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

Open AccessPublished:September 29, 2022DOI:https://doi.org/10.1016/j.vgie.2022.08.016

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      EUS-guided ileal-ascending colon anastomosis with water-filled technique for pallation of cecal colon cancer invading the ileo-cecal valve, after failed attempt to perform ileal stenting.

      Abbreviations:

      EC-LAMS (electrocautery-enhanced lumen-apposing metal stent), SEMS (self-expandable metal stent)
      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.
      • Watson A.J.
      • Nicol L.
      • Donaldson S.
      • et al.
      Complications of stomas: their aetiology and management.
      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.
      • Mangiavillano B.
      • Carrara S.
      • Eusebi L.H.
      • et al.
      Water-filled technique for therapeutic pancreato-biliary EUS in patients with surgically altered anatomy.
      ,
      • Mangiavillano B.
      • Auriemma F.
      • Mezzanzanica M.
      • et al.
      Fine needle biopsy plus EUS-guided cholecystojejunostomy by LAMS with a water-filled technique in a patient with Roux-en-Y reconstruction.
      Under EUS-guidance, an electrocautery-enhanced 16- × 20-mm lumen-apposing metal stent (EC-LAMS) (Hot-Spaxus; Taewoong Medical, Gyeonggi-do, South Korea)
      • Mangiavillano B.
      • Auriemma F.
      • Bianchetti M.
      • et al.
      A cholecystoduodenostomy with a new type of lumen-apposing metal stent.
      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.
      • Al Ghamdi S.S.
      • Khashab M.A.
      Endoscopic ultrasound-guided colonic anastomosis: pushing the boundaries.
      Figure thumbnail gr1
      Figure 1A, Endoscopic view of adenocarcinoma of the colon. B, Sphincterotome and guidewire to place a self-expandable metal stent. C, Endosonographic guidance for the positioning of the lumen-apposing metal stent.
      Figure thumbnail gr2
      Figure 2A, Endoscopic view of the lumen-apposing metal stent. B, CT scan demonstrating correct placement of the lumen-apposing metal stent.

      Disclosure

      Dr Repici is a consultant for Boston Scientific and Fujifilm. All other authors disclosed no financial relationships.

      Supplementary data

      References

        • Watson A.J.
        • Nicol L.
        • Donaldson S.
        • et al.
        Complications of stomas: their aetiology and management.
        Br J Community Nurs. 2013; 18 (114, 116): 111-112
        • Mangiavillano B.
        • Carrara S.
        • Eusebi L.H.
        • et al.
        Water-filled technique for therapeutic pancreato-biliary EUS in patients with surgically altered anatomy.
        Endosc Int Open. 2021; 9: E487-E489
        • Mangiavillano B.
        • Auriemma F.
        • Mezzanzanica M.
        • et al.
        Fine needle biopsy plus EUS-guided cholecystojejunostomy by LAMS with a water-filled technique in a patient with Roux-en-Y reconstruction.
        Am J Gastroenterol. 2020; 115: 1572
        • Mangiavillano B.
        • Auriemma F.
        • Bianchetti M.
        • et al.
        A cholecystoduodenostomy with a new type of lumen-apposing metal stent.
        Dig Liver Dis. Epub 2020 Sep 2;
        • Al Ghamdi S.S.
        • Khashab M.A.
        Endoscopic ultrasound-guided colonic anastomosis: pushing the boundaries.
        Endoscopy. Epub 2020 Nov 26;