Palliation of malignant distal colonic obstruction via percutaneous endoscopic colostomy using a lumen-apposing metal stent

Video

Video 1

Palliation of malignant distal colonic obstruction via a percutaneous endoscopic colostomy using a lumen-apposing metal stent.

Introduction

Colonic stents have improved emergent and palliative management of large bowel obstruction; however, the risk of stent malfunction and reintervention remains.¹ We describe the first percutaneous endoscopic colostomy using a lumen-apposing metal stent (LAMS).

Case

A 49-year-old man with a history of kidney transplantation, bladder augmentation with subsequent mucinous adenocarcinoma from within it, stage IV mucinous colonic adenocarcinoma, and recurrent small- and large-bowel obstruction underwent placement of overlapping colonic stents for palliation over 2 procedures, most recently 1 week before this admission.

Upon transfer to our institution, he was cachectic-appearing with a distended abdomen. Contrast abdominopelvic CT demonstrated near-complete obstruction owing to inadequate stent expansion, with a 90-degree posterior kink at the junction of overlapping stents (Fig. 1). Management options discussed included (1) placement of a third colonic stent, (2) diverting surgical ostomy, or (3) diverting endoscopic ostomy. Given his comorbidities and poor functional status, he elected to proceed with endoscopic therapy.

Figure 1.

CT sagittal view demonstrating inadequate stent expansion with a 90-degree posterior kink at the junction of the superior and inferior stents.

Technique

Piperacillin/tazobactam was administered preprocedurally. With the patient in the supine position and using fluoroscopy under general endotracheal anesthesia, a small-caliber colonoscope (PCF-190) (Olympus Corporation, Center Valley, Pa, USA) was advanced transanally through the collapsed stents to the proximal transverse colon. Preprocedural review of the transverse axial CT images showed that the distance from the abdominal wall to the colon was <10 mm (Fig. 2). Similar to prior reports on percutaneous endoscopic colostomy,² the abdominal wall was prepped in a sterile fashion, and transillumination and indentation were performed to allow determination of the optimal site. External T-tags were used to anchor the colon to the abdominal wall (Fig. 3).

Figure 2.

CT sagittal (left) and axial (right) views on admission demonstrating signs of large-bowel obstruction.

Figure 3.

Placement of external T-tags in the transverse colon.

A needle was passed percutaneously into the colon. A standard 0.025”, 450-cm biliary guidewire (VisiGlide, Olympus) was passed through the needle and grasped with a snare. A 20-mm-diameter × 10-mm-long LAMS with an electrocautery-enhanced tip (AXIOS-EC; Boston Scientific, Marlborough, Mass, USA) was passed over the wire externally, and pure cutting current was used to advance the device percutaneously across the abdominal wall and into the colon without use of a skin incision. The internal stent flange was deployed under endoscopic visualization (Video 1, available online at www.giejournal.org), with additional balloon dilation of the LAMS lumen, after which an ostomy bag was placed (Figure 4, Figure 5, Figure 6, Figure 7, Figure 8). The colonic stents were removed with forceps, and the colonoscope was withdrawn. Follow-up CT demonstrated excellent position of the stent (Fig. 9) with colonic decompression and good stool output.

Figure 4.

Advancement of a lumen-apposing metal stent into the colon under direct endoscopic visualization.

Figure 5.

Endoscopic deployment of internal flange with withdrawal from the external side to allow apposition to the colonic wall.

Figure 6.

Deployed stent with balloon dilation catheter within the stent lumen.

Figure 7.

Fluoroscopic view of colonoscope in the right colon segment and deployment of stent across the colostomy tract.

Figure 8.

Image taken with the endoscope showing esophageal stent placed in the ostomy track at the time of transostomy EUS-guided ileocolonic anastomosis for subsequent small-bowel obstruction.

Figure 9.

CT imaging sagittal (left) and axial (right) views after the procedure in which the lumen-apposing metal stent can be seen.

Unfortunately, within 1 week, the patient developed overt small-bowel obstruction with a focal transition point unmasked after colonic decompression. The LAMS was replaced with a partially covered esophageal self-expanding metal sent, through which an EUS-guided ileocolonic anastomosis was created. The patient experienced no acute adverse events from either procedure or issues with stent migration. He was eventually placed under hospice care where long-term follow-up was limited, and he died of his disease 10 weeks later.

Conclusions

This case represents a proof of principle for the creation of a percutaneous endoscopic colostomy using LAMSs. This technique can be considered for palliation as a last resort when conventional treatment options have failed or are not possible. Limitations include high body mass index, large abdominal circumference, and the presence of peritoneal disease or ascites. Longer stent options would be needed to make this more widely applicable. Further studies are needed to assess short- and long-term outcomes.

Disclosure

Dr Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, Medtronic, and Olympus America. The other author disclosed no financial relationships.

Supplementary data

Video 1

Palliation of malignant distal colonic obstruction via a percutaneous endoscopic colostomy using a lumen-apposing metal stent.