This presentation is titled EUS Guided Tandem LAMPS Placement to alleviate malignant bowel obstruction in a patient with small bowel adenocarcinoma with carcinomatosis. Small bowel adenocarcinoma is a rare tumor which often presents with small bowel obstruction. The surgical management of malignant obstruction is a reasonable approach. However, this is associated with significant morbidity and mortality. Endoscopic management of a focal malignant obstruction is well established either using a duodenal stent or endoscopic gastrointestinal ostomy with lumen opposing metal stents. The endoscopic management of multiple areas of obstruction is not as well documented. We present a case of a 55 year old female with small bowel adenocarcinoma with carcinomatosis actively on immunotherapy presenting with worsening abdominal distension and discomfort as well as nausea and vomiting. CT image shows severe dilation of multiple areas of small bowel. In these axial cross section you can see multiple air fluid filled loops of distended small bowel which measure up to 4.6 centimeters. She was also seen by colorectal surgery but was deemed a poor surgical candidate. After a multidisciplinary discussion she was considered for a venting gastrostomy tube. However, after a close review of the images with our radiology colleagues it was apparent she had several levels of obstruction and a venting gastrostomy tube would only alleviate the gastro duodenal portion of her obstruction. The patient and her family wish to alleviate her pain and give her as much time at home as possible in order for her to be present for her daughter's upcoming wedding. As such and after careful consideration of the potentially life-threatening complications we decided to pursue the placement of tandem lumen opposing metal stents with a venting jejunostomy tube to alleviate the obstruction in small bowel and colon. We explained to the patient and her family that this is not curative and it was purely palliative in nature. For the placement of the first lens we used an adult gastroscope to evaluate the lumen and determine the degree of fluid or debris present within the stomach and small bowel. We then used a linear array endoscope for the placement of electrocautery enhanced lumen opposing metal stents that as you can see above is being advanced freehand to access the distal gastro duodenal lumen where the distal flange is deployed and pulled to oppose the jejunum wall followed by the deployment of the proximal flange into the scope channel then to the gastric lumen site. It was sutured in place using endoscopic suturing device. In the end it was dilated to 20 millimeters using a controlled radical expansion balloon. A gastroscope was then used to traverse the gastroenterostomy which revealed a very dilated and ischemic appearing small bowel with diffuse louching as well as ulcers suggesting compromised vascular perfusion. This process was subsequently repeated for the placement of second lens. We used a combination of direct endoscope endoscopic ultrasound and transabdominal ultrasound to identify the next area of lens placement for an endoenterostomy. This is the endoscopic view of the jejunum as we find an optimal location for the stent placement. With the same technique used in the first stent placement you can now see a 20 millimeter lumen opposing metal stent being placed between the jejunum and a downstream obstructed portion of the small bowel. In this endoscopic view you can appreciate the copious amount of fluid being released after the stent placement. It was also dilated to 20 millimeters using a controlled radical expansion balloon. The stent was sutured in place using endoscopic suturing device. As you follow along with the video you can see this area of small bowel also shows diffuse dilation and ischemic changes. We also attempted a flexible sigmoidoscopy in order to place the third coloenteric lens but due to severe extrinsic compression of the colon this was not feasible. We ended by placing a venting percutaneous jejunostomy tube for palliative purposes. As you can see a needle is passed through the jejunum wall and identified on the endoscopic camera. The catheter sheet with the needle is entrapped by a snare passed from the endoscope. Once entrapped it is removed through the mouth. Now you can visualize the tube is carefully guided from the patient's mouth into the jejunum. Now let's take a look at the post-procedural CT scan. This is the first LAMPS placement followed by the visualization of the percutaneous jejunostomy tube and lastly the second LAMPS placement. In this chronal CT scan you can see both the gastroenterol and enteroenterol stent. You can also appreciate the dramatic improvement in small bowel obstruction. After the procedure patient had significant improvement in quality of life. She was also able to continue oral intake due to the placement of venting percutaneous jejunostomy tube. Patient had no post-procedural complications and was discharged home on hospice. She was also not readmitted for any problems related to her tandem LAMPS stent. She lived to see her daughter's wedding and ultimately passed away three months later from complications of metastatic cancer. We have successfully demonstrated the use of US guided gastroenterostomy and enteroenterostomy in palliative alleviation of multi-level small bowel obstruction. This ultimately opens up new avenues for tandem LAMPS placement being a feasible option in high-risk patients with small bowel obstruction especially for palliative purposes.

EUS-guided tandem LAMPS placement

malignant bowel obstruction

small bowel adenocarcinoma

carcinomatosis

tandem lumen opposing metal stents