This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. EOS guided ileocolostomy with lambs for malignant small bowel obstruction. These are our disclosures. Standard management of small bowel obstruction consists of bowel rest and nasogastric tube decompression. When these conservative measures fail, there is a risk of spontaneous perforation, which could be catastrophic. In these situations, additional intervention may be necessary to prevent this. However, patients with malignant obstruction are often deemed to be high-risk surgical candidates. Non-surgical options for malignant obstruction have traditionally involved venting PEG tubes or intraluminal stents. However, the efficacy and durability of these options may be limited, especially in patients with peritoneal carcinomatosis, where the point of obstruction often originates from extrinsic compression. Additionally, in cases where there are multifocal points of downstream obstruction, addressing a single stricture would be ineffective. Endoscopic ultrasound guided lumen opposing metal stent, or LAMS, insertion has been described as an effective method for treating malignant gastric outlet and or proximal enteric obstructions. The benefits of transluminal LAMS approach over standard intraluminal stenting include the ability to provide a conduit to effectively bypass multiple potential sites of obstruction. Additionally, LAMS can circumvent the limitations of luminal stents, such as potential for tumor ingrowth or incomplete stent expansion, which tend to occur in the setting of extrinsic compression. And lastly, LAMS provides the potential to intervene on distal small bowel strictures that may not be directly reachable endoscopically. We present a case of a 78-year-old man with recurrent duodenal adenocarcinoma, status post-whipple resection in 2018 and on palliative chemotherapy, admitted with a distal small bowel obstruction. The patient had been struggling with two weeks of progressive nausea and vomiting, abdominal pain and distension, which acutely worsened three days prior to admission, accompanied by obstipation. The CT scan revealed small bowel obstruction with marked dilatation and at least one suspected transition point at the distal ilium, where there was associated wall thickening, representing a metastatic implant. There are multiple other diffuse peritoneal metastases and likely multifocal points of obstruction in the small bowel. The absence of gastric distension suggested there may be an additional point of partial obstruction proximally or decompression from vomiting, but this did not lend itself to a site of palliation with a gastrostomy tube. The patient was kept strict to NPO and an NG tube was placed to suction, which put out two and a half liters of bilious fluid. Following NG tube decompression, there was still no appropriate target for a PEG due to interposed small bowel loops and failure to decompress the small bowel. The patient had been evaluated by surgery and deemed to not be an appropriate candidate due to the presence of some ascites and due to the extent of his peritoneal disease. The patient and family not being ready for comfort care and after discussing the risks versus benefits, a decision was made to proceed with EUS guided ileocolostomy as a palliative means for bowel decompression if we were unable to reach the small bowel to place a luminal stent. At the start of the colonoscopy, after recognizing our inability to reach the actual point of ileal obstruction, a therapeutic upper endoscope was inserted through the rectum and advanced to the transverse colon using primarily water immersion with caution to avoid excess carbon dioxide insufflation. A guide wire was inserted just proximal to the hepatic flexure. The wire was then left in place with removal of the endoscope to allow guidance for passage of the linear echoendoscope due to the unprepped colon. A therapeutic linear echoendoscope was then inserted alongside the wire and advanced under fluoroscopic guidance to the transverse colon. From here, distended loops of small bowel were visualized by EUS as an appropriate target for LAMS placement. A 19-gauge needle was used for transluminal puncture after which contrast was injected and confirmed appropriate positioning in the target loop of small bowel. A 10-millimeter by 15-millimeter cautery enhanced LAMS was deployed successfully using free hand technique from the transverse colon to the distal ileum. First, the internal flange was deployed under EUS, followed by the colonic flange, also under EUS visualization. There was some fairly inspissated small bowel contents traversing into the stent appearing to occlude it. Therefore, the LAMS was dilated using an 8- to 10-millimeter balloon. This resulted in immediate flow of copious amounts of liquid contents from the ileum. The abdomen was notably less distended at the end of the procedure. Final film confirmed no free air. The following day, the patient reported stable abdominal pain. He was now passing flatus but having minimal stool output. The abdominal X-ray on day one post-procedure showed overall unchanged small bowel dilatation, measuring 6.7 centimeters. He was started on a gentle osmotic laxative with the NG tube continued on suction. A CT scan was repeated on post-procedure day two, now revealing significant improvement in the degree of small bowel dilatation compared to pre-intervention. Notably, there was less extrinsic compression on structures such as the liver from markedly dilated bowel loops. By day five, he was able to advance to a liquid diet by mouth and begin having more consistent bowel movements, about two to three per day without diarrhea. He was discharged with home hospice, where he was tolerating a low-residue diet. He lived for an additional six weeks without recurrent admissions or obstruction. Clinical Implications. There can be multiple points of obstruction in patients with peritoneal carcinomatosis. To allow passage of an oblique-viewing echoendoscope through a tortuous and unprepped colon, one could place a guide wire and use fluoroscopy to help navigate. The anastomosis should be created preferably proximal to the splenic flexure to allow adequate length of colon distally to the anastomosis to reduce the risk of diarrhea. One must also avoid the use of any insufflation, even carbon dioxide, as much as possible to reduce the risk of perforation of the obstructed bowel. Response to therapy may not be immediate due to the severe distension and result in ileus, often developing for weeks preceding the acute presentation. NG tube decompression may be continued pending follow-up imaging and clinical response. Addressing goals of care and obtaining multidisciplinary input from surgery and oncology colleagues is also crucial. In conclusion, EOS-guided ileocolostomy can successfully palliate and may be the only option for malignant distal small bowel obstruction when surgery, intraluminal stenting, or a palliative venting gastrostomy are not feasible. Further studies are required to assess efficacy and safety profile of this approach.

endoscopic ultrasound-guided ileocolostomy

malignant small bowel obstruction

bowel rest

nasogastric tube decompression

venting PEG tubes