Endoscopic ultrasound guided choleoileal anastomosis with lumen opposing metal stent for successful management of malignant distal ileal obstruction in peritoneal carcinomatosis with altered anatomy. Malignant small bowel obstruction is a life-threatening condition and requires immediate relief. Failure of conservative measures necessitates a need for surgical intervention. However, most of the patients with high-grade malignant small bowel obstruction are poor candidates for surgery. Endoscopic management or small bowel obstruction in patients unfit for surgery significantly improves the clinical outcomes by providing rapid decompression. This video demonstrates EOS-guided choleo-allele anastomosis with LAMS for successful management of malignant distal allele obstruction in peritoneal carcinomatosis with altered anatomy. 58-year-old female was diagnosed with CA cervix and peritoneal carcinomatosis. She also underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and anterior resection with peritoneal carcinomatosis. She also underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and anterior resection with sigmoid rectum end-to-side anastomosis in 2022. She also had background history of heart failure. Now, she presented with fecal and vomiting, abdominal distension, constipation and inability to pass flay test. CT showed dilated small bowel loops with abrupt transition point in the distal allelium CT showed dilated small bowel loops with abrupt transition point in the distal allelium secondary to encasement by thick peritoneal deposit. Hence, with the diagnosis of adhesive malignant allele obstruction, our plan was to proceed with an EOS-guided choleo-entrostomy. The procedure was performed with the patient in the left lateral position under MAC for about 15 minutes prior to the procedure. Sigmoid rectum end-to-side anastomotic site was noted. Acute angulation was encountered while negotiating the colonoscope into the proximal bowel. Once the colonoscope was negotiated into the proximal bowel, Once the colonoscope was negotiated into the proximal bowel, a guide wire was passed deep into the proximal bowel and the colonoscope was slowly withdrawn. a guide wire was passed deep into the proximal bowel and the colonoscope was slowly withdrawn. The EOS scope was railroaded onto the guide wire and was negotiated towards the anastomotic site. However, the scope could not be negotiated across the anastomotic site However, the scope could not be negotiated across the anastomotic site in view of the acute angulation. Hence, CRE dilatation was done at the anastomotic site up to 13.5 mm. Hence, CRE dilatation was done at the anastomotic site up to 13.5 mm. Once the dilatation was performed, the EOS scope was negotiated across the anastomotic site. the EOS scope was negotiated across the anastomotic site. EOS showed grossly distended small bowel loops. EOS showed grossly distended small bowel loops. A 19-gauge needle was passed into the bowel loop and showed fecal contents. Contrast was also injected for confirmation. A 20 x 10 mm cotri-enhanced LAMPS was deployed into the obstructed small bowel loop. Once the proximal flange of the lamps was deployed, faecal drainage was noted across the lamps. The stent was dilated up to 15 mm with a CRE balloon. Free flow of fecal matter was noted across the lambs after dilatation. Immediate decompression was achieved with symptomatic relief post-procedure. Oral diet was resumed at the end of 48 hours and IV antibiotics were continued. Adhesive small bowel obstruction is a prevalent complication of peritoneal carcinomatosis. Surgical management in adhesive small bowel obstruction is associated with significant morbidity and mortality. Adhesive small bowel obstruction is less commonly amenable for luminal stenting due to its poor accessibility, tight kinks and extensive compression on the bowel. Intestinal stoma for diversion is the most frequent intervention for palliation. However, it is also associated with significant morbidity and adverse events. Transluminal coloentric anastomosis using lambs is a novel approach to the management of small bowel obstruction and it provides straight access to the obstructed small bowel segment. Advancing the EOS scope till the ascending colon can often be challenging or may not be feasible due to additions and altered anatomy. However, identifying the obstructed small bowel segment from the sigmoid can significantly reduce the procedure time and facilitate easier intervention in the event of future stent blockages. This video demonstrates EOS-guided colo-allele anastomosis with lambs for successful management of malignant distal allele obstruction in peritoneal carcinomatosis with altered anatomy.

EOS-guided choleoileal anastomosis

lumen-apposing metal stent

malignant distal ileal obstruction

peritoneal carcinomatosis

endoscopic procedure