Reduction of Lams-Related Adverse Events with Accumulating Experience in a Large-Volume Tertiary Referral Center

Lumen-apposing metal stents for anastomosis creation throughout the gastrointestinal tract: A large single-center experience

Objectives

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound. This study aims to evaluate the efficacy and safety of LAMS in creating an endoscopic ultrasound-guided anastomosis between two segments of the gastrointestinal (GI) tract.

Methods

Data from all consecutive LAMS procedures for anastomosis creation between two segments of the GI, conducted between October 2019 and February 2024, were retrospectively analyzed for technical success (defined as correct deployment of the LAMS in the target), clinical success (defined as achievement of the intended clinical goal), and adverse events.

Results

A total of 145 LAMS procedures were performed in 136 patients. Indications for LAMS procedures included the need for endoscopic access to or reversal of surgically excluded segments of the GI tract (n = 73, 50.3%), and the alleviation of any GI outflow obstruction (n = 72, 49.7%). The overall technical and clinical success rates were very high (97.2% and 95.2%, respectively). Adverse events were observed in 20/145 (13.8%) cases, including 11 (7.6%) minor events (AGREE <3) and nine (6.2%) major events (AGREE ≥3). Major events included stent migration (n = 1), persisting fistula (n = 3), and bleeding (n = 4). All adverse events were successfully managed, and there were no procedure-related deaths. Loss of LAMS patency occurred in 4/145 (2.8%) cases and could be endoscopically managed in all cases.

Conclusions

The creation of anastomoses with LAMS between two segments of the GI tract appears to be effective and safe, with a low reintervention rate due to loss of LAMS patency.

Analysis of Adverse Events of Endoscopic Ultrasound-Guided Lumen-Apposing Metal Stent Placement: Insights Across Various Indications and Techniques

Background

Endoscopic ultrasound (EUS)-guided lumen-apposing metal stent (LAMS) placement is increasingly being used in lieu of surgery for multiple procedures, including transmural fluid drainage. However, few studies have evaluated adverse events (AEs) associated with LAMS placement. Our aim was to characterize the rates of AEs associated with several LAMS placement strategies across different procedures and indications.

Methods

A single-center retrospective cross-sectional study was conducted on patients who underwent EUS-guided LAMS placement between 2015 and 2023 at a single institution. Technical and clinical success rates and rates of early and late AEs were analyzed. Comparisons of AE rates were determined for patients who had LAMS dilation versus those without dilation, patients who had plastic stent placement in addition to LAMS placement versus those with no plastic stents, and patients who had combined dilation and plastic stent procedures versus those with LAMS dilation only.

Results

A total of 243 patients underwent EUS-guided LAMS interventions: 110 (45.3%) women and 133 (54.7%) men (mean age 53.7 ± 15.9 years). There were 96 (39.5%) patients who had at least one AE. Abdominal pain was the most common early and late AE. Plastic stent placement alongside LAMS placement was associated with a significantly higher rate of overall AEs (48.3% vs 29.9%; P = 0.009), late AEs (33% vs 17.9%; P = 0.021), and stent occlusion (5.7% vs 0%; P = 0.046). LAMS dilation was associated with higher rates of late AEs (34.2% vs 20.6%; P = 0.022) and stent occlusion (6.2% vs 1.0%; P = 0.049).

Conclusions

LAMS placement showed high technical and clinical success rates across different indications with mostly mild AEs, suggesting that LAMSs may be safe and effective for pancreatic and biliary drainage.

Role of endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) directs bile flow into the digestive tract and has been mostly used in patients with malignant biliary obstruction (MBO) where endoscopic retrograde cholangiopancreatography-guided biliary drainage was unsuccessful or was not feasible. Lumen apposing metal stents (LAMS) are deployed during EUS-BD, with the newer electrocautery-enhanced LAMS reducing procedure time and complication rates due to the inbuilt cautery at the catheter tip. EUS-BD with electrocautery-enhanced LAMS has high technical and clinical success rates for palliation of MBO, with bleeding, cholangitis, and stent occlusion being the most common adverse events. Recent studies have even suggested comparable efficacy between EUS-BD and endoscopic retrograde cholangiopancreatography as the primary approach for distal MBO. In this editorial, we commented on the article by Peng et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2024.

International Consensus Recommendations for Safe Use of LAMS for On- and Off-Label Indications Using a Modified Delphi Process

INTRODUCTION

The study aimed to develop international consensus recommendations on the safe use of lumen-apposing metal stents (LAMSs) for on- and off-label indications.

METHODS

Based on the available literature, statements were formulated and grouped into the following categories: general safety measures, peripancreatic fluid collections, endoscopic ultrasound (EUS)-biliary drainage, EUS-gallbladder drainage, EUS-gastroenterostomy, and gastric access temporary for endoscopy. The evidence level of each statement was determined using the Grading of Recommendations Assessment, Development, and Evaluation methodology.International LAMS experts were invited to participate in a modified Delphi process. When no 80% consensus was reached, the statement was modified based on expert feedback. Statements were rejected if no consensus was reached after the third Delphi round.

RESULTS

Fifty-six (93.3%) of 60 formulated statements were accepted, of which 35 (58.3%) in the first round. Consensus was reached on the optimal learning path, preprocedural imaging, the need for airway protection and essential safety measures during the procedure, such as the use of Doppler, and measurement of the distance between the gastrointestinal lumen and the target structure. Specific consensus recommendations were generated for the different LAMS indications, covering, among others, careful patient selection, the preferred size of the LAMS, the need for antibiotics, the preferred anatomic location of the LAMS, the need for coaxial pigtail placement, and the appropriate management of LAMS-related adverse events.

DISCUSSION

Through a modified international Delphi process, we developed general and indication-specific experience- and evidence-based recommendations on the safe use of LAMS.