Post written by Michael Lajin, MD, from Sharp HealthCare, San Diego, California, USA.

A 64-year-old woman with a history of perforated goblet cell carcinoid tumor of the appendix underwent extensive cytoreductive surgery with heated intraperitoneal chemotherapy 5 years prior. She had a recent small-bowel obstruction requiring exploratory laparotomy with extensive lysis of adhesions and resection of recurrent tumor.

Four months later, she presented with recurrent distal small-bowel obstruction. A nasogastric tube was placed for decompression. She was considered a poor candidate for further surgical interventions.

After reviewing her CT scan, we noted good opposition between the rectum and a distended distal ileal loop. After a multidisciplinary discussion, a decision was made to proceed with EUS-guided decompression. 

The procedure was performed with the patient under general anesthesia. Contrast with methylene blue was injected through the nasogastric tube to distend the distal ileal loops. A linear echoendoscope was advanced to the rectum.

At the rectosigmoid junction, a distended ileal loop was identified on EUS. This loop was opposed to the colon with no intervening organs or blood vessels. An electrocautery-enhanced lumen-apposing metal stent (15 x 10 mm) was deployed, connecting the colon to the ileum proximal to the obstruction. The stent was dilated to 15 mm.

There were no adverse events after the procedure. Postoperative CT confirmed a successful ileocolostomy with complete decompression of the small bowel. She was advanced to a soft diet and discharged home under hospice care. She had no recurrence of small-bowel obstruction until she died 3 months later.

EUS-guided interventions to treat luminal and biliary obstructions in patients with advanced GI malignancies offer faster recovery and a better quality of life than surgical and percutaneous interventions, respectively.

Retrograde EUS-guided ileocolostomy is an effective palliative tool in select patients with advanced malignancies presenting with small-bowel obstruction. Additional studies are required to determine the safety and effectiveness of this technique.

Coronal CT image of the ileocolostomy (yellow arrow) and decompression of the small bowel.

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