Creating a New Path: EUS-Guided Gastrojejunostomy With Lumen-Apposing Stent

Abstract

Malignant small bowel obstruction is a frequent complication in advanced cancer patients, especially in those with abdominal tumors. A small bowel obstruction occurs when there is blockage of the forward flow of gastric and intestinal contents through the gastrointestinal tract. This results in a delay or inability of gas and fluid to move through the tract. Surgery should be considered for patients in with a single level of occlusion. Less invasive approaches such as duodenal or colonic stenting should be considered when the patient is a poor surgical candidate, or if there are multiple levels of obstruction. However small bowel decompression through lumen opposing stent technology is rare and has yet to be fully described. We present a case of an elderly male with a small bowel obstruction secondary to metastatic colon cancer that was relived with a lumen-apposing stent (Axxios). An 84-year-old male with a metastatic colon cancer, with deposits to the proximal small bowel presented with nausea, vomiting and abdominal distension. The patient noted not having bowel movements or passing gas for several days prior to presentation. The vomit was non-bloody and non-bilious and at times was dry heaving. He stated the nausea was not relieved by anti-emetics including high dose ondansetron. The gastroscope was inserted into the esophagus, which was unremarkable. The gastroscope was exchanged for a linear scope, which was advanced to the gastric antrum. A dilated loop of small intestine was seen adjacent the gastric wall. A cystotome was used to puncture the gastric and small intestinal walls to gain access to the dilate loop of bowel. A guide-wire was advanced into the loop of bowel. The Axxios stent was deployed over the wire, securing the tract between the stomach and dilated loop of bowel. About 2 liters of fluid drained into the stomach from the dilated loop of bowel and was suctioned. Contrast injected into the Axxios stent was seen entering loops of bowel on fluoroscopy. The patient subsequently felt better after the procedure. Treatment options for malignant bowel obstruction must be carefully explored with the patient and family. This diagnosis is often an indication of disease progression, further highlighting the noncurable nature of the underlying disease. EUS Guided gastrojejunostomy with an Axxios stent for a malignant proximal small bowel obstruction should be considered in patients who require decompression. The system allows for a bypass of the small bowel in patients who are poor surgical candidates due to multiple comorbidities or for palliative purposes.