Restoration of Colonic Continuity Utilizing an EUS Guided Rendezvous Procedure. The primary author is D. Chamille Codepilli, M.D. The co-authors for this video submission are Eric J. Vargas, M.D., Cadman Leggett, M.D., Michael J. Levy, M.D., and Louis-Michel Wong-Ki-Song, M.D. These are our disclosures. This is the case of a 73-year-old man with rectal adenocarcinoma who underwent a low anterior resection with left coloproctostomy and diverting loop ileostomy. His post-surgical course was complicated by pulmonary embolism on therapy with rivaroxaban since then. He completed 12 cycles of full-fox chemotherapy approximately 10 months after his initial diagnosis. At approximately 1 year after his initial surgery, a merium enema was obtained prior to takedown of his diverting loop ileostomy. This showed no passage of contrast beyond the proximal rectum. A flexible sigmoidoscopy was subsequently performed, which showed complete fibrotic occlusion of the colorectal anastomosis at approximately 15 cm from the anal verge. Biopsies of this area were negative for malignancy. The complete luminal obliteration at the anastomosis was attributed to ischemia and disuse. Surgery was offered to resect and revise the colorectal anastomosis. Due to the patient's reluctance to proceed with surgery, he was referred to our institution for consideration of endoscopic treatment options. We proceeded with an EOS-guided rendezvous procedure to recanalize the anastomotic lumen. Our approach consisted of passing a single-balloon enteroscope without an overtube through the loop ileostomy to the obstruction site and a linear echoendoscope in the rectal remnant. With the endoscopes in a rendezvous position, EOS-guided fine needle advancement and guidewire insertion through the complete anastomotic obstruction was performed, followed by luminal recanalization via placement of a lumen-opposing metal stent. Antigrade access to the site of anastomotic obstruction was achieved through the loop ileostomy, which could only accommodate passage of a slim, single-balloon enteroscope but without its balloon overtube. Transmission of the floppy enteroscope through the distal ileum and colon to the colorectal anastomosis was challenging and facilitated by the use of a wire stiffener placed in the working channel of the enteroscope in addition to well-positioned abdominal pressure under fluoroscopic view. A flexible sigmoidoscope was then inserted into the rectal remnant to estimate the length of the complete luminal occlusion afluoroscopy with the endoscopes in a rendezvous position. The distance between the tips of the endoscopes was approximately one centimeter. Here, complete anastomotic obstruction with fibrotic scarring is shown as seen from the Antigrade enteroscope. With the light source of the Antigrade enteroscope temporarily switched off, transillumination emanating from the rectally-positioned endoscope through the obstructed anastomosis is appreciated. For the recanalization procedure, however, we elected to replace the flexible sigmoidoscope with a linear echoendoscope to assess for and avoid surrounding vascular structures during fine-needle puncture of the obliterated anastomosis. As seen in this EUS video clip, the tip of the Antigrade enteroscope and colonic lumen proximal to the occluded anastomosis are visualized. Transmission of water to distend the colon segment above the anastomosis and to facilitate EUS intervention can be appreciated. Under both endoscopic and fluoroscopic guidance, an EUS-guided fine-needle puncture of the occluded anastomosis was performed. Through the needle, a flexible guide wire was inserted and grasped with a snare passed from the Antigrade enteroscope. Shown here is a view of the captured guide wire from the Antigrade enteroscope. By holding the guide wire taut at both ends, the delivery catheter of a 15-millimeter diameter lumen-opposing metal stent was inserted in a retrograde fashion through the anastomotic obstruction under both endoscopic and fluoroscopic view. The proximal flange of the stent was deployed, and the delivery catheter pulled transanally so the flange would seat securely on the proximal aspect of the anastomosis. Shown here is the deployed proximal flange of the stent seated against the anastomosis. The distal flange was then deployed under continuous endoscopic and fluoroscopic monitoring. Endoscopic imaging demonstrates the stent's waist through the recanalized anastomosis. The distal flange of the stent was well-positioned below the recanalized anastomosis, and illumination from the Antigrade enteroscope can be seen through the stent. With the stent fully deployed, stool material can be seen exiting the stent. Endoscopic and fluoroscopic contrast injection flowed relatively freely through the stent and anastomosis into the rectum and without extra luminal leak. This outpatient procedure was well-tolerated, and the patient returned for follow-up at one month. The lumen-opposing metal stent was fully expanded across the anastomosis with surrounding granulation tissue, allowing easy passage of the endoscope into the proximal colon. Notches of disused colitis were noted in the proximal colon. The stent was removed uneventfully using a rat-toothed forceps. Through-the-scoop of balloon dilation of the anastomosis was performed to a maximum diameter of 18 millimeters. Fluoroscopic contrast installation following balloon dilation showed free flow of contrast material through the anastomosis without extra luminal leak. The patient is scheduled for a follow-up flexible sigmoidoscopy in two months to ensure ongoing patency of the colorectal anastomosis prior to takedown of the loop ileostomy. Complete luminal obstruction is rare after colocolonic or colorectal anastomosis. In select patients with a diverting loop anterostomy, major revisional surgery may be avoided using an EUS-guided endoscopic rendezvous approach to restore luminal continuity. Restoration of intestinal continuity utilizing an endoscopic rendezvous approach is feasible in select patients with complete fibrotic obstruction at the colorectal anastomosis. When technically feasible, an EUS-guided rendezvous approach is advised to avoid the risk of injury to surrounding vascular structures during luminal recanalization.

rectal adenocarcinoma

fibrotic occlusion

colorectal anastomosis

EUS-guided rendezvous procedure

lumen-opposing metal stent