Prospective multicenter international study on the outcomes of a newly developed self-approximating lumen-apposing metallic stent for drainage of pancreatic fluid collections and endoscopic necrosectomy

Lumen-apposing metal stents for the treatment of pancreatic and peripancreatic fluid collections and bleeding risk: a propensity matched study

INTRODUCTION

 Endoscopic ultrasound (EUS)-guided drainage of symptomatic pancreatic fluid collections (PFCs) using the Hot-Axios device has recently been associated with a significant risk of bleeding. This adverse event (AE) seems to occur less frequently with the use of a different device, the Spaxus stent. The aim of the current study was to compare the rates of bleeding between the two stents.

METHODS

 Patients admitted for treatment of PFCs by EUS plus lumen-apposing metal stent in 18 endoscopy referral centers between 10 July 2019 and 28 February 2022 were identified and their outcomes compared using a propensity-matching analysis.

RESULTS

 363 patients were evaluated. After a 1-to-1 propensity score match, 264 patients were selected (132 per group). The technical and clinical success rates were comparable between the two groups. Significantly more bleeding requiring transfusion and/or intervention occurred in the Hot-Axios group than in the Spaxus group (6.8% vs. 1.5%; P = 0.03); stent type was a significant predictor of bleeding in both univariate and multivariate regression analyses (P = 0.03 and 0.04, respectively). Bleeding necessitating arterial embolization did not however differ significantly between the two groups (3.0% vs. 0%; P = 0.12). In addition, the Hot-Axios was associated with a significantly higher rate of overall AEs compared with the Spaxus stent (9.8% vs. 3.0%; P = 0.04).

CONCLUSION

 Our study showed that, in patients with PFCs, bleeding requiring transfusion and/or intervention occurred significantly more frequently with use of the Hot-Axios stent than with the Spaxus stent, although this was not the case for bleeding requiring embolization.

Multicenter study of the efficacy and safety of electrocautery-enhanced lumen-apposing metal stents for the internal drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) including pancreatic pseudocyst (PP) and walled-off necrosis (WON) are complications after acute pancreatitis. We aimed to evaluate the efficacy and safety of endoscopic ultrasound (EUS)-guided lumen-apposing metal stent (LAMS) placement to manage PFCs. Between June 2019 and May 2023, patients with symptomatic PFCs who underwent EUS-guided electrocautery-enhanced LAMS drainage were enrolled retrospectively from eight tertiary centers in Taiwan. In total, 33 [14 (42.42%) PP and 19 (57.58%) WON] patients were enrolled. Gallstones (27.27%) and abdominal pain (72.73%) were the most common etiology and indication for drainage. The technical and clinical success rates were 100% and 96.97%, respectively, and the mean procedure time was 30.55 (± 16.17) min. Complications included one (3.03%) case of self-limited bleeding; there were no cases of mortality. Seven (21.21%) patients had recurrence. Patients with disconnected pancreatic duct syndrome (DPDS) had a higher recurrence rate than those without (71.43% vs. 38.46%, p = 0.05). After replacing LAMSs with transmural double-pigtail plastic stents (DPSs) in the DPDS patients, the DPS migration rate was higher in the patients with recurrence (100% vs. 33.33%, p = 0.04). In conclusion, drainage of symptomatic PFCs with EUS-guided electrocautery-enhanced LAMS appears to be efficient and safe. Replacing LAMSs with DPSs in DPDS patients was associated with a lower recurrence rate.

Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group from the Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past years, the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques, such as endoscopic ultrasound guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group from the Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) have the purpose to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: A systematic review focusing on issues and rescue management

BACKGROUND

The introduction of lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings. Nevertheless, the procedure may conceal unexpected pitfalls. LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences. Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. To date, no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.

AIM

To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (EUS-PFC) and to describe the endoscopic rescue strategies adopted under the circumstance.

METHODS

We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022. The search was carried out using the exploded medical subject heading terms “lumen apposing metal stent”, “LAMS”, “endoscopic ultrasound” and “choledochoduodenostomy” or “gallbladder” or “pancreatic fluid collections”. We included in the review on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. Only those publications reporting EUS-guided LAMS positioning were considered. The studies reporting a technical success rate of 100% and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment, while studies not reporting the causes of technical failure were excluded. Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques. The following data were collected from each study: Author, year of publication, study design, study population, clinical indication, technical success, reported number of misdeployment, stent type and size, flange misdeployed and type of rescue strategy.

RESULTS

The overall technical success rate of EUS-CDS, EUS-GBD and EUS-PFC was 93.7%, 96.1%, and 98.1% respectively. Significant rates of LAMS misdeployment have been reported for EUS-CDS, EUS-GBD and EUS-PFC drainage, respectively 5.8%, 3.4%, and 2.0%. Endoscopic rescue treatment was feasible in 86.8%, 80%, and 96.8% of cases. Non endoscopic rescue strategies were required only in 10.3%, 16% and 3.2% for EUS-CDS, EUS-GBD, and EUS-PFC. The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%, 8% and 64.5% and stent-in-stent in 23.5%, 60%, and 12.9%, respectively for EUS-CDS, EUS-GBD, and EUS-PFC. Further therapeutic option were endoscopic rendezvous in 11.8% of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1% of EUS-PFC.

CONCLUSION

LAMS misdeployment is a relatively common adverse event in EUS-guided drainages. There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario, anatomical characteristics, and local expertise. In this review, we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used, with the aim of providing useful data for endoscopists and to improve patient outcomes.

Management of Pancreatic Fluid Collections: An Evidence-based Approach

Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.

Laparoscopic vs Endoscopic Management of Pancreatic Pseudocysts: A Scoping Review

Pancreatic pseudocyst (PPC) and walled-off necrosis (WON) develop as late complications of acute pancreatitis that have been historically managed surgically. With the advancement in endoscopic equipment and the evolution of endoscopic surgery, the management of PPC has evolved considerably in recent years from surgical drainage to transmural endoscopic drainage. Till the end of the 20th century, a limited number of surgeons performed laparoscopic drainage of PPCs. Due to the steep learning curve needed for performing advanced laparoscopic suturing, a majority of studies conducted during this period have compared open surgical drainage with endoscopy. The efficacy of these modalities has largely been evaluated using retrospective studies and a few meta-analyses particularly due to the low-volume caseload of individual centres. Also, these studies include PPC and WON together in data analysis despite WON being a distinct entity. There are limited prospective well-designed clinical trials comparing endoscopic and laparoscopic management of pure PPCs. There is also a lack of specific recommendations for the management of PPCs. Considerable overlap of indications between these two modalities exists. The efficacy of endoscopic transmural drainage as an index intervention when compared to laparoscopy has not been proven in the research literature. Previous studies have not considered multiple endoscopic interventions within a four-week period of index intervention as a failure. We reviewed the literature using appropriate MeSH terms on the PubMed search engine for articles comparing laparoscopic and endoscopic transmural management of PPCs according to our inclusion and exclusion criteria. Seven articles were identified for inclusion in the qualitative synthesis. This scoping review was conducted to answer some pertinent unanswered questions, identify gaps in knowledge regarding the laparoscopic vs endoscopic management of PPCs, and guide further research.

Novel 15-mm-long lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections located ≥10 mm from the luminal wall

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) by cautery-enhanced lumen-apposing metal stents (LAMS) has largely been limited to collections located < 10 mm from the luminal wall. We present outcomes of the use of a novel 15-mm-long cautery-enhanced LAMS for drainage of PFCs located ≥ 10 mm away.

METHODS

This international, multicenter study analyzed all adults with PFCs located ≥ 10 mm from the luminal wall who were treated by EUS-guided drainage using the 15-mm-long cautery-enhanced LAMS. The primary outcome was technical success. Secondary outcomes included clinical success (decrease in PFC size by ≥ 50 % at 30 days and resolution of clinical symptoms without surgical intervention), complications, and recurrence.

RESULTS

35 patients (median age 57 years; interquartile range [IQR] 47-64 years; 49 % male) underwent novel LAMS placement for drainage of PFCs (26 walled-off necrosis, 9 pseudocysts), measuring 85 mm (IQR 64-117) maximal diameter and located 11.8 mm (IQR 10-12.3; range 10-14) from the gastric/duodenal wall. Technical and clinical success were high (both 97 %), with recurrence in one patient (3 %) at a median follow-up of 123 days (58-236). Three complications occurred (9 %; one mild, two moderate).

CONCLUSIONS

The 15-mm-long cautery-enhanced LAMS was feasible and safe for drainage of PFCs located 10-14 mm from the luminal wall.

How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology?

Fluoroscopy-guided endoscopic procedures (FGEPs) are rapidly gaining popularity in the field of gastroenterology. Radiation is a well-known health hazard. Gastroenterologists who perform FGEPs are required to protect themselves, patients, as well as nurses and radiologists engaged in examinations from radiation exposure. To achieve this, all gastroenterologists must first understand and adhere to the International Commission on Radiological Protection Publication. In particular, it is necessary to understand the three principles of radiation protection (Justification, Optimization, and Dose Limits), the As Low As Reasonably Achievable principle, and the Diagnostic Reference Levels (DRLs) according to them. This review will mainly explain the three principles of radiation exposure protection, DRLs, and occupational radiological protection in interventional procedures while introducing related findings. Gastroenterologists must gain knowledge of radiation exposure protection and keep it updated.

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.

Experimental study of a physician-controlled electrocautery-enhanced delivery system incorporating a newly developed lumen-apposing metal stent for interventional endoscopic ultrasound (with videos)

BACKGROUND/PURPOSE

Although the lumen-apposing metal stent (LAMS) is useful for interventional endoscopic ultrasound (EUS) procedures, there has been some concern about the potential for stent-induced adverse events because of the high lumen-apposing force. A newly designed LAMS with less lumen-apposing force has been developed for use with a physician-controlled electrocautery-enhanced delivery system. The aim of this animal study was to evaluate the feasibility of performing interventional EUS using this newly designed LAMS system.

METHODS

EUS-guided cystogastrostomy was performed using the novel LAMS 3 times in a wet simulation model. EUS-guided gastroenterostomy and EUS-guided gallbladder drainage were then performed using the system in 4 pigs.

RESULTS

The LAMS was successfully placed in all 3 EUS-guided cystogastrostomy procedures using the wet simulation model and in all 4 EUS-guided gastroenterostomy and gallbladder drainage procedures in the animal model. In the 3 weeks following the procedure, eating behavior was normal in all animals and there were no adverse events. The stents remained patent during this time and were removed without difficulty. The fistula was mature in all cases and a standard upper gastrointestinal endoscope was easily advanced via the fistula to observe the afferent and efferent loops or the lumen of the gallbladder. Necropsy confirmed complete adhesion between the stomach and the wall of the jejunum or gallbladder.

CONCLUSIONS

Our study findings demonstrate the feasibility of this new LAMS system and its potential clinical value for interventional EUS.

Managing adverse events after endoscopic ultrasound-guided drainage of the biliary tract and pancreatic fluid collections: Narrative review (with video)

Endoscopic ultrasound (EUS)-guided therapeutic procedures have become increasingly common in clinical practice. The development of EUS-guided fine needle aspiration cytology led to the concept of interventional EUS. However, it carries a considerable risk of adverse events (AEs), which occur in approximately 23% of the procedures performed for the drainage of pancreatic fluid collections and 2.5-37.0% of those performed for drainage of the biliary tract. Although the vast majority of AEs occurring after EUS-guided drainage are mild, a deep understanding of such events is necessary for their appropriate management. Because EUS-guided drainage is a novel procedure, there have been few studies of the topic. To our knowledge, this is the first narrative review that focuses on the management and resolution of AEs occurring after EUS-guided drainage of pancreatic fluid collections or the biliary tract. We also include an explanatory video.

Use of a novel lumen apposing metallic stent for drainage of the bile duct and gallbladder: Long term outcomes of a prospective international trial

BACKGROUND

Long-term placement of lumen apposing metal stents (LAMS) with high lumen apposing force may result in adverse events. The aim of the current study was to assess the long-term efficacy and safety of a self-approximating LAMS with lower lumen apposing force for endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and -gallbladder drainage (EUS-GBD).

METHODS

Five Asian institutions participated in this study. Consecutive patients suffering from obstructive jaundice with failed ERCP or acute cholecystitis that were at high risk for cholecystectomy were recruited. We evaluated the technical and clinical success rates, adverse events rates, types of interventions through the stent and the patency profile.

RESULTS

From June 2017 to Oct 2018, a total of 53 patients received EUS-CDS (26) and EUS-GBD (27). The technical and clinical success rates were similar between the two groups (88.5% vs 88.9%, P = 1 and 88.5% vs 88.9%, P = 1 respectively). The differences in 30-day mortality rates [2 (7.7%) vs 2 (7.7%), P = 1] and adverse events [3 (11.5%) vs 3 (11.5%), P = 1] did not reach significance. Regarding long-term outcomes, two patients in each group suffered from adverse events (P = 1). One patient in the EUS-GBD group who was on direct oral anticoagulant suffered from stent induced bleeding.

CONCLUSION

The self-approximating LAMS with lower lumen apposing force was effective and safe with a low risk of buried stent syndrome and bleeding in the longer term. The ClinicalTrials.gov Identifier was NCT03002051.

Lumen-apposing metal stents (with videos)

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMSs) are a novel class of devices that have expanded the spectrum of endoscopic GI interventions. LAMSs with their dumbbell configuration, short saddle length, and large inner luminal diameter provide favorable stent characteristics to facilitate anastomosis formation between the gut lumen and adjacent structures.

METHODS

The MEDLINE database was searched through April 2021 for articles related to LAMSs by using additional relevant keywords such as "walled-off pancreatic necrosis," "pseudocysts," "pancreatic fluid collection," "cholecystitis," "gastroenterostomy," in addition to "endoscopic treatment" and "endoscopic management," among others.

RESULTS

This technology review describes the full spectrum of LAMS designs and delivery systems, techniques for deployment, procedural outcomes, safety, training issues, and financial considerations.

CONCLUSIONS

Although LAMSs were initially introduced for drainage of pancreatic pseudocysts and walled-off necrosis, the versatility of these devices has led to a variety of off-label uses including gallbladder drainage, enteric bypass with the creation of gastroenterostomies, and treatment of luminal GI strictures.

A Practical Approach to Management of Acute Pancreatitis: Similarities and Dissimilarities of Disease in Children and Adults

Acute pancreatitis (AP) is associated with significant morbidity and mortality, and it substantially contributes to the healthcare burden of gastrointestinal disease and quality of life in children and adults. AP across the lifespan is characterized by similarities and differences in epidemiology, diagnostic modality, etiologies, management, adverse events, long-term outcomes, and areas in greatest need of research. In this review, we touch on each of these shared and distinctive features of AP in children and adults, with an emphasis on recent advances in the conceptualization and management of AP.

Endoscopic management of walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WON) can develop in the late phase of necrotizing pancreatitis. When the WON is accompanied by an infection in the necrotic bed, it becomes a life-threatening complication. Open necrosectomy with drainage has been the standard treatment; however, it is associated with a significant morbidity and high mortality. Therefore, minimally invasive therapeutic alternatives are in demand. Recently, a new treatment algorithm for necrotizing pancreatitis, known as the step-up approach, has been proposed. The initial report on it consisted of percutaneous drainage followed by, if necessary, a minimally invasive retroperitoneal necrosectomy. However, the endoscopic step-up approach, which consists of EUS-guided transluminal drainage followed by, if necessary, endoscopic necrosectomy, was later introduced. Recent studies have suggested that an endoscopic step-up approach might be more advantageous than a minimally invasive surgical step-up approach. A lumen apposing metal stent (LAMS) with a cautery-enhanced delivery system is currently preferred over the conventional plastic stents for endoscopic interventions, because it decreases the technical difficulty of the procedure and may obviate the need for an adjunctive debridement procedure. However, some recent findings suggest that LAMS could be associated with a higher risk of stent-related complications than conventional plastic stents, especially in patients with long-term placement. Therefore, early removal of LAMS at 3 weeks post-intervention is proposed if the WON is resolved on CT examination. Thus, endoscopic interventions have emerged as a key player in the management of WON. However, multidisciplinary treatment approaches should be considered because the endoscopic approach has limitations in treating complicated WON.

Endoscopic gastrointestinal anastomosis: a review of established techniques

Technologic advancements in the field of therapeutic endoscopy have led to the development of minimally invasive techniques to create GI anastomosis without requiring surgery. Examples of the potential clinical applications include bypassing malignant and benign gastric outlet obstruction, providing access to the pancreatobiliary tree in those who have undergone Roux-en-Y gastric bypass, and relieving pancreatobiliary symptoms in afferent loop syndrome. Endoscopic GI anastomosis is less invasive and less expensive than surgical approaches, result in improved outcomes, and therefore are more appealing to patients and providers. The aim of this review is to present the evolution of luminal endoscopic gastroenteric and enteroenteric anastomosis dating back to the first compression devices and to describe the clinical techniques being used today, such as magnets, natural orifice transluminal endoscopic surgery, and EUS-guided techniques. Through continued innovation, endoscopic interventions will rise to the forefront of the therapeutic arsenal available for patients requiring GI anastomosis.

A Comparison of Endoscopic Versus Surgical Creation of a Cystogastrostomy to Drain Pancreatic Pseudocysts and Walled-Off Pancreatic Necrosis in 5500 Patients

Objective

To determine the success, morbidity, and mortality rates of endoscopic and surgical creation of pancreatic cystenterostomies for the drainage of peripancreatic fluid collections, pseudocysts with necrotic debris, and walled-off pancreatic necrosis.

Summary Background Data

Endoscopic methods of cystenterostomy creation to drain pancreatic pseudocysts (with and without necrotic debris) and infected peripancreatic fluid collections are perceived to be less morbid than surgery. Contemporary reports document a very high complication rate with endoscopic methods.

Methods

A meta-analysis of 5500 patients.

Results

Open and laparoscopic surgical techniques to drain chronic pancreatic pseudocysts, infected pancreatic fluid collections, and walled-off pancreatic necrosis are more successful with less morbidity and mortality than endoscopic methods.

Conclusions

In regards to a surgical step-up approach to treat chronic infected pancreatic fluid collections or walled-off pancreatic necrosis, surgical creation of a cystenterostomy is more successful with fewer complications than endoscopic methods and should be given priority if less invasive or conservative methods fail.

Endoscopic ultrasound-guided anastomosis: Is it ready for prime time?

Significant advancements in endoscopic ultrasound (EUS)-guided drainage procedures and EUS-guided anastomosis have recently been described. The described procedures include EUS-guided drainage of pancreatic fluid collections, biliary drainage, pancreatic duct drainage, gallbladder drainage, and gastroenterostomy. These procedures have been made possible with novel devices that can reduce the difficulties of the procedures and potentially reducing the risk of adverse events. The procedures are also becoming standardized, which is essential for dissemination of the techniques. Furthermore, results from randomized studies are becoming available showing definite benefits associated with these procedures. In this paper, we will provide a review on EUS-guided anastomotic procedures.

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.

Effectiveness and safety of EUS-guided choledochoduodenostomy using lumen-apposing metal stents (LAMS): a systematic review and meta-analysis. Surg Endosc. 2020;34:2866-2877. [PMID: 32140862 DOI: 10.1007/s00464-020-07484-w]

BACKGROUND

Endoscopic ultrasound-guided choledochoduodenostomy (CDD) is emerging as an alternative technique for biliary drainage in patients who fail conventional endoscopic retrograde cholangiopancreatography (ERCP). The lumen-apposing metal stents (LAMS) are being increasingly used for CDD. We performed a systematic review and meta-analysis to evaluate the effectiveness and safety of CDD using LAMS.

METHODS

We performed a systematic search of multiple databases through May 2019 to identify studies on CDD using covered self-expanding metal stents. Pooled rates of technical success, clinical success, adverse events, and recurrent jaundice associated with CDD using LAMS were estimated. A subgroup analysis was performed based on use of LAMS with electrocautery-enhanced delivery system (EC-LAMS).

RESULTS

Seven studies on CDD using LAMS (with 284 patients) were included in the meta-analysis. Pooled rates of technical and clinical success (per-protocol analysis) were 95.7% (95% CI 93.2-98.1) and 95.9% (95% CI 92.8-98.9), respectively. Pooled rate of post-procedure adverse events was 5.2% (95% CI 2.6-7.9). Pooled rate of recurrent jaundice was 8.7% (95% CI 4.5-12.8). On subgroup analysis of CDD using EC-LAMS (5 studies with 201 patients), the pooled rates of technical and clinical success (per-protocol analysis) were 93.8% (95% CI 90.4-97.1) and 95.9% (95% CI 91.9-99.9), respectively. Pooled rate of post-procedure adverse events was 5.6% (95% CI 1.7-9.5). Pooled rate of recurrent jaundice was 11.3% (95% CI 6.9-15.7). Heterogeneity (I²) was low to moderate in the analyses.

CONCLUSION

CDD using LAMS/EC-LAMS is an effective and safe technique for biliary decompression in patients who failed ERCP. Further studies are needed to assess CDD using LAMS as primary treatment modality for biliary obstruction.