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.

Introduction

First-line approach for complicated acute diverticulitis is conservative treatment with bowel rest and systemic antibiotics. The presence of pericolic, mesocolic, or distant (usually deep pelvic) abscess ≥4 cm (1a or II stages according to Hinchey classification) represents an indication for drainage, either trans-abdominal, trans-gluteal, trans-rectal, or trans-vaginal. Endoscopic-ultrasound-guided pelvic abscess drainage (EUS-PAD) with lumen-apposing metal stents (LAMS) has been reported as a safe and effective alternative approach for complicated diverticular disease.

Aims & Methods

We aimed to assess the safety and efficacy of EUS-PAD with LAMS in a homogeneous population of patients with acute diverticulitis complicated by a pericolic, mesocolic, or pelvic abscess. A multicenter study was conducted from 2019-2023 retrieving all consecutive patients who underwent EUS drainage attempts for complicated acute diverticulitis in three referral centers. All cases have been considered suitable for EUS-PAD by local multidisciplinary teams. Continuous variables are expressed as median [interquartile range].

Results

Sixty-six patients underwent EUS assessment with interventional intent; however, in 13 cases, no sign (no. 5) or a small abscess (no. 8) was found. Finally, 53 patients (29 female 54.7%) with a median age of 74 [62-83] year-old were considered. Most cases (no. 40, 75.5%) had a pelvic abscess (Hinchey stage II) while 13 (24.5%) had a para-colonic abscess (stage 1b); thirty-one (58.5%) did not receive any antiplatelet or anticoagulant agent, while 10 (18.9%) were on low molecular weight heparin, and 12 (22.6%) on antiplatelet agents. No patient had fecal diversion. The median abscess size was 50 [40-60] mm. EUS-PAD have been conducted under conscious sedation in 14 (26.4%), deep sedation in 12 cases (22.6%), or general anesthesia in 27 cases (50.9%) with electrocautery-enhanced LAMS (Hot Axios, Boston Scientific, US). Six patients (11.3%) underwent concomitant percutaneous drainage, while in one case (1.9%) two LAMS have been used. In 34 cases (64.2%) trans-rectal EUS-PAD was performed, in 19 (35.8%) a trans-colonic route was required. Technical success was achieved in 49 (92.5%). A trend toward a higher technical success rate was observed for the trans-rectal route (odd ratio 6.19; 95% C.I 0.60 - 64.3; P 0.13); abscess size ≥50 mm was independently related to a higher technical success rate (OR 18.0 [1.63 - 198]; P 0.02). Stent size was 6x8mm (no. 2), 8x8 mm (no. 11), 10x10mm (no. 20), 15x10mm (no. 15), and 15x15mm (no. 1). Clinical success rate was 88.7%. The incidence of adverse events was 3.8%, with 1 minor procedural bleeding (AGREE II) and one late proximal migration (AGREE IIIa). LAMS were removed after a median of 19 [14-28] days and substituted with a double pigtail plastic stent in 9 cases. Patients were followed for 12 [8-12] months. Four (7.5%) patients underwent urgent Hartmann sigmoidectomy; during follow-up 12 (22.6%) patients required elective surgery; finally, 2 (3.8%) patients presented recurrent diverticular abscesses. No procedure-related or disease-specific mortality was observed during follow-up.

Conclusion

EUS-guided pelvic abscess drainage (EUS-PAD) with LAMS could be considered a safe and effective approach among conservative treatments for complicated acute diverticulitis.
EUS drainage with LAMS was confirmed as an effective treatment modality for encapsulated collections larger than 5 cm and close to colonic wall; trans-rectal approach seems safer while no difference in stent size were observed in terms of safety and efficacy.

References

Fugazzola P, Ceresoli M, Coccolini F, et al. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg. 2022;17: 5.
Nagata N, Ishii N, Manabe N, et al. Guidelines for Colonic Diverticular Bleeding and Colonic Diverticulitis: Japan Gastroenterological Association. Digestion. 2019; 99 (Suppl 1): 1-26.
Kruis W, Germer CT, Böhm S, et al. German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and the German Society of General and Visceral Surgery (DGAV). German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management. United European Gastroenterol J. 2022; 10: 940-957.
Donatelli G, Cereatti F, Fazi M, et al. Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series. J Minim Access Surg. 2021; 17: 513-518.
Poincloux L, Caillol F, Allimant C, et al. Long-term outcome of endoscopic ultrasound-guided pelvic abscess drainage: a two-center series. Endoscopy. 2017; 49: 484-490.
Lisotti A, Cominardi A, Bacchilega I, et al. EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series. VideoGIE. 2020; 5: 380-385.

Disclosure

Andrea Lisotti had a proctorship contract with Boston Scientific in 2021 and 2022.

Clinical Case Summary

A female patient, 67 years old, with no previous medical history, was referred to our hospital because of a metastatic sigmoid colon cancer (T3,Ν1c,M1a) that was found during colonoscopy for bright red blood per rectum and changes in bowel habits. The tumor occupied 80% of the lumen and following MDT discussion a laparoscopic anterior resection was performed. Patient recovered well and 3 weeks later recieved 6 cycles of FOLFOX.
Patient presented 1 month after the operation at the emergency department with abdominal distension, vomiting and inhibition of gas and fecal excretion.
Fluoroscopy and CT scan confirmed the anastomotic stenosis.
A flexible sigmoidoscopy was also performed in order to exclude local recurrence. An anastomotic stricture was recognized 8cm from the anal verge, preventing the passage of the diagnostic gastroscope 9,2mm.
EUS was also performed, which revealed 1cm hypoechoic stenosis and FNB biopsies were obtained, which showed inflammation and fibrosis, but no sign of local recurrence.
The patient underwent two flexible sigmoidoscopies with CRE balloon dilation up to 15mm, with no clinical or endoscopic response. It was then decided to proceed to LAMS placement under direct vision. A guide wire was passed through the stenosis using a dilatation balloon catheter under fluoroscopic guidance and then 20mm x10mm LAMS was successfully deployed at the anastomotic stricture. Dilation of the LAMS was performed with a CRE balloon at 12mm.
Then laparotomy and resection of 3 liver metastases was performed.
Eight weeks later a control flexible sigmoidoscopy was performed that showed the stent in good position with maintained patency. The stent was then removed with a rat-tooth forceps, with clean base ulcerations. Additional biopsies were obtained precautionally that were negative for malignancy.
Patient carried on with chemo while remaining asymptomatic for 6 months of follow-up period without any hospitalization for obstructive symptoms.

References

Baron T., Grimm I., and Irani S., Lumen-apposing covered self-expandable metal stents for short-length gastrointestinal strictures: will they take hold?, Endoscopy. (2017)
Santos-Fernandez J., Paiji C., Shakhatreh M. et al., Lumen-apposing metal stents for benign gastrointestinal tract strictures: an international multicenter experience, World Journal of Gastrointestinal Endoscopy. (2017)
Michael Coles, Pearl Uy, Victoria Madray, John Erikson Yap, Subbaramiah Sridhar, The Off-Label Use of a Lumen-Apposing Metal Stent (LAMS) for a Benign Colon Anastomotic Stricture Causing Recurrent Bowel Obstruction in a Patient with Keloids, Gastrointestinal Medicine. (2021)

Introduction

Benign gastrointestinal strictures are often refractory to endoscopic dilations and standard covered stents have been disappointing. Our aim was to evaluate the clinical efficacy of lumen apposing metallic stent in the treatment of short and anastomotic benign strictures”

Aims & Methods

This study was conducted by the endoscopic department at a tertiary level hospital in France. Consecutive patients who underwent lumen apposing metal stent placement from February 2018 to August 2021 for lower gastrointestinal benign anastomotic strictures were prospectively followed for a minimum of 6 months. Primary outcome measure was clinical success, defined as improvement or resolution of underlying symptoms; secondary endpoints were technical success and adverse events.

Results

A total of 20 patients bearing as many strictures were included and underwent a total of 22 procedures for stent placement. Etiology of GI stricture included : prior carcinologic surgery ( n = 5), IBD surgery (n = 14), sigmoiditis (n= 1). Technical success was achieved in 22/22 procedures. Mean follow-up was 1.26 +/- 0.94 years . Sustained clinical success (up to the end of follow-up) was observed in 16/20 patients (80%). Three adverse events occurred in 2 patients patients (10%), including 2 cases of post procedure pain and one unextractable stent. An indwelling stent was left in situ permanently in 1 patient while all the other remaining stents were easily removed (n= 19 , 95%).

Conclusion

​Lumen apposing metal stent for the treatment of benign anastomotic strictures is technically feasible and safe with a high rate of clinical success on the medium term. Also, removal of lumen apposing metal stent is generally easy and safe. lumen apposing metal stent may be an option to treat selected patients with benign anastomotic stricture.