Introduction

Some malignant diseases such as ovarian carcinoma, neuroendocrine neoplasias or gastrointestinal cancers tend to manifest with peritoneal carcinomatosis. The accompanying small-bowel ileus (SBI) is often decisive for the prognosis even in an otherwise controlled oncologic setting while posing a significant burden on the patients quality of life (QoL). Conventional procedures of palliative care such as bypass surgery or gastric tube placement deliver unsatisfying results and are not well-tolerated by patients. A new method for improving the quality of life and possibly survival may therefore be to restore the passage through the endosonographic (EUS) placement of lumen-apposing metal stents (LAMSs) for creation of a colo-enterostomy (CE), without opening the abdominal cavity.

Aims & Methods

Aim of this ongoing multicenter intervention study is a comprehensive evaluation of feasibility and clinical value of CE in patients with malignant SBI. Biometric, technical and clinical data, symptoms, periinterventional management, QoL (EORTC_QLQ_C30), adverse events as well as the ability to tolerate oncologic treatment and enteral nutrition are recorded longitudinally at predefined time points (d-1, d+2, d+10, d+34).

Results

We report on 10 patients that underwent EUS-guided CE so far. Eight of these patients (80%) were female and 4/10 (40%) had an intestinal neuroendocrine tumor, 4/10 (40%) an ovarian carcinoma and 2/10 (20%) colorectal cancer. The intervention was technically successful in 10/10 (100%) and clinically successful 9/10 (90%) patients. In one patient, only a second technically successful CE on day 3 could induce clinical symptom relief. Subsequently, all patients experienced considerable improvement of ileus-related symptoms (e.g. vomiting, stool frequency, abdominal pain) and an increase in QoL to an extent, were 10/10 (100%) were able to tolerate enteral nutrition and 6/10 (60%) could be re-exposed to systemic oncologic treatment. All 4 patients (100%) depending on morphine based pain medication prior to SBI could be reintroduced to their previous regimen after the intervention.

Conclusion

EUS-guided CE for treatment of malignant SBI is feasible and safe. The intervention boasts a high technical and clinical success rate with immediate symptom relief and improved QoL. A relevant number of patients was enabled to be reintroduced to systemic oncologic treatment and morphine based pain medication. Larger cohorts and long-term data are needed to evaluate sustainability as well as possible impact on survival and to form the foundation for prospective trials.

Disclosure

Alexander Meining: Ovesco Consultant
Alexander Weich: Novartis Pharma Gmbh Consulant

Introduction

Surgery is the first-choice treatment for malignant intestinal obstruction (MIO), however many patients are deemed inoperable. Endoscopic ultrasound guided enterocolostomy (EUS-EC) with lumen apposing metal stents (LAMS) could represent a new treatment option.

Aims & Methods

The primary aim of the present multicentre retrospective study was to assess the technical success rate of EUS-EC in patients with malignant intestinal occlusion unfit for surgery. Secondary aims of the study included the clinical success rate, the safety of the procedure, the time of re-feeding, the duration of hospital stay and the clinical outcome.
All consecutive patients undergoing EUS-EC for MBO from November 2021 to September 2023 were retrospectively enrolled at four tertiary referral European centres. All cases were discussed in a multidisciplinary meeting. Inclusion criteria were: 1) malignant small bowel/colonic obstruction; 2) CT-scan showing ileal or colonic MIO with dilated intestinal loops <7 days from procedure; 3) multidisciplinary meeting discussion; 4) unfit for surgery; 5) unsafe colonic stent positioning. Exclusion criteria were: 1) acute MIO requiring emergency treatment; 2) unavailability of CT scan <7 days; 3)rectal malignancy. Demographic, clinical and procedural data including the clinical outcome and adverse events were recorded. Technical success was defined as ability to deploy the LAMS between the colon and the colonic or small bowel target, clinical success as resolution of MIO for at least 2 weeks from the procedure and adverse events defined and classified according to the AGREE classification. Data were expressed as median [range]. Comparisons were made by using the χ2 test, Student t-test, or Mann-Whitney u-test.

Results

Twelve patients were enrolled (58.3% female, median age 72.5 [42-85] years). The most frequent cause of MIO was colonic adenocarcinoma in 9 (75%) patients. The majority (11 [91.7%]) of patients had a Stage IV disease and the median malignancy duration was 13 [1-108] years. Site of MIO was ileum and right colon in 3 (25%) patients and left colon in 6 (50%). in In 83.3% of the procedures the LAMS used was the Hot AXIOS, in 16.7% the Hot SPAXUS. In 7 (58.3%) patients a EUS-guided ileo-colostomy was performed while in 5 (41.7%) a colo-colostomy. Technical success was achieved in all procedures (100%). No LAMS misdeployment or procedural adverse events were observed. Post-procedural complications were recorded in 3 (25%) patients, however direct correlation with the procedure could not be ascertained. Clinical success was achieved in 10 (83.3%) patients. The median time of oral diet resumption was 1 [1-2] day. The median post-procedure hospital stay was 9 [1-20] days and overall median survival was 47.5 [2-270] days. When comparing EUS-guided ileo-colostomy vs colo-colostomy no difference were observed in terms of technical (7/7 [100%] vs 5/5 [100%], p=1) or clinical (5/7 [71.4%] vs 5/5 [100%], p=0.6) success or adverse events (3/7 [42.8%] vs 0/5 [0%], p=0.31). Time of re-feeding, duration of hospital stay and survival were also comparable between these 2 subgroups of patients (p=0.06, p=0.78, p=0.2, respectively).

Conclusion

EUS-EC is a feasible technique and could be considered as a valid alternative to standard approaches for MIO in highly selected patients.

References

1. Jonica ER, Mahadev S, Gilman AJ, et al. EUS-guided enterocolostomy with lumen-apposing metal stent for palliation of malignant small-bowel obstruction (with video). Gastrointest Endosc. 2023; 97 (5): 927-933.

Clinical Case Summary

Peritoneal dissemination from cancer of extraperitoneal origin is rare^1,2.We report a patient who presented with symptoms and signs of small bowel obstruction(SBO)due to breast metastasis in the omentum.A 73-year-old female complained of irregular bowel movement,flatulence and abdominal pain.Her past medical history was significant for breast examination 2 years earlier with suspicion of tumor,but without confirmation of any tumor on control breast ultrasound and radiography.After upper and lower endoscopy showed no significant pathology, her initial presentation was characterized as irritable colon syndrome.After worsening of the symptoms with nausea and vomiting and weight loss for the period of one year, the patient was referred to our Clinic.Initial magnetic resonance enterography showed slight dilatation of small bowel loops,without other pathology.She was sent to the surgeon who excluded indication for surgery.Three months later,the patient came back to the GI with same symptoms of suboclusion.Repeat MRE showed small bowel loops dilatation(40 mm),slight ascites and again no other pathology was detected.The patient had undergone explorative laparotomy when marked dilatation of small bowel loops was noted as well as thickening and multiple secondary lesions of the omentum.Ex-tempore biopsy of the omentum confirmed malignancy.The patient was treated for adhesion-induced ileus and a biopsy of the omentum was performed.Histopathology and immunohistochemistry were consistent with peritoneal dissemination from the breast cancer.The surgery was uneventful, and the patient was started with hormonal therapy(letrozole).At the latest follow up 6 months after the surgery, no oclusion episodes were reported.Diagnosis of peritoneal metastasis is challenging and may require surgical exploration as it was shown in our case.Physicians should be aware of the possibility of SBO caused by metastasis from the breast cancer, particularly in patients with a related history of cancer.

References

1. Bertozzi S, Londero AP, Cedolini C, Uzzau A, Seriau L, Bernardi S, Bacchetti S, Pasqual EM, Risaliti A. Prevalence, risk factors, and prognosis of peritoneal metastasis from breast cancer. Springerplus. 2015 Nov 10;4:688.
2. Flanagan M, Solon J, Chang KH, Deady S, Moran B, Cahill R, Shields C, Mulsow J. Peritoneal metastases from extra-abdominal cancer - A population-based study. Eur J Surg Oncol. 2018 Nov;44(11):1811-1817. doi: 10.1016/j.ejso.2018.07.049. Epub 2018 Jul 26. PMID: 30139510.