Palliation of advanced LIMO not amenable to enteral stenting is clinically challenging. Feeding/decompressing tubes negatively impact QoL and limit oncological treatment, whereas surgery carries high morbidity. Preliminary data suggesting that EUS-EA with LAMS could potentially restore intestinal transit in this setting warrant confirmation. We aimed to assess the safety and efficacy of EUS-EAwith LAMS in patients with advanced LIMO not amenable to standard endoscopic treatment with enteral stents.

Retrospective multicenter study at eight tertiary hospitals in consecutive LIMO patients who failed or were not deemed candidates for enteral stenting and then underwent attempted EUS-guided EA from January 2018 to August 2025. Baseline clinical, procedural and follow-up variables were pooled. A descriptive analysis andcomparison between groups was performed using χ² and Fisher's exact test. Odds ratios with 95% CI were estimated to test associations.

Twenty-four patients were included (42% women, age 66 [40-97] years). Colo-rectal cancer was the most common etiology (38%); 63% had metastatic disease and 54%were receiving active oncological treatment. 71% had carcinomatosis and 42% had ascites. LIMO location was ileum (42%), jejunum (25%), and colon (24%). 71% had received previous treatment with decompressive tubes, 13% had received stents, and 8% had undergone surgery.

79% of procedures were performed in a retrograde approach; 74% with direct puncture and 95% with a freehand technique. Prophylactic antibiotic therapy was administered in 70% of cases, associated with a lower infection rate (6.2% vs. 42%;χ² p=0.040), with OR –2.351 (95% CI –4.9873 to –0.170). Axios LAMS were used in 95% of cases and Spaxus LAMS in 5%. LAMS diameters were 20 mm in 77% ofcases and 15 mm in the remainder. Sedation was most commonly performed by an anesthesiologist with endotracheal intubation (50%). Yet, in 29% of cases,

endoscopist-led sedation was undertaken, with comparable safety outcomes. Location of LAMS anastomosis was entero-colonic (64%), entero-enteric (23%), and colo-colonic (14%).Technical success was 92%, with no differences between patients with/without ascites or carcinomatosis. Overall clinical success was 87% (73% complete, and 14% partial). Oral tolerance was restored at a median of 1 day (IQR 1–2) following EUS-EA. There were 3 perforations (14%), 4 infections (18%), and 1 death (5%), with no cases of aspiration, bleeding, or misdeployment. Median hospital stay was 10 days (IQR 6–26). Sixty-five percent of patients did not require additional procedures over a median 63-day follow-up (IQR 21–121). Three patients were readmitted for recurrent LIMO after a median of 64 days. Median survival was 32 days (IQR 14–80); five patients remain alive after a median of 868 days.

EUS-EA with LAMS appears feasible and safe at expert centers in selected patients with advanced LIMO not amenable to enteral stenting, even in the presence of carcinomatosis or ascites. Early reintroduction of oral feeding and resumption of oncological treatment are possible in most cases. This novel procedure can be offered to patients with advanced LIMO when EUS-EA expertise is available.