LAUSR

Developments in therapeutic endoscopic ultrasound (EUS) have allowed the endoscopic creation of gastrointestinal anastomoses for gastric outlet obstruction [1, 2]. However, this approach is rarely performed for the lower gastrointestinal tract because of the technical challenge of EUS-guided colocolostomy. Herein, we describe EUS-guided colocolostomy in a patient with malignant obstruction affecting a long segment of the transverse colon after failure of enteral stenting. A 54-year-old woman with metastatic gastric cancer developed vomiting and abdominal distension 12 months after a Billroth II gastrectomy. Abdominal computed tomography demonstrated a long segment of stenosis affecting the transverse colon near the hepatic flexure with luminal dilatation and effusion in the ascending colon proximal to the lesion (▶Fig. 1). Colonoscopy revealed severe stricturing of the transverse colon (▶Fig. 2 a). A guidewire was passed through the stricture; however, colonic enteral stenting was unsuccessful. A nasobiliary catheter was placed across the stricture and a linear echoendoscope (GF-UCT260; Olympus, Tokyo, Japan) was advanced into the descending–sigmoid colon flexure. Saline solution was instilled to facilitate puncture under EUS guidance from the descending–sigmoid junction (▶Fig. 2b). The dilated lumen was punctured with a 19-gauge FNA needle followed by a 5-Fr cystoenterostomy needle knife (Cook Medical, Indiana, USA), which provided sufficient force to create a bypass across the long obstructing segment (▶Video 1). A 16×15-mm electrocautery lumen-apposing metal stent (Axios-EC, Boston Scientific, USA) was then advanced into the hepatic flexure to form a colocolostomy (▶Fig. 2 c, d). Gastrointestinal radiography with contrast after the procedure demonstrated an unobstructed enteroenteral bypass. The patient was provided a liquid diet from postoperative day 1 and reported multiple subsequent bowel movements. A semiliquid diet was maintained until follow-up at 4 months after the procedure. EUS-guided colocolostomy represents a novel endoscopic method of managing colonic obstruction. This approach allows aggressive endoscopic interventions in patients where colonic enteral stenting has failed. E-Videos