Alternative uses of lumen apposing metal stents

Comprehensive analysis of adverse events associated with transmural use of LAMS in patients with liver cirrhosis: International multicenter study

Background and study aims Endoscopic ultrasound (EUS)-guided transmural (TM) deployment of lumen-apposing metal stents (LAMS) is considered relatively safe in non-cirrhotic patients and is cautiously offered to cirrhotic patients. Patients and methods This was a retrospective, multicenter, international matched case-control study to study the safety of EUS-guided TM deployment of LAMS in cirrhotic patients. Results Forty-three cirrhotic patients with model for end-stage liver disease score 12.5 ± 5, with 23 having ascites and 16 with varices underwent EUS-guided TM LAMS deployment, including 19 for pancreatic fluid collection (PFC) drainage, 13 gallbladder drainage, six for endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP), three for EDGI, one for endoscopic ultrasound-directed transenteric ERCP, and one postsurgical collection drainage. Technical failure occurred in one LAMS for PFC drainage. Clinical failure was encountered in another PFC. Nine adverse events (AEs) occurred. The most common AE was LAMS migration (3), followed by non-bleeding mucosal erosion (2), delayed bleeding (2), sepsis (1), and anesthesia-related complication (pulseless electrical activity) (1). Most AEs were graded as mild (6), followed by severe (2), and moderate (1); the majority were managed conservatively. On univariable comparison, risk of AE was higher when using a 20 × 10 mm LAMS and the absence of through-the-LAMS plastic stent(s). Conditional logistic regression of matched case-control patients did not show any association between potential predicting factors and occurrence of AEs. Conclusions Our study demonstrated that mainly in patients with Child-Pugh scores A and B cirrhosis and despite the presence of mild-to-moderate ascites in over half of cases, the majority of AEs were mild and could be managed conservatively. Further studies are warranted to verify the safety of LAMS in cirrhotic patients.

Off-label use of Lumen-apposing metal stents for treatment of short benign biliary strictures

BACKGROUND

Endoscopic stenting is the mainstay of treatment for benign biliary strictures. There is a not-negligible rate of recurrence and stent migration. Lumen-apposing metal stents (LAMS) have a unique design with short length, large diameter and wide flanges which make them less prone to migration.

AIMS

To describe the intraluminal use of LAMS to treat short benign biliary strictures.

METHODS

All consecutive patients who underwent bi-flanged LAMS placement for benign biliary strictures, in approximately 6 years, were retrospectively included. Primary outcomes were technical and clinical success; secondary outcomes were number of endoscopic procedures, adverse events evaluation and stricture recurrence during follow-up.

RESULTS

Seventy patients (35 male, mean age 67) were enrolled; bilio-enteric anastomotic stricture was the most common etiology. Technical and clinical success were 100 % and 85.7 %, respectively. Patients with post-surgical stricture had a higher success rate than patients with non-surgical stricture or with bilio-enteric anastomotic stricture (90.4 %, 86.3 % and 81.4 %, respectively). Adverse events were 12/70 (17.1 %): stent migration was the most frequent (8/70, 11.4 %). Stricture recurrence was found in 10/54 patients (18.5 %).

CONCLUSION

LAMS placement could be safe and effective treatment for short benign biliary strictures in patients in which a significant caliber disproportion between stricture and the duct above was revealed.

Colonic-enteric lumen-apposing metal stents: a promising and safe alternative for endoscopic management of small-bowel obstruction

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMSs) have revolutionized the treatment of various gastroenterologic conditions that previously required surgery. The use of LAMSs for the management of small-bowel obstruction (SBO) involves EUS-guided coloenterostomy (EUS-CE) between the colon and a dilated loop of the small intestine proximal to the point of obstruction. This procedure is potentially beneficial for patients with malignant SBO who are poor surgical candidates.

METHODS

A retrospective cohort study was conducted at 2 tertiary care hospitals. Patients who underwent EUS-CE for SBO were identified, and data regarding patient demographics, indication for the procedure, location of the obstruction, procedural details, and adverse events were collected. The primary outcome was technical success of the procedure. Secondary outcomes were clinical success, resolution of symptoms, ability to tolerate enteral nutrition, and adverse events.

RESULTS

Twenty-six patients who underwent the EUS-CE procedure were included. Technical success was achieved in all 26 patients, clinical success (resolution of obstructive symptoms) was achieved in 92.3% of patients (24/26), and the ability to resume enteral nutrition in 84.6% (22/26). Adverse events occurred in 4 patients (15.4%) and included bleeding (1/26), diarrhea (2/26), and postprocedure sepsis (1/26). Patients were followed for a mean of 54.8 days (range, 2-190).

CONCLUSIONS

This study highlights that EUS-CE with LAMSs can be performed with high technical and clinical success for the management of SBO, particularly in patients with malignant obstructions who are not suitable candidates for surgical interventions. Further research with larger sample sizes will be essential to substantiate its efficacy and safety.

Long-term palliation of a malignant colonic anastomotic stricture using a lumen-apposing metal stent (LAMS)

Malignant recurrent colonic strictures at the anastomotic site are difficult to treat long term with traditional uncovered metal stents due to the location and risk for tumour ingrowth. We present a case with the use of a lumen-apposing metal stent (LAMS) to successfully palliate a high-grade obstruction at an anastomotic site without recurrence of obstructive symptoms for 14 months.

Endoscopic Management of Surgical Complications of Bariatric Surgery

Bariatric surgery, although highly effective, may lead to several surgical complications like ulceration, strictures, leaks, and fistulas. Newer endoscopic tools have emerged as safe and effective therapeutic options for these conditions. This article reviews post-bariatric surgery complications and the role of endoscopy in their management.

Lumen-apposing metal stents for the treatment of benign gastrointestinal tract strictures: a single-center experience and proposed treatment algorithm

BACKGROUND

Lumen-apposing metal stents (LAMS) are an alternative therapeutic option for benign gastrointestinal (GI) tract strictures. Our study aimed to evaluate the safety and efficacy of LAMS for the management of benign GI strictures.

METHODS

Consecutive patients who underwent a LAMS placement for benign luminal GI strictures at a tertiary care center between January 2014 and July 2021 were reviewed. Primary outcomes included technical success, early clinical success, and adverse events (AEs). Other outcomes included rates of stent migration and re-intervention after LAMS removal.

RESULTS

One hundred and nine patients who underwent 128 LAMS placements (67.9% female, mean age of 54.3 ± 14.2 years) were included, and 70.6% of the patients had failed prior endoscopic treatments. The majority of strictures (83.5%) were anastomotic, and the most common stricture site was the gastrojejunal anastomosis (65.9%). Technical success was achieved in 100% of procedures, while early clinical success was achieved in 98.4%. The overall stent-related AE rate was 25%. The migration rate was 27.3% (35/128). Of these, five stents were successfully repositioned endoscopically. The median stent dwell time was 119 days [interquartile range (IQR) 68-189 days], and the median follow-up duration was 668.5 days [IQR: 285.5-1441.5 days]. The re-intervention rate after LAMS removal was 58.3%.

CONCLUSIONS

LAMS is an effective therapeutic option for benign GI strictures, offering high technical and early clinical success. However, the re-intervention rate after LAMS removal was high. In select cases, using LAMS placement as destination therapy with close surveillance is a reasonable option.

Short benign ileocolonic anastomotic strictures - management with bi-flanged metal stents: Six case reports and review of literature

BACKGROUND

The endoscopic management of benign short post-anastomotic ileocolonic stricture (PAICS) that is refractory to primary and secondary treatment modalities remains challenging. The lumen-apposing metal stent (LAMS) is a novel device recently developed for therapeutic gastrointestinal endoscopy. LAMSs have demonstrated significantly better results with regard to stent migration than fully covered self-expandable metal stents (FCSEMSs).

CASE SUMMARY

This article presents six cases of symptomatic PAICS successfully treated with a LAMS and a review of the relevant literature. We report a life-saving technique not previously documented and the use of technology to improve patient outcomes. The six patients (median age, 75 years) suffered from vomiting, constipation and recurrent abdominal pain, with symptoms starting 23-25 wk post-surgery. The median stricture length was 1.83 cm. All six patients underwent successful and uneventful bi-flanged metal stent (BFMS)-LAMS placement for benign PAICS. All patients remained asymptomatic during the three months of stent indwelling and up to a median of 7 mo after stent removal. According to the literature, the application of LAMS for PAICS is associated with a < 10% risk of migration and a < 5% risk of bleeding. Conversely, FCSEMS has a high migration rate (15%-50%).

CONCLUSION

The evolving role of interventional endoscopy and the availability of LAMSs provide patients with minimally invasive treatment options, allowing them to avoid more invasive surgical interventions. The BFMS (NAGI stent) is longer and larger than the prototype AXIOS-LAMS, which should be considered in the management of short ileocolonic post-anastomotic strictures longer than 10 mm and shorter than 30 mm.

Revision Bariatric Procedures and Management of Complications from Bariatric Surgery

Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Ruptured Splenic Artery Pseudoaneurysm Causing Hemorrhage Into a Pancreatic Pseudocyst

ABSTRACT

This case report describes fatal exsanguination due to splenic artery hemorrhage into a pancreatic pseudocyst with cystogastrostomy in a 46-year-old woman. The decedent had a complicated medical history including necrotizing pancreatitis, giant pseudocyst formation after cystogastrostomy procedure, and coiling of a hemorrhagic splenic artery. While hospitalized, she underwent embolization of a ruptured splenic artery pseudoaneurysm. Weeks later, she went into hemorrhagic shock and was ultimately pronounced at the hospital. Doctors suspected an upper gastrointestinal (GI) bleed as the cause of death; however, the patient was too unstable to undergo interventional radiology at the time.At autopsy, the pancreas was hemorrhagic and included a 15 × 15 × 15-cm pseudocyst, which contained a metallic stent from a cystogastrostomy. This case describes a unique co-occurrence of numerous common complications of chronic pancreatitis. There are multiple ways by which pancreatitis can cause upper and lower GI bleeds. In this case, the presence of a cystogastrostomy stent allowed for a ruptured pseudoaneurysm to hemorrhage through the pancreatic pseudocyst and into the stomach and duodenum, mimicking the presentation of a more common upper GI bleed. The pseudocyst then ruptured causing abdominal hemorrhage. The passage of hemorrhage through a cystogastrostomy stent is not described in other literature.

Ileosigmoid Anastomotic Perforation Three Weeks After Placement of Lumen-Apposing Metal Stent (LAMS)

Benign anastomotic intestinal strictures are difficult to manage as there may be limited response to dilation. Fully covered self-expanding metal stents have been utilized in small case series; however, stent suturing is required due to the high risk of stent migration. Lumen-apposing metal stents (LAMS) are fully covered and have a novel dumbbell shape that prevents stent migration. Initial reports identify low migration rates and good clinical success rates. This is the first report of perforation following treatment of an ileosigmoid stricture in a 52-year-old female, three weeks after LAMS placement.

Lumen-apposing metal stents: How far are we from standardization? An Italian survey

Background and Objectives:

EUS-guided transluminal drainage has increasingly developed, especially after the era of lumen-apposing metal stent (LAMS): a fully covered, barbell-shaped, metal stent with anti-migratory properties allowing direct therapeutic interventions through a wide and short channel. The aim of this survey is to investigate the current management of patients undergoing LAMS placement nationwide.

Materials and Methods:

Forty-eight questions were submitted to Italian centers about expertise, peri- and intra-procedural aspects, budget/refund, and future perspectives. Statistical analyzer was SPSS®.

Results:

Thirty-six centers completed the survey. Indications for LAMS positioning are pancreatic fluid collection drainage (PFCD, 97.2%), biliary drainage (BD, 80.5%), gallbladder drainage (GBD, 75%), and gastroentero-anastomosis (GEA, 19.4%). A total of 77.7% of the endoscopists perform only on-label procedures and 22.2% both on-label and off-label. 38.8% attended a training preliminary course, 27.7% were just supported by an expert, 22.2% had both the opportunities, and 8.3% none of them. Management of antiplatelets and sedation protocol is very heterogeneous. Only 50% involves a multidisciplinary meeting and 30.5% has a specialized clinic for follow-up. Acid suppression is usually continued after PFCD. The type and timing of postprocedural imaging varies widely. 8.3% of the endoscopists work without fluoroscopy. Refund for LAMS is mostly not guaranteed. Main future growing indications appear to be BD, GBD, and GEA (69.4%, 55.5%, and 55.5%, respectively).

Conclusions:

This is the first survey assessing the state of the art on LAMS almost 10 years after their advent. There are currently wide variations in practice nationwide, which demonstrates a pressing need to define technical, qualitative, and peri-procedural requirements to carry out this procedure, toward a standardization.

Novel Uses of Lumen-apposing Metal Stents: A Review of the Literature

The field of therapeutic endoscopy has seen many recent advancements. One such emerging field is the use of lumen-apposing metal stents (LAMS). Although a few LAMS have been developed, the most commonly reviewed and the only Food and Drug Administration (FDA)-approved LAMS is the Axios stent by Boston Scientific. In 2013, LAMS were initially approved by the FDA for the management of pancreatic fluid collection drainage in the presence walled-off necrosis. Pancreatic fluid collections are traditionally drained with either a plastic stent or a covered biliary self-expanding metal stent. Plastic stents have a double pigtail feature which prevents stent migration. However, their narrow lumen poses limitations as it can lead to early stent occlusion. Fully covered metal stents have larger diameters, allowing improved drainage and decreased stent occlusion but their tubular shape is prone to migration. Consequently, this results in leakage, and frequent retrievals. Over the years, due to their versatility, LAMS now have many off label uses. This includes management of gastric outlet obstruction, superior mesenteric artery syndrome, strictures, gallbladder drainage, and postsurgical collection drainage. In this review, we will be discussing the FDA approved and the nonapproved uses of LAMS.

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction

Gastric outlet obstruction (GOO) is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum. GOO can be caused by either benign or malignant etiologies, often resulting in early satiety, nausea, vomiting and poor oral intake. GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies. Traditional treatment options for GOO can be broadly divided into surgical [surgical gastrojejunostomy (GJ)] and endoscopic interventions (dilation and/or placement of luminal self-expanding metal stents). While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting, it has also been associated with a higher rate of adverse events. Furthermore, many patients with advanced metastatic disease are not good surgical candidates. More recently, endoscopic ultrasound (EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches. This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.