Endoscopic ultrasound-guided transmural drainage by cautery-tipped lumen-apposing metal stent: exploring the possible indications

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.

Diagnosis of Gastric Cancer in the Excluded Stomach After RYGB by Jejunogastrostomy Using a LAMS

For patients after bariatric surgery, diagnosis of gastric cancer is a challenge. We present a patient after Roux-en-Y gastric bypass with upper abdominal pain and abnormal computed tomography scan with diffuse wall thickening of the gastric antrum. Various biopsy techniques have been described, with surgical (laparoscopic) exploration being the most common. We were able to successfully diagnose gastric cancer in the excluded stomach by biopsy using a jejunogastrostomy, which proved to be safe and effective.

Direct Endoscopic Necrosectomy: Timing and Technique

Walled-off pancreatic necrosis (WOPN) is one of the local complications of acute pancreatitis (AP). Several interventional techniques have been developed over the last few years. The purpose of this narrative review is to explore such methodologies, with specific focus on endoscopic drainage and direct endoscopic necrosectomy (DEN), through evaluation of their indications and timing for intervention. Findings indicated how, after the introduction of lumen-apposing metal stents (LAMS), DEN is becoming the favorite technique to treat WOPN, especially when large solid debris or infection are present. Additionally, DEN is associated with a lower adverse events rate and hospital stay, and with improved clinical outcome.

Common bile duct size in malignant distal obstruction and lumen-apposing metal stents: a multicenter prospective study

Background and study aims  Feasibility of EUS-guided choledochoduodenostomy (EUS-CDS) using available lumen-apposing stents (LAMS) is limited by the size of the common bile duct (CBD) (≤ 12 mm, cut-off for experts; 15 mm, cut-off for non-experts). We aimed to assess the prevalence and predictive factors associated with CBD size ≥ 12 and 15 mm in naïve patients with malignant distal biliary obstruction (MDBO). Patients and methods  This was a prospective cohort study involving 22 centers with assessment of CBD diameter and subjective feasibility of the EUS-CDS performance in naïve jaundiced patients undergoing EUS evaluation for MDBO. Results  A total of 491 patients (mean age 69 ± 12 years) with mean serum bilirubin of 12.7 ± 6.6 mg/dL entered the final analysis. Dilation of the CBD ≥ 12 and 15 mm was detected in 78.8 % and 51.9 % of cases, respectively. Subjective feasibility of EUS-CDS was expressed by endosonographers in 91.2 % for a CBD ≥ 12 mm and in 96.5 % for a CBD ≥ 15 mm. On multivariate analysis, age ( P  < 0.01) and bilirubin level ( P  ≤ 0.001) were the only factors associated with both CBD dilation ≥ 12 and ≥ 15 mm. These variables were poorly associated with the extent of duct dilation; however, based on them a prediction model could be constructed that satisfactorily predicted CBD size ≥ 12 mm in patients at least 70 years and a bilirubin level ≥ 7 mg/dL. Conclusions  Our study showed that at presentation in a large cohort of patients with MDBO, EUS-CDS can be potentially performed in three quarters to half of cases by expert and less experienced endosonographers, respectively. Dedicated stents or devices with different designs able to overcome the limitations of existing electrocautery-enhanced LAMS for EUS-CDS are needed.

[Endoscopic Ultrasound Drainage of the Gallbladder in Acute Cholecystitis in Patients at High Surgical Risk]

BACKGROUND

The standard treatment for acute cholecystitis is laparoscopic cholecystectomy. Alternative procedures are used for patients at high surgical risk. Percutaneous drainage is widely available. The alternative of transpapillary drainage of the gallbladder via the ductus cysticus has only limited prospects of success. With the widespread use of interventional endoscopic ultrasound and the development of new stent systems, endoscopic ultrasound gallbladder drainage has proven to be a safe and reliable procedure.

MATERIAL AND METHOD

We retrospectively report on our experiences in 11 consecutive patients with endoscopic ultrasound gallbladder drainage in acute cholecystitis between December 2018 and January 2021.

RESULTS

11 patients with acute cholecystitis with a mean age of 84.5 years (70-95 years) are reported. All patients had severe general comorbidities or advanced abdominal tumours or a combination of these conditions. After interdisciplinary debate, the indication for interventional therapy was made. This was carried out in 9 cases by means of endosonographic drainage alone and in 2 cases by means of percutaneous and two-stage endosonographic drainage. Technical success was achieved in 10 cases (91%), clinical success in 9 cases (82%). In 2 cases there were procedural complications that led to the operation.

CONCLUSION

In the case of high surgical risks, endosonographic drainage of the gall bladder is a safe and definitive therapy. This can be performed alone or in combination with percutaneous drainage. Endoscopic ultrasound drainage is superior to percutaneous drainage alone, due to its lower complication rates and lower rates of necessary follow-up interventions. Therefore, in cases of relatively high surgical risk, endoscopic ultrasound drainage of the gall bladder should be preferred to percutaneous drainage, especially when definitive therapy is required.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients’ survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

Are Lumen-Apposing Metal Stents More Effective Than Plastic Stents for the Management of Pancreatic Fluid Collections: An Updated Systematic Review and Meta-analysis

Background and Aims

Recently, a new type of metal stent, named lumen-apposing metal stents (LAMS), has been designed to manage pancreatic fluid collections (PFC), and a few studies have reported its efficacy and safety. Therefore, we conducted this meta-analysis to investigate the role of LAMS for PFC.

Methods

We searched the studies from PubMed, MEDLINE, Embase, and Cochrane databases from inception to May 2019. We extracted the data and analyzed the technical success, clinical success, and adverse events of LAMS to evaluate its efficacy and safety.

Results

Twenty studies with 1534 patients were included. The pooled technical success, clinical success, and adverse event rates of LAMS for PFC were 96.2% (95% confidence interval (CI): 94.6%-97.4%), 86.8% (95% CI: 83.1%-89.8%), and 20.7% (95% CI: 16.1%-26.1%), respectively. Eight studies including 875 patients compared the clinical outcomes of LAMS with plastic stents. The pooled risk ratio (RR) of technical success and clinical success for LAMS and plastic stent was 1.01 (95% CI: 0.98-1.04, P = 0.62) and 1.06 (95% CI: 1.01-1.12, P = 0.03), respectively. As for the overall adverse events, the pooled RR was 1.51 (95% CI: 0.67-3.44, P = 0.32).

Conclusions

Our current study revealed that LAMS has advantages over plastic stents for PFC, with higher clinical success rate and lower complication rate of infection and occlusion.

EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis

BACKGROUND

In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage (GBD). There are several limitations associated with PC. Endoscopic GBD [Endoscopic transpapillary GBD (ET-GBD) and EUS-guided GBD (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the effectiveness and safety of EUS-GBD versus ET-GBD.

METHODS

We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in the management of acute cholecystitis in high-risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated.

RESULTS

Five studies with a total of 857 patients (EUS-GBD vs ET-GBD: 259 vs 598 patients) were included in the analysis. EUS-GBD was associated with higher technical [pooled OR 5.22 (95% CI 2.03-13.44; p = 0.0006; I² = 20%)] and clinical success [pooled OR 4.16 (95% CI 2.00-8.66; p = 0.0001; I² = 19%)] compared to ET-GBD. There was no statistically significant difference in the rate of overall adverse events [pooled OR 1.30 (95% CI 0.77-2.22; p = 0.33, I² = 0%)]. EUS-GBD was associated with lower rate of recurrent cholecystitis [pooled OR 0.33 (95% CI 0.14-0.79; p = 0.01; I² = 0%)]. There was low heterogeneity in the analyses.

CONCLUSION

EUS-GBD has higher rate of technical and clinical success compared to ET-GBD. While the rates of overall adverse events are statistically similar, EUS-GBD has lower rate of recurrent cholecystitis. Hence, EUS-GBD is preferable to ET-GBD for endoscopic management of acute cholecystitis in select high-risk surgical patients.

Lumen-apposing metal stents for malignant biliary obstruction: Is this the ultimate horizon of our experience?

In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUS-guided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and EC-LAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.