Clinical outcomes of lumen-apposing metal stent in the management of benign gastrointestinal strictures: a systematic review and meta-analysis

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.

Clinical application and follow-up of electrocautery-enhanced lumen-apposing metal stents for endoscopic ultrasonography-guided interventions

Aim: The lumen-apposing metal stent (LAMS) is a new device that expands the scope of gastrointestinal intervention under endoscopy. LAMS was initially used for the treatment of pancreatic fluid collections (PFCs), but is increasingly being used off-label. The electrocautery system simplifies the deployment of LAMS, making it more suitable for off-label situations. The short-term results of electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) are satisfactory; however, the long-term follow-up results must be evaluated. The aim of this article is to review the expanded clinical application of ECE-LAMS, the clinical value of on-label and off-label use, and follow-up results.Methods: After searching in PubMed and Web of Science databases using 'electrocautery-enhanced lumen-apposing metal stents' and 'endoscopic ultrasonography (EUS) -guided interventions' as keywords, studies related were compiled and examined.Results: ECE-LAMS are widely used for on-label and off-label situations. The short-term and long-term results of ECE-LAMS are satisfactory, but there are still some studies that do not agree with this viewpoint.Conclusion: The clinical application of ECE-LAMS is relatively safe and reliable but more well-designed randomized trials and prospective studies are needed to evaluate the impact of this technology on therapeutic EUS, to improve the safety and success rate of EUS-guided LAMS implantation, and to expand its application in other indications.

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.

Hybrid gastroenterostomy using a lumen-apposing metal stent: a case report focusing on misdeployment and systematic review of the current literature

Background

Gastric outlet obstruction can result from several benign and malignant diseases, in particular gastric, duodenal or pancreatic tumors. Surgical gastroenterostomy and enteral endoscopic stenting have represented effective therapeutic options, although recently endoscopic ultrasound-guided gastroenterostomy using lumen-apposing metal stent (LAMS) is spreading improving the outcome of this condition. However, this procedure, although mini-invasive, is burdened with not negligible complications, including misdeployment.

Main body

We report the case of a 60-year-old male with gastric outlet obstruction who underwent ultrasound-guided gastroenterostomy using LAMS. The procedure was complicated by LAMS misdeployment being managed by laparoscopy-assisted placement of a second LAMS.

We performed a systematic review in order to identify all reported cases of misdeployment in EUS-GE and their management. The literature shows that misdeployment occurs in up to 10% of all EUS-GE procedures with a wide spectrum of possible strategies of treatment.

Conclusion

The here reported hybrid technique may offer an innovative strategy to manage LAMS misdeployment when this occurs. Moreover, a hybrid approach may be valuable to overcome this complication, especially in early phases of training of EUS-guided gastroenterostomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00409-z.

Futuristic Developments and Applications in Endoluminal Stenting

Endoscopic stenting is a well-established option for the treatment of malignant obstruction, temporary management of benign strictures, and sealing transmural defects, as well as drainage of pancreatic fluid collections and biliary obstruction. In recent years, in addition to expansion in indications for endoscopic stenting, considerable strides have been made in stent technology, and several types of devices with advanced designs and materials are continuously being developed. In this review, we discuss the important developments in stent designs and novel indications for endoluminal and transluminal stenting. Our discussion specifically focuses on (i) biodegradable as well as (ii) irradiating and drug-eluting stents for esophageal, gastroduodenal, biliary, and colonic indications, (iii) endoscopic stenting in inflammatory bowel disease, and (iv) lumen-apposing metal stent.

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.

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.

Clinical and Endoscopic Predictors of Hydrostatic Balloon Dilation Failure for Post-Bariatric Anastomotic Stricture Treatment

BACKGROUND

Roux-en-Y gastric bypass (RYGB) patients can develop anastomotic strictures. The initial management relies on endoscopic hydrostatic balloon dilation, but in a subset of patients, it may be unsuccessful despite several dilations, requiring a different treatment modality. We evaluated the factors associated with balloon dilation failure and need for revision surgery.

METHODS

Retrospective analysis from patients presenting with a post-RYGB anastomotic stricture who underwent balloon dilation from 2005 to 2018 at Cleveland Clinic Florida and Cleveland Clinic Main Campus. Demographic, clinical, surgical, endoscopic, and post-procedural variables were collected. Univariate and multivariate analysis with odds ratio (OR) and 95% confidence interval (95% CI) calculation for factors associated to dilation failure was performed.

RESULTS

Eighty-nine patients were included in the analysis. Population was predominantly white (85.4%) and female (87.6%), with mean age 46.4 years and followed for a mean of 97.4 months. All patients presented dysphagia, with mean stricture diameter of 7.7 mm and associated marginal ulcer in 69%. Successful dilation was achieved in 65 patients, while 24 patients had dilation failure and underwent revisional surgery. Multivariate analysis showed a higher risk of dilation failure if time from RYGB to first dilation was >3 months (OR 4.95, 1.29-19.04; p = 0.02), and if nausea/vomiting were present before first dilation (OR 4.37, 1.11-17.16; p = 0.03). One patient had a perforation after dilation and was treated surgically.

CONCLUSIONS

Post-RYGB anastomotic strictures can be successfully treated with hydrostatic balloon dilation. However, patients with dilations performed > 3 months after initial RYGB and nausea/vomiting have an increased risk of dilation failure and need for further interventions.

Endoscopic Management of Refractory Benign Esophageal Strictures

Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.

Endoscopic incision for treatment of benign gastrointestinal strictures

INTRODUCTION

Benign gastrointestinal strictures are common, and can be congenital or acquired (anastomotic, corrosive, induced by Crohn's disease or endoscopic treatments, etc.). Patients usually present with stricture-related symptoms such as vomiting, dysphagia, dyschezia, abdominal pain, which impair their quality of life. Endoscopic balloon dilation (EBD) is the first-line treatment for most of the benign strictures; however, long-term efficacy is suboptimal, and the recurrence rate can be up to 38%. Endoscopic incision (EI) was firstly reported for treatment of congenital membranous stricture, and then applied to other benign gastrointestinal strictures.

AREA COVERED

In the present review, we provided a comprehensive review of EI for the treatment of benign gastrointestinal strictures, mainly focus on the technical details, indication, safety, and efficacy of EI. The present review is expected to provide tips for operators who are going to perform EI.

EXPERT OPINION

EI can serve as an alternative method for treatment of gastrointestinal strictures, the best indications are congenital membranous stricture and short-segmental (<1 cm) anastomotic strictures refractory to EBD. EI may also be attempted for strictures induced by other reasons. Combination with other endoscopic methods such as EBD, local steroid injection, stent placement, may improve the efficacy of EI.