Endoscopic ultrasound-guided drainage with lumen-apposing metal stents: a good safety profile also in the long term?

Feasibility and patency of echoendoscopic anastomoses with lumen apposing metal stents depending on the gastrointestinal segment involved

EUS-guided anastomoses with LAMS have emerged as a therapeutic option for patients with obstruction of the digestive tract. However, the long-term permeability of these anastomoses remains unknown. Most of the published cases involve the gastric wall and experience in distal obstruction is limited to few case reports. We review our series of patients treated with LAMS for gastrointestinal obstruction and describe the technical success according to the anastomotic site and the long-term follow-up in those cases in which the stent migrated spontaneously or was removed. Out of 30 cases treated with LAMS, EUS-guided anastomosis did not involve the gastric wall in 6 patients. These procedures were technically more challenging as two failures were recorded (2/6, 33%) while technical success was achieved in 100% of the cases in which the stent was placed through the gastric wall. In two of the patients, one with entero-enteric and another with recto-colic anastomosis, stent removal after spontaneous displacement was followed by long term permeability of the EUS-guided anastomosis (172 and 234 days respectively). In a EUS-guided gastroenterostomy the stent was removed at 118 days, but closure of the fistula was confirmed 26 days later. Our experience suggests that LAMS placement between bowel loops is feasible and might allow the creation of an anastomosis with long-term patency. As compared to LAMS placement between bowel loops, when LAMS are placed through the gastric wall, removal of the LAMS seems to lead to closure of the fistula.

Guessing the future of endoscopic drainage of walled-off necrosis

The endoscopic treatment of walled-off necrosis is rapidly evolving concurrently with an increasing number of endoscopic techniques, devices, and combined procedures. Thus, there is a growing armamentarium of alternatives for those patients in whom the conventional direct endoscopic necrosectomy is not enough. However, when the patient reaches this point he enters in an unexplored field and choosing the correct option can be challenging. Furthermore, there is no consensus on the number of endoscopic procedures to perform before considering that direct endoscopic necrosectomy has failed and therefore another strategy should be considered.