Let’s appose our hands together and anastomose the digestive tract – that’s our destiny

What can be learned in 10 years? A period of 10 years represents the typical time frame for a newborn to reach the age of adolescence, and for an adolescent to become an adult. A decade was the interval during which endoscopists began to treat functional diseases via the orificial route. It was the interval where the fine-needle aspiration technique for endoscopic ultrasound (EUS) sampling gradually ceased to be used in favor of biopsy needles, which offered higher histological precision. Ten years was the (short) time taken for luminal apposition to move from a concept to an indispensable technique, from a new means of draining paradigestive collections to a means of performing digestive anastomoses under remarkably safe conditions.

So, what does the study by Neri et al. in this issue of Endoscopy tell us? The study demonstrates that the EUS-guided lumen-apposing metal stent (LAMS) procedure is feasible in almost any location within the digestive tract [1]. Furthermore, the resulting digestive wall fusion mechanism, which is monitored by the covered metallic material, is equally effective and leakproof in the colon or small bowel. Similarly, EUS-guided gastro-enterostomy has recently been validated by international guidelines, particularly in the management of tumoral gastric outlet obstruction for poor surgical candidates [2]. As a consequence, this technique of EUS-guided entero-colostomy with LAMS as a rescue treatment for malignant intestinal occlusion could therefore have a definite future. Anastomotic bypasses obtained in an established palliative setting (91.7% of patients had stage IV disease in the present study) resulted in a rapid improvement in patient comfort, with the entire study population resuming oral nutrition and half resuming chemotherapy [1]. It is acknowledged that the average survival rate remains low, but what would it be like if these patients were unable to resume digestive transit at the end of their course?

“The high technical success rate in this case study, which remains the largest published to date, should not detract from the high level of operator expertise required.”

So, will the ongoing popularity of endoscopic luminal apposition in recent years spread via the transanal route? Yes, of course, because first of all it seems difficult, if not impossible, to expect a direct comparative study with bypass surgery or stoma, the performance of which can always raise questions about quality of life in a palliative context, especially in the case of peritoneal carcinomatosis (which was the case for the majority of patients treated in this series). Similarly, it is well known that the results obtained in this setting are predictive of technical difficulties and less clinical success when trying to insert luminal self-expandable metal stent (SEMS) in cases of colonic occlusion [3] [4]. We can do better. Finally, in the context of localized primary colon disease and in operable patients, relief of the obstruction using LAMS could potentially reduce the risk of malignant cells spreading, which has been suggested to be associated with the insertion of SEMS and the bowel perforations it causes [5].

However, EUS-guided entero-colostomy with LAMS remains a delicate technique that depends on favorable anatomical conditions. Recognition of the anatomical landmarks that may help to map which segment of the colon or small bowel is connected to another can also be a problem, even with fluoroscopically guided placement. The high technical success rate in this case study, which remains the largest published to date, should not detract from the high level of operator expertise required. In addition, the insertion of the linear EUS scope beyond the rectosigmoid junction, sometimes with a guidewire, in 7 of the 12 patients, means that this procedure should still be considered a reference or expert center procedure. Postoperative infectious complications also seem to be frequent (3 patients out of 12, i.e. a quarter of the total) and serious, with two deaths observed despite systematic antibiotic prophylaxis. It is difficult to know at this stage whether these complications were directly related to the procedure, as the deterioration of the patients’ clinical condition may have contributed to these adverse events, and the antibiotic prophylaxis protocol used in this case study was not standardized. However, it may be logical to observe more septic complications in a transluminal colorectal procedure.

So yes, we can continue to proclaim the long life of EUS-guided luminal apposition! Of course, we need to wait for more robust prospective studies. We also need to find a solution to improve localization in these extra-anatomical drainage techniques (and this is clearly not limited to this indication and location). We need to provide patients with the best possible medical support during these procedures, which are likely to carry a higher risk of infection. Nevertheless, we can be sure that the future will be even better for our patients thanks to these procedures, which are becoming less invasive, faster, more intuitive, and more effective.

Publication History

Article published online:
08 October 2024

• References

• 1 Neri B, Stigliano S, Biasutto D. et al. Endoscopic ultrasound-guided entero-colostomy with lumen-apposing metal stent as a rescue treatment for malignant intestinal occlusion: a multicenter study. Endoscopy 2024; 56 DOI: 10.1055/a-2354-3352.
• 2 van der Merwe SW, van Wanrooij RLJ, Bronswijk M. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 185-205 DOI: 10.1055/a-1717-1391. (PMID: 34937098)
• 3 Kuwai T, Yamaguchi T, Imagawa H. et al. Factors related to difficult self-expandable metallic stent placement for malignant colonic obstruction: a post-hoc analysis of a multicenter study across Japan. Dig Endosc 2019; 31: 51-58 DOI: 10.1111/den.13260. (PMID: 30113095)
• 4 Park JJ, Rhee K, Yoon JY. et al. Impact of peritoneal carcinomatosis on clinical outcomes of patients receiving self-expandable metal stents for malignant colorectal obstruction. Endoscopy 2018; 50: 1163-1174 DOI: 10.1055/a-0657-3764. (PMID: 30170328)
• 5 Amelung FJ, Borstlap WAA, Consten ECJ. et al. Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction. Br J Surg 2019; 106: 1075-1086