon anastomosis as an alternative to surgical stoma in the palliation of the cecal cancer invading the ileocecal valve

The formation of an intestinal stoma for fecal diversion is one of the most frequent interventions for the palliation in intestinal obstruction from colon cancer in inoperable patients. However, it is burdened by high morbidity and adverse events such as ischemia, necrosis, retraction, or stoma prolapse. We describe a case of EUS-guided ileal-ascending colon anastomosis in a patient with cecal cancer, unfit for surgery. A 71-year-old man presented to the emergency department of our hospital complaining of severe abdominal pain, nausea, and vomiting. Computed tomography scanning showed a metastatic cecal neoplasia invading the ileocecal valve with a complete small-bowel obstruction, confirmed by a subsequent colonoscopy (Fig. 1A). After a multidisciplinary case discussion, it was decided to perform an endoscopic decompression with a self-expandable metal stent (SEMS) in the terminal ileum, through the ileocecal valve. The attempts to place a SEMS in the terminal ileum, through the ileocecal valve, were unsuccessful (Fig. 1B). For this reason, the procedure advanced to a linear echoendoscope (GF-UCT180; Olympus, Tokyo, Japan) using the water-filled technique up to the ascending colon, identifying multiple dilated bowel loops.^, Under EUS-guidance, an electrocautery-enhanced 16- × 20-mm lumen-apposing metal stent (EC-LAMS) (Hot-Spaxus; Taewoong Medical, Gyeonggi-do, South Korea) was deployed between a dilated jejunal loop and the ascending colon (Fig. 1C) with the freehand technique and intracanalar release of the proximal flange. Immediately after its deployment, liquid fecal stools went out into the ascending colon through the EC-LAMS (Fig. 2A and Video 1, available online at www.giejournal.org). No immediate adverse events were noted. However, the day after the procedure, the patient died from hypovolemic shock because of acute renal failure. The hypovolemic shock was thought to be unrelated; however, it is difficult to exclude a possible relationship with the procedure. The control CT scan demonstrated correct decompression of the small bowel (Fig. 2B). In our opinion, EUS-guided ileo-colon anastomosis could be a valid alternative to surgical stoma, although it should be only considered in select cases with expert hands where all therapeutic options for palliative relief of malignant small-bowel obstruction have failed.