EUS-guided enterocolostomy with lumen-apposing metal stents for palliative management of malignant bowel obstruction: a systematic review and meta-analysis

Abstract

Background:

Malignant bowel obstruction (MBO) is a frequent and debilitating complication in advanced abdominal cancers, particularly ovarian, colorectal, and gastric malignancies associated with peritoneal carcinomatosis. Surgery is often not feasible, and conventional decompression carries substantial morbidity. Endoscopic ultrasound-guided enterocolostomy (EUS-EC) with lumen-apposing metal stents (LAMS) has emerged as a minimally invasive alternative, but the evidence remains limited.

Objectives:

To systematically evaluate the feasibility, safety, and clinical outcomes of EUS-EC with LAMS for the palliation of MBO.

Design:

Systematic review and meta-analysis.

Methods:

A comprehensive literature search was performed across PubMed, Embase, Cochrane Library, and Web of Science from database inception through August 2025. Studies were eligible for inclusion if they involved patients with MBO undergoing EUS-EC using LAMS. Statistical analysis was performed using a random-effects model with Hartung–Knapp adjustments. Primary outcomes were technical success (defined as successful stent deployment) and clinical success (defined as relief of obstruction and restoration of bowel function).

Results:

Twenty-three studies (78 patients) were included. Pooled technical and clinical success rates were 96.1% and 88.4%, respectively. The mean hospital stay was 10.6 days, and oral intake resumed after a mean of 3.1 days. Mean post-procedure survival was 91 days, consistent with the advanced disease stage of most included patients. Adverse events were uncommon: diarrhea (6.4%), perforation (3.8%), bleeding (2.5%), and aspiration (1.2%). Stent misdeployment occurred in one cohort (26.6%), but all cases were managed endoscopically without major sequelae. Among 33 deaths reported, most (78.8%) were due to disease progression, with only 6.1% procedure-related.

Conclusion:

EUS-EC with LAMS demonstrates high technical and clinical success, rapid symptom relief, and low procedure-related morbidity, supporting its potential as an emerging palliative option for carefully selected patients with MBO. Evidence remains limited to small retrospective cohorts and case reports, highlighting the need for prospective comparative trials with patient-centered outcomes.

Introduction

Malignant bowel obstruction (MBO) in patients with advanced cancer presents a complex clinical challenge that requires an individualized and nuanced approach. ¹ Management decisions are influenced by prior surgical history, tumor burden, the extent of disease dissemination, and overall prognosis. Reported prevalence varies by cancer type and study population, with estimates ranging from approximately 5% to 51% in ovarian cancer, 10% to 28% in colorectal cancer, and 3% to 15% in other malignancies. ² The wide range, particularly in ovarian cancer, reflects differences in patient cohorts, disease stage, and diagnostic criteria across studies. In a large review of 490 cancer patients at MD Anderson Cancer Center, 68% of obstructions were tumor-related, most commonly involving the small bowel (64%), followed by the colon (20%) and gastric outlet (16%). ³

Treatment of MBO is individualized, aligning with each patient’s prognosis and goals of care. Palliative surgery is not routinely performed due to critical considerations, including the obstruction's location, tumor burden, comorbidities, and patient performance status. ⁴ Although surgery may extend symptom-free intervals compared to conservative care, it is associated with significant postoperative morbidity in over half of patients and carries a notable risk of mortality from complications. ⁵ Only one-third of surgically treated patients achieve sustained palliation, with a median survival of just 90 days, often accompanied by substantial treatment-related morbidity. ⁶ For inoperable MBO, symptomatic management such as gastric venting, cessation of oral intake, intravenous hydration, and parenteral antiemetics may relieve symptoms. However, prolonged nasogastric aspiration can lead to discomfort and complications such as esophagitis, nasal erosion, and bronchoaspiration.^4,7 Alternative management for non-resectable tumors, including creation of a permanent stoma, carries high morbidity and mortality and significantly impacts quality of life, increasing caregiver burden.^8,9

Recent advances have promoted self-expanding metal stents (SEMS) as an effective endoscopic alternative for proximal small bowel and colonic obstructions. ⁵ SEMS are well-established for left-sided malignant obstructions, as demonstrated by trials such as CReST and ESCO, which found SEMS significantly reduced stoma formation without compromising long-term survival.^10–12 The European Society of Gastrointestinal Endoscopy recommends SEMS as the preferred palliative option and a viable alternative to emergency resection. ¹³ For right-sided malignant colonic obstruction, evidence remains limited, though meta-analyses suggest SEMS may facilitate minimally invasive surgery without increasing mortality or anastomotic failure. ¹⁴

Building on these developments, lumen-apposing metal stents (LAMS), originally approved for the drainage of pancreatic fluid collections—have been increasingly adapted for off-label use in transluminal procedures such as cholecystoduodenostomy, gastroenterostomy, and jejunojejunostomy.^15–20 Among these, EUS-guided gastroenterostomy (EUS-GE) has demonstrated superior technical success, durability, and clinical outcomes compared with duodenal SEMS for both benign and malignant gastric outlet obstruction.^19,21 Extending this principle beyond the upper gastrointestinal tract, endoscopists have developed EUS-guided enterocolostomy (EUS-EC), a technique in which a cautery-enhanced LAMS is deployed to create an anastomosis between the colon and a dilated proximal small-bowel loop upstream from the obstruction. The procedure is typically performed under general anesthesia with broad-spectrum antibiotics: a linear echoendoscope is advanced through the colon, dilated small-bowel loops are identified using ultrasound and fluoroscopy, and the stent is deployed to establish a bypass. Successful case reports include EUS-guided transmural LAMS placement for benign anastomotic strictures in high-risk surgical patients, EUS-guided ileocolonic anastomosis for recurrent SBO in an HIV-positive patient, and EUS-guided ileosigmoidostomy for malignant distal SBO.^22–24

EUS-EC with LAMS is a relatively novel intervention that holds promise for reducing reinterventions related to tissue ingrowth, expediting the resumption of nutrition and chemotherapy, and overcoming the limitations inherent in conventional surgical methods. ²⁵ However, the current evidence is derived almost entirely from case reports and small retrospective cohorts, which limits both the strength and generalizability of existing data. To date, no systematic review or meta-analysis has synthesized these fragmented findings to provide pooled estimates of efficacy, safety, clinical outcomes, and patient-centered outcomes. The objective of this review is to provide the first comprehensive synthesis of the available evidence on EUS-EC with LAMS for MBO. By clarifying its effectiveness, safety profile, and impact on patient care, this review aims to inform clinical decision-making in the palliative setting and identify priorities for future prospective and comparative studies.

Methods

Study design

This systematic review and meta-analysis were conducted in accordance with the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.^26,27 The protocol was registered with PROSPERO (CRD42025636186). Because this investigation utilized data exclusively from previously published studies, no ethical approval or approval from the institutional review board (IRB) was required.

Search strategy

A comprehensive literature search was conducted in four databases, PubMed, Embase (Elsevier), Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL), covering all records from each database’s inception through August 28, 2025. Medical Subject Headings (MeSH) terms and free-text keywords were combined using Boolean operators. The primary search terms included “coloenterostomy,” “enterocolostomy,” “endoscopic ultrasound guided,” “anastomosis,” and “bowel obstruction.” Specific search strings for each database, along with additional details, can be found in Supplemental Table 1. All referenced studies were thoroughly examined to identify any additional studies that may have been overlooked by the initial search terms. Only those studies that met the inclusion criteria were incorporated into the analysis.

Eligibility criteria

For the descriptive analysis, all study types that met the inclusion criteria were considered eligible, including case reports, case series, conference proceedings (published abstracts), observational studies (retrospective and prospective), open-label trials, and randomized controlled trials. The study population comprised patients with MBO, defined as obstruction resulting from an underlying malignant pathology, who underwent creation of an anastomosis using a LAMS placed under endoscopic ultrasound (EUS) guidance. All forms of MBO (proximal or distal, complete or partial) were included.

The intervention of interest was EUS-EC, in which a LAMS was used to establish an anastomosis between the small and large bowel, thereby bypassing the obstruction and providing an alternative route for bowel contents. To qualify for inclusion, studies were required to report at least one primary outcome, defined as either technical success or clinical success.

Exclusion criteria were studies with insufficient data, those addressing indications other than MBO, animal studies, unpublished or non-peer-reviewed articles, guidelines, letters, review articles, and duplicates. Patients with functional bowel obstruction (e.g., pseudo-obstruction) were also excluded. When multiple publications reported overlapping data, the most recent and comprehensive study was prioritized. Only studies published in English were considered.

Study selection

All references identified through the search were imported into Mendeley Reference Manager (version 1.19.8) (Amsterdam, North Holland, Netherlands) for duplicate removal. Three independent reviewers (M.S., K.K., and B.B.) screened the titles and abstracts in a blinded manner to identify potentially eligible studies. Full-text versions of these shortlisted articles were subsequently assessed against the inclusion and exclusion criteria. Any disagreements were resolved through discussion; if consensus was not reached, two additional reviewers (I.E. and H.R.) were consulted. The study selection process is visually summarized in a PRISMA flow diagram (Figure 1).

Figure 1.

PRISMA flow diagram of study selection.

Flowchart showing identification, screening, eligibility assessment, and final inclusion of studies in the systematic review and meta-analysis of EUS-EC with LAMS.

EUS-EC, EUS-guided enterocolostomy; LAMS, lumen-apposing metal stents; PRISMA, preferred reporting items for systematic reviews and meta-analyses.

Outcomes

The primary outcomes of this study were meticulously defined to ensure a comprehensive understanding of the procedure’s effectiveness. These outcomes included technical success was defined as the accurate placement of a LAMS, creating a connection between the colon and a dilated segment of small intestine located upstream from the obstruction. ¹⁰ Clinical success referred to relief of the bowel obstruction following the procedure, demonstrated by improvement in obstructive symptoms, restoration of bowel movements, and removal of any nasogastric or nasojejunal tube when present. ¹⁰

Secondary outcomes included the time to resume oral intake, length of hospital stay (measured in days), survival duration post-procedure (also measured in days), adverse events, and overall mortality rates. Causes of death included factors such as progressive cancer under comfort care or hospice, sepsis, and any complications related to the procedure. Additionally, the study explored adverse events of interest, such as diarrhea, perforation, bleeding, and aspiration associated with the procedure.

Data extraction

Two reviewers (K.K. and B.B.) systematically and independently extracted data using a predefined Excel form. Extracted information included critical study characteristics—such as authors, publication year, country, and study design—as well as patient demographics, such as age, gender distribution, and sample size. Details of the intervention, including the location of the obstruction, type of LAMS used, balloon dilation after LAMS placement, periprocedural antibiotic use, and techniques, were documented, along with all other relevant outcomes as outlined in the eligibility criteria. Any discrepancies that arose were resolved either through consensus or by consulting a third reviewer (M.S.) to ensure the accuracy and integrity of the data.

Quality assessment

The quality and risk of bias of the included cohort and case-control studies were assessed using the Newcastle–Ottawa Scale (NOS) for observational studies. ²⁸ This tool evaluates studies based on three domains: selection of study groups, comparability of groups, and outcome assessment. The selection domain assessed representativeness of the exposed cohort, selection of the non-exposed cohort, ascertainment of exposure, and demonstration that the outcome was not present at the start of the study. The comparability domain evaluated whether the study controlled for confounding factors. The outcome assessment domain considered the assessment of outcome, follow-up duration, and adequacy of follow-up. Studies were awarded a maximum of nine points. Scores of 7–9 were considered high quality, 4–6 indicated fair quality (moderate to high risk of bias), and ⩽3 denoted low quality (very high risk of bias).

For the case reports, methodological quality was appraised using the JBI Critical Appraisal Checklist for Case Reports, which includes eight items assessing reporting of patient demographics, clinical history, condition on presentation, diagnostic tests and results, intervention details, post-intervention outcomes, adverse or unanticipated events, and key takeaway lessons.

Data analysis

Descriptive statistics were used to summarize the data. Categorical variables were presented as frequencies and percentages, while continuous variables were reported as means with standard deviations (SDs) or confidence intervals (CIs), as available. Meta-analyses of single-arm continuous outcomes were performed using the meta package (version 8.2.1) in R (version 4.5.1, R Foundation for Statistical Computing, Vienna, Austria).^29,30 Pooled estimates were calculated using an inverse-variance random-effects model, with the between-study variance (τ²) estimated by Restricted Maximum Likelihood (REML). To provide more reliable inference in the setting of a limited number of studies, Hartung–Knapp adjustments were applied for the confidence intervals. Because the outcomes of interest (length of stay, days to oral intake, and survival time) are measured in days and restricted to positive values, analyses were performed on the log-normal scale and subsequently back-transformed, ensuring pooled estimates and confidence intervals remained clinically interpretable and non-negative. For sensitivity analyses, raw-scale models were also examined. Between-study heterogeneity was assessed using the Cochran Q test (p < 0.10 considered significant) and quantified with the I² statistic, with thresholds of 25%, 50%, and 75% interpreted as low, moderate, and high heterogeneity, respectively. In addition to pooled means and 95% CIs, 95% prediction intervals were reported to indicate the range of effects expected in future comparable settings.

For subgroup analyses, cohort studies were analyzed separately from case reports, and tests for subgroup differences were performed. When SDs were missing or reported as zero, they were imputed using the median SD from other included studies, and this assumption was explicitly reported. Given the small number of studies (k < 10 for all outcomes), publication bias was not formally assessed, as funnel plot asymmetry and Egger’s regression test are unreliable under these conditions.

When studies reported medians instead of means, Wan et al.'s method was used to estimate means and SDs. ³¹ Log transformation was applied where appropriate to normalize skewed distributions before conversion. ³²

Results

Study selection and population characteristics

From an initial 7540 records identified via database searches, 23 studies ultimately met the inclusion criteria after full-text review. This review included 78 patients drawn from five retrospective studies (60 patients) and 18 case reports (18 patients).^{22–24,33–46} The retrospective studies comprised one single-center series, two multicenter cohorts, and two additional case series conducted between 2018 and 2025 at tertiary centers across Europe, the United States, and Asia, with a majority of male patients (53%–56%) and ages ranging from 26 to 92 years. Malignant obstructions were most commonly observed in the distal small bowel (70.5%), with 3.8% at the ileocolonic valve and 20.5% in the colon. When deployment data were available, LAMS placements were most frequent in the ileum (29.5%) and jejunum (17.9%), with less frequent placements in the duodenum (1.3%) and in various colonic segments (ascending 5.1%, transverse 12.8%, descending 14.1%, sigmoid 19.2%). Metastatic cancer accounted for the majority of cases. Other identified etiologies included rectal carcinoma and peritoneal carcinomatosis. Significant comorbidities (e.g., COPD, hepatic metastases, and pelvic recurrence) and prior surgeries (e.g., hemicolectomy and cystectomy) often rendered surgical intervention unsuitable. Failed decompression attempts were reported in 41.8% of cases with nasogastric tubes, 12.1% with enteral stents, 27.8% with venting PEG or jejunostomy tubes, and 38.2% with surgical debulking. These cases subsequently underwent EUS-guided LAMS placement. A detailed breakdown of the characteristics of the included case reports is provided in Tables 1 and 2, and patient population data for all included studies are presented in Table 3.

Table 1.

Study characteristics and demographics of patients undergoing EUS-guided enterocolostomy.

Author	Publication year	Study period	Country	Type of study	Sample size	Age	Gender	Underlying malignancy	Stage /ECOG	Prior therapy	Intervention	Complications/adverse events	Palliative intent
Case reports
Vanella et al. 35	2023	NR	Italy	Case report	1	53	Male	Bladder carcinoma with peritoneal recurrence	NR	Radical cystectomy, neobladder removal, colostomy	EUS-guided transstomal ileocolostomy with 22 mm LAMS + balloon dilation	NR	Yes
James et al. 22	2020	NR	USA	Case report	1	65	Male	Anal squamous cell carcinoma	NR	HIV, COPD, and hypertension	EUS-guided ileocolonic anastomosis with 20 mm LAMS + balloon dilation	NR	Yes
Westerveld et al. 24	2022	NR	USA	Case report	1	91	Male	Recurrent right-sided colon cancer	NR	Previous hemicolectomy	EUS-guided ileosigmoidostomy with 15 mm ECE-LAMS + balloon dilation + double-pigtail stent	NR	Yes
Rodgers et al. 37	2024	NR	USA	Case report	1	76	Male	Cecal adenocarcinoma with liver metastases	NR	Declined surgery	EUS-guided enterocolostomy with 15 × 10 mm LAMS + balloon dilation	NR	Yes
Martínez-Moreno et al. 41	2021	NR	Spain	Case report	1	40	Male	Rectal cancer with pelvic recurrence and liver/bone metastases	NR	Abdominoperineal amputation	EUS-guided colo-enterostomy with LAMS (size not specified)	NR	Yes
Mir et al. 39	2019	NR	USA	Case report	1	72	Female	Pancreatic adenocarcinoma (metastatic) with history of lymphoma, breast cancer	Stage IV	Prior bowel obstruction	EUS-guided enterocolostomy with 15 × 10 mm AXIOS LAMS	Nausea, vomiting	Yes
DuBroff et al. 34	2024	NR	USA	Case report	1	44	Female	Stage IV adenocarcinoma	Stage IV	Roux-en-Y gastric bypass	EUS-guided enterocolostomy with 20 × 10 mm AXIOS LAMS	NR	Yes
Lee et al. 42	2024	NR	South Korea	Case report	1	52	Female	Gastric cancer with peritoneal carcinomatosis	NR	Subtotal gastrectomy with Billroth I	EUS-guided ileocolostomy with HOT SPAXUS LAMS	NR	Yes
Gasmi et al. 33	2021	NR	France	Case report	1	46	Male	Recurrent small-bowel adenocarcinoma with peritoneal carcinomatosis	NR	Prior surgeries	EUS-guided colojejunal anastomosis with 20 mm LAMS	NR	Yes
Gjeorgjievski et al. 46	2022	NR	USA	Case report	1	66	Female	Metastatic pancreatic carcinoma with peritoneal carcinomatosis	Stage IV	NR	EUS-guided coloenterostomy with Hot Axios LAMS; stent misdeployment managed	Stent displacement, perforation	Yes
Lajin et al. 43	2024	NR	USA	Case report	1	64	Female	Pulmonary adenocarcinoma and goblet cell carcinoid (appendix)	NR	Extensive prior cytoreduction + HIPEC	Retrograde EUS-guided ileocolostomy with 15 × 10 mm LAMS	NR	Yes
Miranda et al. 38	2023	NR	USA	Case report	1	75	Male	Crohn’s disease with small-bowel adenocarcinoma, carcinomatosis	Stage IV	PEG 2 months earlier	EUS-guided jejuno-colostomy with 20 × 10 mm LAMS	NR	Yes
Sooklal et al. 36	2019	NR	USA	Case report	1	43	Male	Metastatic signet ring adenocarcinoma with peritoneal carcinomatosis	Stage IV	Multiple prior surgeries, HIPEC	EUS-guided duodeno-colonic anastomosis with 15 × 10 mm LAMS	NR	Yes
Keith et al. 44	2024	NR	USA	Case report	1	73	Male	Metastatic gallbladder adenocarcinoma	Stage IV	NR	EUS-guided ileocolostomy with 15 × 10 mm LAMS	NR	Yes
Mba Eya et al. 40	2024	NR	USA	Case report	1	49	Male	Metastatic adenocarcinoma of appendix	Stage IV	Multiple prior surgeries + HIPEC	EUS-guided jejuno-colonic anastomosis with LAMS	NR	Yes
Mai et al. 23	2018	NR	USA	Case report	1	52	Male	Appendiceal mucinous adenocarcinoma	NR	Previous chemotherapy and surgical interventions	EUS-guided colo-enterostomy with 15 mm Axios LAMS	NR	Yes
Goyal et al. 45	2025	NR	USA	Case report	1	50	Female	Stage IV cervical squamous cell carcinoma with peritoneal carcinomatosis	Stage IV	Chemoradiation + brachytherapy	Sigmoid WallFlex colonic stent followed by EUS-guided jejuno-colonic anastomosis with Axios LAMS	Mild LLQ pain, later death due to neutropenia/sepsis (non-procedural)	Yes
Lee et al. 49	2025	NR	South Korea	Case report	1	64	Female	Locally advanced pancreatic cancer with peritoneal carcinomatosis	Stage IV	NR	EUS-guided ileocolostomy with HOT SPAXUS LAMS; later SEMS placed through LAMS for synchronous ileal obstruction	NR	Yes
Retrospective studies
Gao et al. 50	2025	July 2022–Dec 2023	China	Retrospective cohort	15	Mean 57.1 ± 12.8	80% Female	Ovarian adenocarcinoma (40%), pancreatic adenocarcinoma (20%), ileocecal adenocarcinoma (13.3%), gastric with ovarian/colonic metastasis (20%), cervical SCC (6.7%)	Stage IV (86.7% with peritoneal carcinomatosis)	73.3% debulking surgery, 20% recent chemoradiotherapy, 11/15 prior GOO interventions (NGT, SEMS, EUS-GE)	EUS-guided coloenterostomy with 15 × 10 mm AXIOS LAMS (sigmoid/descending colon approach)	26.7% (1 leak, 1 bleed, 3 diarrhea; 1 death from peritonitis)	Yes
Jonica et al. 25	2023	Sept 2021 – Apr 2022	USA (3 centers)	Retrospective case series	10	64.5 ± 14	90% male	Colorectal/appendiceal (40%), pancreatic (40%), duodenal (10%), anal SCC (10%)	NR	Some prior chemo, 1 PEG, 1 on chemo at procedure	EUS-EC with AXIOS LAMS 15 × 10 or 20 × 10	Aspiration (10%), 1 death progression	Yes
Neri et al. 47	2024	Nov 2021 – Sept 2023	Italy, France (4 centers)	Retrospective multicenter	12	72.5 (42–85)	58% female	Colorectal (75%), ovarian (17%), cholangiocarcinoma (8%)	92% stage IV	Majority prior chemo; MDT decision	EUS-EC with AXIOS or SPAXUS LAMS (15–20 mm)	25% AE (sepsis, death)	Yes
Mitsuhashi et al. 10	2024	June 2014–Apr 2023	USA (2 centers)	Retrospective cohort	26	66.2 (26–89)	54% female	GI malignancies with peritoneal mets (96%)	Advanced	81% prior surgery; 24 on chemo; many TPN	EUS-EC with AXIOS LAMS 15 × 10 or 20 × 10	15% AE (bleeding, diarrhea, sepsis), 2 deaths	Yes
Betés et al. 48	2021	Mar 2018–Oct 2019	Spain (single center)	Retrospective single-center	30	67.1 ± 11.5	53% male	Pancreatic (11), duodenal (2), gastric (4), gallbladder (1), colorectal/ovarian/pelvic implants	27/30 malignant, 22 with metastases	Prior surgery in several; some rescue after failed surgery/stent	EUS-anastomosis with Hot AXIOS LAMS (20 mm)	2 failures distal EC (perforation, misplacement), 2 migrations, 1 leak, 1 sepsis	Yes

COPD, chronic obstructive pulmonary disease; EUS, endoscopic ultrasound; LAMS, lumen-apposing metal stent; NR, not reported; SCC, squamous cell carcinoma; NGT, Nasogastric Tube.

Table 2.

Clinical characteristics and outcomes of patients undergoing EUS-guided enterocolostomy in reported cases.

Author	Pathology	Procedure overview/Procedure performed	Indication for intervention
Case reports
Vanella et al. 35	Acute SBO secondary to metastatic bladder carcinoma	The procedure involved an EUS-guided ileocolonic anastomosis using a lateral-viewing endoscope. A 20 mm electrocautery-enhanced LAMS was deployed, and fecal material backflow was observed upon the release of the LAMS. Following stent placement, progressive dilation (15–16.5 mm) of the LAMS was performed using a balloon to ensure proper patency.	The patient was admitted for complete intestinal obstruction. Abdominal CT revealed massive dilation of the jejunum and ileum due to neoplastic recurrence in the left iliac fossa. The obstruction was deemed inoperable due to the patient being unfit for surgery.
James et al. 22	SBO due to adhesive disease	The procedure involved an EUS-directed ileocolonic anastomosis performed using a forward-viewing curvilinear array echoendoscope. A 20 mm electrocautery-enhanced LAMS was deployed under EUS guidance, followed by dilation using a 20-mm through-the-scope balloon dilator.	The patient had a history of recurrent SBO due to adhesions. Despite undergoing surgical lysis of adhesions and ileocolonic anastomosis, the lumen was completely obliterated. The patient was found to be a poor candidate for further surgery due to the complexity of the obstruction.
Westerveld et al. 24	Malignant SBO due to right-sided colon carcinoma	An EUS-guided ileosigmoidostomy was performed using LAMS for palliative decompression. A 15-mm balloon was used for dilation of the LAMS, and a double-pigtail plastic stent was placed to help prevent stool impaction.	The patient had a circumferential mass from right-sided colon cancer located at the ileocolonic anastomosis, leading to significant upstream small-bowel dilatation consistent with high-grade SBO. The patient had a history of the right hemicolectomy and tumor recurrence, presenting with worsening abdominal symptoms.
Rodgers et al. 37	Malignant small-bowel obstruction from cecal adenocarcinoma	A therapeutic upper endoscope was exchanged for a linear echoendoscope to perform EUS-guided enterocolostomy with LAMS for palliation of small-bowel obstruction. The 12 mm LAMS was placed, followed by dilation using a through-the-scope balloon dilator.	The patient presented with SBO caused by metastatic cecal adenocarcinoma, with associated liver metastasis. Surgical options were limited due to the extent of the metastatic disease, prompting the use of endoscopic management for symptomatic relief.
Martínez-Moreno et al. 41	High-grade SBO at the preterminal ileum due to peritoneal implant in metastatic rectal cancer	An EUS-guided colo-enterostomy was performed using a curved linear-array echoendoscope and LAMS for small-bowel obstruction relief.	The patient had rectal cancer with abdominoperineal amputation and developed high-grade SBO at the preterminal ileum due to a peritoneal implant. The patient also had pelvic recurrence and bone and liver metastases. After two weeks of conservative management, the patient opted for endoscopic management over further surgical intervention.
Mir et al. 39	Malignant SBO due to mass effect from multiple carcinomas	EUS-guided colo-enterostomy with LAMS was performed for small-bowel obstruction relief.	The patient had a history of non-Hodgkin lymphoma, breast cancer, and advanced metastatic pancreatic adenocarcinoma, currently undergoing chemotherapy. They presented with SBO secondary to mass effect after a transverse colonic stent was placed, complicating their gastrointestinal function.
DuBroff et al. 34	Stage IV adenocarcinoma of unknown primary causing SBO secondary to peritoneal carcinomatosis	EUS-guided colo-enterostomy was performed with LAMS under fluoroscopic guidance to palliate the small-bowel obstruction.	The patient was diagnosed with SBO secondary to carcinoma of unknown primary, complicated by peritoneal disease and ascites. The patient was deemed a poor candidate for standard palliative interventions (e.g., decompressive gastrostomy) due to surgical limitations and peritoneal carcinomatosis.
Lee et al. 49	Recurrent peritoneal carcinomatosis leading to ileal stricture and SBO	EUS-guided ileocolostomy with a novel electrocautery-enhanced LAMS was used to alleviate the small-bowel obstruction.	The patient presented with a stricture of the distal ileum due to recurrent peritoneal carcinomatosis. This resulted in SBO, necessitating endoscopic intervention rather than surgery, which was not deemed feasible due to the extensive disease.
Gasmi et al. 33	pT4N0R0 adenocarcinoma of the small bowel resulting in recurrent peritoneal carcinomatosis and SBO	EUS-guided colojejunal anastomosis was performed using LAMS to relieve small-bowel obstruction.	The patient had pT4N0R0 small-bowel adenocarcinoma complicated by peritoneal carcinomatosis. After undergoing bowel resection and chemotherapy, tumor recurrence led to SBO, which was unresponsive to conservative management. The patient opted for endoscopic palliation rather than additional surgical options.
Gjeorgjievski et al. 46	Metastatic pancreatic carcinoma with peritoneal carcinomatosis causing small-bowel thickening and SBO	EUS-guided enterocolostomy was performed for small-bowel obstruction relief.	The patient had metastatic pancreatic carcinoma with peritoneal carcinomatosis leading to thickening of the distal ileal loop and resultant SBO. The patient was not a candidate for surgical resection due to the extensive metastatic disease, but they opted for endoscopic management to address the obstruction and potentially resume chemotherapy.
Lajin et al. 43	Small-bowel obstruction due to adhesions and recurrent tumor	A retrograde EUS-guided ileocolostomy was performed using electrocautery-enhanced LAMS for small-bowel obstruction relief.	The patient had a history of pulmonary adenocarcinoma and a perforated goblet cell carcinoid tumor of the appendix. They underwent extensive cytoreductive surgery with heated intraperitoneal chemotherapy (HIPEC), followed by small-bowel resection and extensive lysis of adhesions. They presented with distal SBO and were deemed a poor candidate for additional surgery.
Miranda et al. 38	Recurrent malignant SBO with severe carcinomatosis and PEG tube placement for palliative decompression	EUS-guided jejunocolostomy using LAMS was performed to relieve small-bowel obstruction.	The patient had Crohn’s disease and adenocarcinoma of the small bowel, status post-ileocecectomy. They developed severe carcinomatosis, resulting in small-bowel obstruction with a transition point in the right abdomen due to the tumor burden. The obstruction failed to resolve with conservative management, and endoscopic management was pursued as an alternative to surgery.
Sooklal et al. 36	Malignant distal SBO due to intraabdominal adhesions and peritoneal carcinomatosis with poorly differentiated signet ring adenocarcinoma of the colon	EUS-guided enterocolostomy between the duodenum and colon using LAMS and 15-mm balloon dilation was performed for SBO.	The patient had a history of poorly differentiated signet ring adenocarcinoma of the colon with peritoneal carcinomatosis and metastases to the omentum. After undergoing multiple surgeries (including left hemicolectomy and colostomy reversal), they presented with recurrent SBO and were considered a poor candidate for further surgery due to dense intraabdominal adhesions and the extensive peritoneal disease.
Keith et al. 44	Metastatic gallbladder adenocarcinoma causing SBO at the terminal ileum	Endoscopic ultrasound-guided ileo-colostomy using LAMS and 8-mm balloon dilation was performed for small-bowel obstruction relief.	The patient, diagnosed with metastatic gallbladder adenocarcinoma, had a 2.6 cm mass at the terminal ileum, causing SBO. Given the metastatic disease and recent chemotherapy, the patient was deemed unsuitable for surgery. While luminal stenting was considered, success was limited
Goyal et al. 45	Malignant SBO secondary to metastatic stage IV cervical squamous cell carcinoma with peritoneal carcinomatosis	A sigmoid colonic WallFlex stent (25 × 60 mm) was first deployed to traverse a severe malignant stricture. One week later, an EUS-guided jejuno-colonic anastomosis was performed from the distal descending colon to mid-jejunum using an Axios LAMS under EUS and fluoroscopy. Balloon dilation (15–18 mm) and three hemostatic clips were used to secure placement.	The patient presented with recurrent malignant SBO (transition point in ileum). She was a poor surgical candidate due to prior chemoradiation and advanced peritoneal disease. Endoscopic palliation was selected after failed conservative management.
Eya et al. 40	SBO with transition to normal-caliber small bowel in the mid-abdomen, secondary to metastatic adenocarcinoma of the appendix	Endoscopic ultrasound-guided jejunal-colonic anastomosis using LAMS was performed.	The patient had a history of metastatic adenocarcinoma of the appendix and underwent multiple surgeries, including laparoscopic appendectomy, right hemicolectomy, partial peritonectomy of peritoneal implants, and liver resection. Despite 12 cycles of adjuvant chemotherapy, disease progression led to recurrent SBO and the development of peritoneal implants. Conservative management failed, and endoscopic intervention was pursued for symptom relief.
Mai et al. 23	SBO due to severe ileocolonic anastomotic stricture post-chemotherapy	EUS-guided colo-enterostomy was performed.	The patient had a history of appendiceal mucinous adenocarcinoma and was status post-right hemicolectomy with ileocolonic anastomosis. They had undergone six cycles of FOLFOX chemotherapy followed by radical omentectomy, wedge liver resection, and hyperthermic intraperitoneal chemotherapy (HIPEC) with Mitomycin-C. Despite the aggressive treatment, the patient developed a severe ileocolonic anastomotic stricture, which led to SBO, unresponsive to conservative management. Endoscopic intervention was chosen over further surgical options due to high surgical morbidity.
Lee et al.	Locally advanced pancreatic cancer with peritoneal carcinomatosis	Stepwise EUS-guided ileocolostomy with HOT SPAXUS LAMS; later uncovered SEMS placed through LAMS for synchronous ileal obstruction	Malignant bowel obstruction due to recurrent peritoneal carcinomatosis, unsuitable for surgery
Retrospective studies
Jonica et al., 2023 25	Malignant small-bowel obstruction (varied primaries: 40% colorectal/appendiceal adenocarcinoma, 40% pancreatic adenocarcinoma, 10% duodenal adenocarcinoma, 10% anal squamous carcinoma) with peritoneal carcinomatosis in 70%	Multicenter retrospective series (n = 10) of EUS-guided enterocolostomy (EUS-EC) using 15 × 10 mm or 20 × 10 mm AXIOS LAMS via left/transverse/right colon to dilated ileum/jejunum. Balloon dilation performed in 62.5%. Technical success in 80%, clinical success in 70%. Median time to oral intake 1 day, median LOS 6.5 days, and median survival 57 days. One major AE (aspiration, 10%).	Patients with malignant SBO unfit for surgery and failed conservative management (NGT suction, bowel rest). Indications included peritoneal disease, multifocal strictures, and inoperable advanced cancers.
Betés et al., 2021 48	Malignant SBO/intestinal obstruction in six patients (rectal stump, jejunum, ileum, colorectal, jejuno-jejunal, ileo-colic)	EUS-guided non-gastric anastomoses with Hot Axios 20 mm LAMS; sites included colorectal, jejuno-jejunal, ileo-ileal, ileo-sigmoid, ileo-colic.	Indications included obstructive recurrence after surgery, carcinomatosis, and strictures; majority palliative cases.
Neri et al., 2024 47	Malignant intestinal obstruction (n = 12, mostly colonic adenocarcinoma)	Multicenter EUS-guided entero-colostomy with Hot Axios/Hot Spaxus LAMS (15–20 mm), freehand technique.	Indication: Malignant intestinal occlusion in advanced cancers, poor surgical candidates.
Mitsuhashi et al., 2024 10	Malignant SBO (n = 26, 96% malignant)	Retrospective EUS-guided coloenterostomy between colon and dilated small bowel using 15–20 mm Axios LAMS.	Indication: Malignant SBO in poor surgical candidates; most had carcinomatosis and prior chemotherapy.
Gao et al., 2025 50	Malignant SBO from ovarian, pancreatic, ileocecal, gastric, and cervical primaries (n = 15)	Retrospective cohort; EUS-guided coloenterostomy via sigmoid/descending colon with 15 × 10 mm Axios LAMS.	Indications: Malignant bowel obstruction with peritoneal carcinomatosis; most had prior debulking surgery or chemoradiation.

CI, confidence interval; COPD, chronic obstructive pulmonary disease; CT, computed tomography; EUS, endoscopic ultrasound; FOLFOX, folinic acid, fluorouracil, and oxaliplatin (Chemotherapy Regimen); HIPEC, hyperthermic intraperitoneal chemotherapy; LAMS, lumen-apposing metal stent; NR, not reported; PEG, percutaneous endoscopic gastrostomy; pT4N0R0, Tumor Stage Pathological Classification; RR, risk ratio; SBO, small-bowel obstruction; SCC, squamous cell carcinoma; Tx, Treatment.

Table 3.

Baseline characteristics of the study population undergoing EUS-guided enterocolostomy.

Studies	Total patient population (N)	Prior decompression modalities attempted (n/N)				Location of obstruction (n/N)
		Nasogastric or nasojejunal tube	Enteral stent	Venting PEG or jejunostomy tube	Surgical debulking	Small intestine	Colon	Ileocolonic anastomosis
Jonica et al. 25	10	2/10	_	2/10	_	8/10	2/10	_
Mitsuhashi et al. 10	26	13/26	3/26	7/26	3/26	20/26	6/26	_
Betés et al. 48	2	_	_	_	_	2/2	0/2	_
Neri et al. 47	7	_	_	3/7	2/7	3/7	4/7	_
Gao et al. 50	15	8/15	1/15	0/15	11/15	15/15	4/15	0/15
Case Reports	18	_	1/18	_	_	10/18	4/18	3/18

Ileocolonic Anastomosis, Surgical Connection Between Ileum and Colon; n/N, Number of Patients with the Feature/Total Number of Patients; N, Total Number of Patients; PEG, percutaneous endoscopic gastrostomy.

Procedural characteristics

Anastomoses created using LAMS were largely unspecified (39.7%), followed by ileocolostomy (29.5%), ileosigmoidostomy (11.5%), jejunocolostomy (17.9%), and duodenocolostomy (1.3%). Among the stents used, 48.7% were 15 × 10 mm AXIOS, while 51.3% were 20 × 10 mm AXIOS, with selective use of HOT SPAXUS reported in individual cases. Balloon dilation was performed in 59% of procedures, and 47% of patients received periprocedural antibiotics where data were available. Two primary techniques were employed: wire-guided methods in 46% of cases and freehand approaches in 51% of cases. A detailed breakdown of procedural characteristics is presented in Table 4.

Table 4.

Procedural characteristics of EUS-guided enterocolostomy.

Studies	LAMS		Balloon dilation after LAMS placement (n/N)	Periprocedural antibiotics (n/N)	Technique (n/N)		Estimated site of deployment (n/N)							Anastomosis created using LAMS (n/N)
	15 x 10 mm AXIOS	20 x 10 mm AXIOS			Wire-guided	Freehand	Duodenum	Jejunum	Ileum	Ascending colon	Transverse Colon	Descending Colon	Sigmoid Colon	Duodenocolostomy	Jejunocolostomy	Ileocolostomy	Ileosigmoidostomy	Unspecified
Jonica et al. 25	1/2	3/10	1/2	7/10	1	0/10	_	_	4/5	1/2	1/5	1/10	_	_	_	1/10	_	_
Mitsuhashi et al. 10	3/13	10/13	1 /13	1/13	7/26	19/26	0/26	7/26	9/26	1/13	2/13	7/26	1/2	_	_	_	_	1/26
Betés et al. 48	_	_	_	_	_	_	_	_	1/7	_	_	_	1/2	_	_	1/2	1/2	_
Neri et al. 47	3/7	2/7	_	1/7	_	1/7	_	_	1/7	2/7	1/7	2/7	1/7	_	_	1/7	_	_
Gao et al. 50	15/15	0/15	0/15	15/15	15/15	0/15	–	5/15	10/15	–	–	5/15	10/15	–	5/15	–	10/15	–
Case Reports	8/18	7/18	7/18	8/18	10/18	5/18	1/18	4/18	4/18	1/18	2/18	5/18	7/18	1/18	4/18	6/18	2/18	5/18

EUS, endoscopic ultrasound; F/U, Follow-Up; LAMS, lumen-apposing metal stent.

Quality assessment

The NOS assessment rated all four retrospective studies as moderate quality, highlighting strengths in cohort representativeness, exposure ascertainment, and follow-up adequacy. A detailed account is presented in Table 5. For the case reports, all 18 clearly described patient demographics, clinical presentation, diagnostic evaluation, intervention performed, and post-intervention outcomes. Overall, all case reports were deemed suitable for inclusion. A detailed account of the JBI assessment is provided in Supplemental Table 2.

Table 5.

NOS evaluation of included studies.

NOS evaluation for a non-randomized study
Study ID	Types of studies	Selection				Outcome			Total score
		Representativeness of the exposed cohort	Ascertainment of exposure	Selection of the non-exposed	Comparability of cohorts	Assessment of outcome	Sufficient follow-up time	Adequacy of follow-up of cohort
Jonica et al. (2023) 25	Retrospective	1	1	0	0	1	1	1	5/9
Neri et al. (2024) 47	Retrospective	1	1	0	0	1	1	1	5/9
Mitsuhashi et al. (2024) 10	Retrospective	1	1	0	0	1	1	1	5/9
Gao et al. (2025) 50	Retrospective	1	1	0	0	1	1	1	5/9

NOS, Newcastle–Ottawa Scale.

Outcomes

A detailed account of outcomes is provided in Table 6.

Table 6.

Clinical outcomes of EUS-guided enterocolostomy.

Studies	Total patient population	Technical success (n)	Clinical success (n)	Death (n)			Adverse events (n)					Length of stay post-procedure (days) (Mean ± SD)	Days until resumption of oral intake (Mean ± SD)	Survival post-procedure (days) (Mean ± SD)	Mean symptom recurrence-free period (days) (Mean ± SD)
				Progressive cancer (comfort care or hospice)	Sepsis	Procedural-related	Diarrhea	Perforation	Bleeding	Aspiration	Stent Misdeployment
Jonica et al. 25	10	8	7	5	0	1	0	0	0	1	_	10.25 ± 7	2.5 ± 2	57.0 ± 93	_
Mitsuhashi et al. 10	26	26	24	2	1	0	2	0	1	_	_	_	9.25 ± 5.75	54.8 ± 47	_
Betés et al. 48	2	1	1	1	0	0	0	1	0	0	_	_	_	60 +-0	_
Neri et al. 47	7	7	5	3	0	0	0	0	0	0	_	9.75 +-4.75	1.25 ± 0.25	91.75 ± 67	_
Gao et al. 50	15	15	14	10	0	1	3	1	1	0	4/15	9.3 +-6.6	21.0 ± 17.2	133.3 ± 92.3	180.8 ± 95.7
Case Reports	18	18	18	5	2	0	0	1	0	0	_	2 ± 0	1.1 ± 0.3	153.8 ± 197.7	_
Aggregated Clinical metrics and outcomes (Mean (SD) and %)	78	96.1%	88.4 %	40 %	4.8 %	2.5 %	6.4 %	3.8 %	2.5 %	1.2 %	26.6%	10.58 ± 17.2	3.10 ± 5.8	91.07 ± 181.0	_

EUS, endoscopic ultrasound; MD, mean difference; SD, standard deviation.

Primary outcomes

The primary outcome included a technical success rate of 96.1% and a clinical success rate of 88.4%, the latter defined as symptom relief and restored bowel function.

Secondary outcomes

The pooled mean hospital stay following the procedure was 10.58 days (95% CI: 3.20–34.97; prediction interval: 1.47–76.04; I² = 77.8%, p = 0.004) (Figure 2). In subgroup analysis, the mean was 12.74 days (95% CI: 6.80–13.99) among cohort studies and 2.00 days (95% CI: 0.40–10.07) among case reports, with a statistically significant difference between subgroups (Q = 4.62, p = 0.0315).

Figure 2.

Forest plot of mean hospital stay following EUS-EC.

Random-effects model displaying pooled estimates of post-procedure length of hospital stay (days) across included studies. Subgroup analyses are stratified by study design (cohort studies vs case reports).

EUS-EC, endoscopic ultrasound-guided enterocolostomy.

The pooled mean survival after the procedure was 91.07 days (95% CI: 56.15–147.72; prediction interval: 29.03–285.74; I² = 71.5%, p = 0.004) (Figure 3). Subgroup analysis demonstrated a mean survival of 81.21 days (95% CI: 53.42–157.60) across cohort studies and 153.80 days (95% CI: 84.93–278.52) among case reports, with subgroup difference approaching significance (Q = 3.20, p = 0.0736).

Figure 3.

Forest plot of mean survival after EUS-EC.

Pooled survival time (days) following EUS-EC across all included studies. Subgroup analyses compare cohort studies with case reports.

EUS-EC, endoscopic ultrasound-guided enterocolostomy.

The average time to resumption of oral intake (Oral intake refers to any enteral intake; diet stage was inconsistently specified) was 3.10 days (95% CI: 0.85–11.38; prediction interval: 0.13–73.50; I² = 98.8%, p < 0.0001) (Figure 4). In subgroup analysis, based on 58 patients from retrospective cohorts and 10 patients from case reports with reported data, the pooled mean was 4.05 days (95% CI: 1.52–4.10) for retrospective cohorts and 1.10 days (95% CI: 0.97–1.25) for case reports, with a statistically significant subgroup difference (Q = 6.63, p = 0.01).

Figure 4.

Forest plot of mean time to oral intake resumption.

Pooled time (days) to resumption of oral intake following EUS-EC. Subgroup analyses are presented for retrospective cohorts and case reports.

EUS-EC, endoscopic ultrasound-guided enterocolostomy.

As an exploratory outcome, symptom recurrence-free survival was reported in Gao et al. ⁵⁰ Using Wan’s method to convert the median (165 days, range 40–353, n = 12) to mean ± SD, the estimated mean recurrence-free survival was 180.8 ± 95.7 days.

Adverse events

Adverse events were relatively uncommon. The most frequently reported complications were diarrhea (6.4%), perforation (3.8%), bleeding (2.5%), and aspiration (1.2%). Stent misdeployment occurred in four cases (26.6%), reported exclusively in Gao et al., ⁵⁰ but all instances were promptly recognized and successfully managed endoscopically without major sequelae.

Across all included studies, a total of 33 deaths (42.3%) were documented. The majority were attributed to progression of underlying malignancy (26 deaths, 78.8%). Other causes included sepsis (three deaths, 9.1%), procedure-related complications (two deaths, 6.1%), and other causes such as delayed digestive hemorrhage and pulmonary abscess (two deaths, 6.1%). Only a small fraction of deaths (6.1%) were directly procedure-related, whereas nearly four-fifths reflected the natural progression of advanced disease.

Discussion

Our systematic review and meta-analysis found that EUS-EC using LAMS is a safe, feasible, and effective palliative option for MBO in appropriately selected patients. The procedure demonstrated consistently high rates of technical and clinical success across heterogeneous study designs and was generally associated with rapid symptom improvement, early resumption of oral intake, and relatively short hospital stays. Adverse events were infrequent and mostly minor, and instances of stent misdeployment, although occasionally reported, were effectively managed endoscopically without major sequelae. Mortality across studies was primarily related to the progression of advanced malignancy rather than procedural complications.

For comparison, SEMS remain the benchmark therapy for malignant obstruction. Reported technical and clinical success rates are 97%–99% and 80%–89% for duodenal obstruction, 95%–100% and 84%–100% for jejunal obstruction, and 81%–95% and 76%–91% for left-sided colonic obstruction, respectively.^51–55 Adverse events occur in 10%–22%, most often migration, occlusion, or perforation, and are usually manageable.^51–56 By contrast, surgical palliation has lower success rates, with diverting stoma, internal bypass, and resection achieving technical success in 80%, 78%, and 63% of cases, respectively. ⁵⁷ Clinical improvement rates vary from 32% to 100%, with diet resumption between 45% and 75%, ⁵⁸ but surgery carries a higher perioperative risk, with complication rates of 7%–37% and mortality ranging from 6% to 32%.^58–60 PEG tube placement provides decompression in selected patients, with technical success of 89%–100% and symptom relief of 77%–96%, though oral intake is inconsistently restored.^1,61–63 Median survival after SEMS for duodenal obstruction is 93–116 days,^53,54 and colonic SEMS achieves outcomes comparable to colectomy. ⁶⁴ Against this backdrop, the pooled technical and clinical success of EUS-EC appears comparable to SEMS and surgery, with the additional advantage of facilitating oral intake.

The success of EUS-EC is underpinned by real-time imaging that permits precise stent deployment, thereby minimizing the risk of misplacement. ⁶⁵ In addition, the flanges on either side of the LAMS provide strong anchoring platforms for maintaining anastomotic patency. The shorter design of LAMS may also reduce the risk of kinking or collapse, given its more rigid structure. Traditional SEMS are prone to tumor ingrowth due to placement adjacent to malignant tissue. EUS-EC circumvents this issue by bypassing the affected tumor segment.^66–68 The inherent design of LAMS reduces the likelihood of migration and occlusion, as evidenced by a low reported reintervention rate of 4%.^66,67 EUS-EC effectively addresses challenges in patients with multifocal strictures or peritoneal carcinomatosis, where traditional endoluminal stents may fail. The procedure’s versatility and feasibility across various bowel locations further support its potential applicability.

Efficiency is reflected in a mean hospital stay of 10.6 days and oral intake resumption within 3.1 days. Minimizing hospital stay reduces morbidity, infection risk, and mortality, particularly in this patient population. ⁶⁹ By comparison, surgical palliation typically requires longer hospitalization (12.5–31 days) and delayed diet resumption, varying by technique, with one study reporting 5 days for surgical gastrojejunostomy versus 3 days for laparoscopic gastrojejunostomy.^58,69–71 Patients undergoing palliative surgery for MBO due to peritoneal carcinomatosis had a mean hospital stay of 20.0 ± 23.1 days, with oral intake resumption as a prerequisite for discharge. However, the study did not explicitly specify the time to oral intake resumption postoperatively. ⁷² In one report, surgical patients spent 61% of their remaining life in the hospital. ⁷³ EUS-EC also reduces procedure time: approximately 36–53 min compared with a median of 152 min for surgery.^25,50,74 Although surgical approaches can restore bowel continuity, their comparable success comes at the cost of longer recovery, which often conflicts with the palliative goal of optimizing quality of life. Mean survival after EUS-EC was approximately three months (91 days), highlighting that long-term outcomes such as stent patency and delayed adverse events remain underexplored.

Adverse events with EUS-EC were infrequent: diarrhea (6.4%), perforation (3.8%), bleeding (2.5%), and aspiration (1.2%). Diarrhea is expected due to the bypass between the small and large intestines, resulting in rapid transit of intestinal contents. Rapid diet resumption may increase the risk of aspiration, which can be mitigated by a gradual increase in oral intake. The overall mortality rate of 42.3% must be interpreted in context: nearly 79% of deaths were due to disease progression, 9% to sepsis, and 6% to procedural complications. Only a minority was directly attributable to the procedure. By comparison, procedure-related mortality with SEMS is 1%–5%,^53,54,75 while surgery is associated with higher complication rates (7%–37%) and mortality of 6%–32%.^58,59,60 Infection rates for surgery vary depending on location and approach, ranging from 4.5% to 32%.^76–78 PEG placement carries aspiration risks of 1.5% and infection rates of 5.4%–30%.^62,79,80 However, this is not commonly observed in EUS-EC, given the minimized tissue trauma from LAMS placement compared with the suturing and stapling required in surgical resection. Overall, palliative surgical resection for MBO carries higher complication rates compared with curative resection, further supporting EUS-EC as a preferred alternative.^76,77 Thus, the mortality observed after EUS-EC largely reflects advanced cancer biology rather than procedural risk.

Cost and resource utilization remain important considerations. LAMS are more expensive than SEMS and require anesthesia, linear echoendoscopes, and advanced expertise, restricting use to tertiary centers.^54–56,81 While EUS-EC provides rapid symptom relief and shorter hospitalization in selected patients, these benefits must be weighed against higher device and procedural costs. SEMS have been shown to be more cost-effective than emergent surgery for malignant colonic obstruction, with lower costs, fewer permanent stomas, and improved QALYs.^{56,64,75,81,82} No large-scale cost-effectiveness studies have compared LAMS directly with SEMS or surgery in MBO, and available data are limited to small retrospective series from expert centers.^53–55 The broader financial feasibility of EUS-EC in palliative care, therefore, remains uncertain.

This study has several limitations that should be considered when interpreting the findings. The current evidence base is primarily composed of small retrospective studies and individual case reports, with no randomized trials available to date. This reliance on lower-level evidence limits both the precision and generalizability of the results. Considerable variability in patient selection, procedural technique, and outcome reporting introduces heterogeneity that reduces the reliability of pooled estimates. Follow-up durations were generally short, with an average post-procedure survival of approximately 3 months, preventing adequate assessment of long-term stent patency, delayed adverse events, or sustained clinical benefit. Incomplete reporting of baseline variables, outcome measures, and denominators, such as diet type and recovery timelines, further weakens the evidence. Patient-centered outcomes, including quality of life, functional recovery, and symptom burden, were infrequently reported. In addition, most studies originated from high-volume tertiary centers, where operator expertise and institutional experience may have influenced outcomes, limiting applicability to lower-volume settings. Publication bias toward favorable or technically successful cases cannot be excluded.

Future research should focus on generating higher-quality evidence through multicenter prospective registries and randomized controlled trials. Comparative studies evaluating EUS-EC against SEMS and surgical palliation are needed to establish relative efficacy, safety, and durability. Standardization of procedural techniques, outcome definitions, and reporting criteria will enhance comparability across studies and allow for more reliable meta-analytic assessment. Longer follow-up periods are necessary to evaluate stent patency, reintervention rates, and delayed complications. Future studies should also incorporate patient-reported outcomes, nutritional recovery, and quality-of-life measures to better capture clinical benefit. Finally, inclusion of economic analyses and participation from centers with varying procedural volumes will improve understanding of real-world feasibility, cost-effectiveness, and generalizability of EUS-EC in the palliative management of MBO.

Conclusion

EUS-guided enterocolostomy with LAMS achieves high technical and clinical success, rapid symptom relief, and low procedure-related morbidity, supporting its role as a viable palliative option for MBO in selected patients. Outcomes appear comparable to SEMS and superior to surgery in terms of recovery, although current evidence is limited to small retrospective series and case reports. Larger prospective studies are needed to confirm efficacy, define patient selection, and evaluate long-term safety, cost-effectiveness, and quality of life.