68 year old female who presented to our hospital with nausea ,vomiting and weight loss.Her medical history included high BMI and stage 3 ovarian cancer with peritoneal metastases.

CT scan of abdmen and pelvis revealed gastric outlet obstruction secondary to metatstatic cancer . Patient was referred to our endoscopy unit for EUS-guided gastro-enterostomy after discussion in multidiciplinary team. 

Procedure was performed under consitious sedation. A loop of small bowel was identified on EUS close to the distal body of stomach. Direct EUS-GJ technique without fluroscopy was used where a 19-G needle was used to puncture the target lumen . After distension of lumen with 600 ml of saline, 20x10mm LAMS stent was placed. Greenish colour discharge was noticed into the stomach.CT scan after the procedure confirmed entry into wrong lumen -inadvertent gastrocolostomy. Complication was discussed in MDT and international expert opinion was taken as this was likely first case of type-4 complication. LAMS was removed 3 weeks after the procedure to ensure fistula was epithelised , tattoo was placed for marking the fistula and NG tube was placed .While patient remained on parenteral nutrition, one week later , fistula was closed with OVESCO Clip. NJ tube was placed to distend the small bowel with saline and indigocarmine . Fluroscopy confirmed NJ guided distension. 20X10 mm Axios stent was placed to connect the right lumen with the stomach , cofirmed with blue dye flow into the stomach and small bowel mucosal images on endoscopic view. Patient was started on oral feed and PN was gradually tapered off. 

EUS-GE is a high risk procedure and accidental placement of LAMS into colon is uncommon complication. Our case highlights the importance of sharing knowledge,complication and involvement of multidiciplinary team to manage rare complications.