Endoscopic ultrasound-guided ileocolostomy creation to manage distal small bowel obstruction. Endoscopic management of proximal malignant small bowel obstructions, or SBOs, via EUS-guided gastroenterostomy is common for patients who are not surgical candidates. Endoscopic management of distal SBOs with EUS-guided ileocolostomy is not widespread or well-described. Here we present a case of successful use of EUS-guided ileocolostomy to manage a distal malignant small bowel obstruction. A 73-year-old male with a history of metastatic gallbladder adenocarcinoma on chemotherapy presented with one week of nausea, vomiting, abdominal pain, and inability to pass stool. CT of the abdomen showed a 2.6 centimeter mass in the terminal ileum causing a small bowel obstruction. The patient was deemed not to be a surgical candidate due to metastatic disease and recent dose of chemotherapy. CT abdomen pelvis in the transverse and coronal fuels demonstrated a 2.6 centimeter mass in the terminal ileum with upstream dilation of small bowel loops consistent with a small bowel obstruction. The patient was initially evaluated by surgery and deemed not to be a surgical candidate due to advanced metastatic disease and recent administration of chemotherapy. Magluminal stenting was considered, however, due to the location in the ileum there was concern about the technical ability to reach the stenosis and successfully place an enteral stent. Venting gastric tube was discussed but would not resolve the obstruction and the patient wanted more definitive therapy. After multidisciplinary discussion with surgery, oncology, and the patient, the decision was made to pursue an EUS-guided ileocolostomy. Colonoscopy was performed under fluoroscopic examination and a guide wire was placed into the cecum. Linear echo endoscope advanced into the descending colon using guide wire for localization. An EUS-guided luminal opposing mantle stent was placed to create an ileocolostomy to relieve the malignant obstruction. The stent was then dilated to eight millimeters to allow passage of stool with patency confirmed by contrast under fluoroscopy. Visualization was limited due to the poor prep in the setting of bowel obstruction. Colonoscopy with water immersion was performed and the colonoscope was advanced to the transverse colon. A long 0.035 stiff guide wire was advanced into the cecum until it coiled multiple times under fluoroscopic guidance. The colonoscope was exchanged for a linear echo endoscope which was advanced alongside the guide wire using it as a guide on endoscopic and fluoroscopic views. Water immersion was utilized to advance the echo endoscope through a tortuous sigmoid colon due to diverticulosis. Because of this, the echo endoscope could only be advanced to the distal descending colon. At this point, endoscopic ultrasound was used to visualize a distended loop of small bowel adjacent to the colon. Doppler was utilized to ensure no blood vessels were in the way. A distance of less than 10 millimeters between the small bowel and colon was identified. An adequate oblique view of over 4 centimeters was identified. Using cautery, a 15 millimeter by 10 millimeter luminal opposing metal stent catheter was advanced into the small bowel. During the puncture, the small bowel appeared to move away from the colon and repeat cautery was applied with catheter advancement. The luminal opposing metal stent was successfully deployed. Stool could be seen emerging from the luminal opposing metal stem. Contrast was injected through the stent and demonstrated placement in the small bowel with no evidence of leak or perforation. The stent was then dilated to eight millimeters with a dilating balloon. The small bowel could also be visualized through the luminal opposing metal stent. On post-operative day one, the patient had four loose bowel movements and was initiated on TPN due to poor nutritional status. The next day his NG tube was removed and he continued to have bowel movements. Over the coming days, his diet was advanced slowly. Due to limited oral intake, the patient underwent upper GI series on post-operative day 11, which showed patent luminal opposing metal stent with passage of contrast. On post-operative day 13, the patient was discharged home. One year post-procedure, the patient continues to do well tolerating oral intake and having soft bowel movements with the continuation of his chemotherapy. CT abdomen and pelvis one year following the procedure re-demonstrated good stent position and patency without obstruction. Clinical Implications. Endoscopic management of distal small bowel obstructions with EUS-guided ileocolostomy is a safe and effective option for non-surgical patients. Luminal opposing metal stent placement in distal colon did not lead to clinically significant diarrhea. A one-year post-procedure follow-up suggests that EUS-guided ileocolostomy may be able to provide patients with a durable treatment with improvement in quality of life in comparison to alternative measures. Conclusions. We reported a successful creation of an EUS-guided ileocolostomy with luminal opposing metal stent placement. In this case, the procedure was safe and effective with long-term durability. Endoscopic ileocolostomy creation should be considered in patients with distal small bowel obstructions who are not surgical candidates.

endoscopic ultrasound

ileocolostomy

small bowel obstruction

metastatic gallbladder cancer

stent placement