EUS guided coloileal anastomosis for management of malignant small bowel obstruction. No disclosures, malignant small bowel obstruction results due to mechanical obstruction of the small bowel preventing passage of stool and sometimes gas. This can commonly occur due to right colon malignancy, peritoneal deposits. Obstruction frequently causes abdominal pain, nausea, vomiting and distention. Definitive management includes surgery for removal of the involved segment. For patients who are poor candidates for surgery, venting peg is offered. However, this is associated with poor quality of life without offering ability to have enteral nutrition. Lumen opposing metal stents have revolutionized the endoscopic treatment of various gastroenterologic conditions including gastric outlet obstruction for malignancy. We describe a case here where an EUS guided lumen opposing metal stent placement was performed to manage small bowel obstruction due to right colon malignancy by creating a coloileal anastomosis. A 68-year-old male presented with a two-month history of abdominal pain and constipation with weight loss of 15 kilograms. He also described an increased intensity of abdominal pain with postprandial vomiting two days prior to presentation. On examination, he was cathartic with a dry mouth, blood pressure was low, he was hypotensive with a mean arterial pressure of 50 millimeters of mercury. An echo showed ejection fraction of 20 percent with global left ventricular hypokinesia. Labs showed mild anemia, renal failure with creatinine up to 1.6 on day 3, electrolyte imbalance with hyponatremia as well as coagulopathy with INR of 2.43. A CT scan was obtained and revealed diffusely dilated small bowel loops with a suspected area of obstruction in the right lower quadrant in the colon. Management options were discussed with the patient. He was offered surgery, but was considered a high-risk candidate and therefore declined. A venting peg was considered, but the patient declined and therefore EUS guided coloileal stenting with a 20 millimeter cautery enhanced lumen opposing metal stent was planned. His coagulopathy was corrected prior to the procedure. The site of obstruction was in the right lower quadrant suspected in the cecum. The plan was made to place a stent from the colon, the right colon into the obstructed small bowel, ideally in the ileum. To facilitate passage of the echo endoscope across the sigmoid turns, an overtube was used which allowed the scope to be advanced to the right colon. A colon scope was advanced across the anal verge into the colon. The colon appears distended and there was large amount of stool which was cleared. The scope was then gradually advanced to the right colon where a mask can be visualized in the cecum which was felt to be the source of obstruction and enteral stent could not be placed. An overtube was then advanced across the sigmoid colon. Through the overtube, the echo endoscope was advanced inside the colon and you can see dilated small bowel loops. My colleague placed his hand in the right lower quadrant and we confirmed the presence of scope tip in the right lower quadrant suspected to be in the right colon. A suitable avascular window with a good runway of 3 centimeters was identified and a 19 gauge FNA needle was then advanced inside this dilated small bowel. Contrast was injected to confirm the needle tip in the small bowel. Next a free hand, cautery enhanced lumen opposing stent was then deployed across the colon wall into the dilated small bowel loops which was felt to be the ileum. And then the inner flange was then deployed inside the colon with free flow of contrast and stool. Additionally you can see there was a situs as well visualized and here is a view of this lumen opposing metal stent going across the small bowel into the colon. Before the procedure, the x-ray reveals dilated small bowel loops with multiple air fluid levels and following the procedure the x-ray shows resolution of the air fluid levels with a lumen opposing metal stent in the right lower quadrant. Post procedure patient had resolution of abdominal pain and past bowel movement the following day. No post procedure adverse events were noted. Intestinal obstruction is considered a surgical emergency. Patients with high grade obstruction who do not proceed to operative management are at high risk for bowel perforation and septic shock from peritonitis. However many patients are not candidates for surgery because of comorbidities. EUS guided colo ileal anastomosis can be successfully performed in the right colon and small bowel obstruction permitting patients to have internal nutrition. In conclusion, EUS guided colo enteric anastomosis is a novel technique for management of acute intestinal obstruction in patients who are unfit for surgery. This offers a minimally invasive management of bowel obstruction where limited alternate management options are available. Thank you.

EUS-guided anastomosis

lumen-opposing metal stent

small bowel obstruction

right colon malignancy

minimally invasive procedure