A comparative study of lumen-apposing metal stent and plastic stent for the treatment of pancreatic walled-off necrosis / 中华消化内镜杂志

Objective:To evaluate the efficacy and safety of lumen-apposing metal stent (LAMS) for the treatment of pancreatic walled-off necrosis (WON).Methods:A retrospective cohort study was performed on data of 43 consecutive patients with pancreatic WON who underwent endoscopic ultrasound-guided drainage by LAMS or plastic stents (PS) in Hangzhou First People's Hospital from December 2010 to June 2020. According to the type of stent used, the patients were divided into the LAMS group ( n=16) and the PS group ( n=27). The technical success rate, the clinical success rate, the operation time, the session of endoscopic necrosectomy, the stent insertion time and adverse events were compared between the two groups. Results:All 43 patients were successfully stented, indicating a technical success rate of 100% in both groups. For the LAMS group, the clinical success rate, the operation time, the session of endoscopic necrosectomy, the stent insertion time and overall incidence of adverse events were 75.0% (12/16), 26.0 (19.1, 39.8) min, 0.5 (0, 2.0) times, (41.3±28.4) days, and 43.7% (7/16), respectively, whereas these indices of the PS group were 37.0% (10/27) ( χ2=5.795, P=0.016), 31.0 (26.0, 48.0) min ( Z=1.221, P=0.222), 0 (0, 0) times ( Z=2.245, P=0.025), (176.1±99.1) days ( t=5.187, P<0.001) and 14.8% (4/27) ( χ2=8.893, P=0.064), respectively. Conclusion:LAMS placement is safe and effective for the treatment of pancreatic WON with a higher clinical success rate compared with PS. However, it requires more endoscopic intervention.

Seguridad y eficacia del drenaje guiado por endosonografía de colecciones pancreáticas usando prótesis plásticas y metálicas tipo LAMS / Safety and efficacy of EUS-guided drainage of pancreatic fluid collections using plastic and lumen apposing metal stents (LAMS)

Background: Pancreatic fluid collections (PFC) are associated with severe acute pancreatitis. After maturation (after 4 weeks) they are classified as pancreatic pseudocyst (PP) and walled-off necrosis (WON). Endoscopic management is associated with lower morbidity and mortality compared with surgery. Aim: To describe the experience of EUS-guided drainage PFC drainage using plastic stent (PS) or metal stent (lumen apposing metal stents, or "LAMS"). Methods: Retrospective, observational study, between 2016-2019. Results: 17 patients in total. 8 cases were symptomatic PP and 9 were WON. Age 12-72 years. 12 cases in men. Indications: abdominal pain 5 cases and infection 11. The 8 cases of PFC were drained successfully using PS, without adverse effects. Regarding WON drainage, 3 cases were managed with PS and 6 with LAMS. In 5 cases, complementary endoscopic necrosectomy was required. A patient with LAMS required complementary surgical cleaning ("step-up") to treat collections far from the LAMS. Complications: one case of PS presented pigment occlusion with superinfection and another case presented migration to the stomach. Regarding LAMS, one case presented self-limited bleeding, another case presented obstruction of the stent with infection, which was managed endoscopically and with antibiotics. Conclusion: The endoscopic management of PFC is effective and safe, with plastic and metal stent (LAMS). The choice of type of stent depends on the characteristics of PFC (liquid vs solid), center experience and costs.

Introducción: Las colecciones pancreáticas (CP) se asocian a pancreatitis agudas graves. Luego de su maduración (después de las 4 semanas) se clasifican en pseudoquistes (PQ) y necrosis encapsulada (NE). El manejo endoscópico se asocia a menor morbimortalidad comparado con el quirúrgico. Objetivo: Describir la experiencia del drenaje de CP mediante el uso de prótesis plásticas (PP) o metálicas (lumen apposing metal stents, o "LAMS") mediante endosonografía. Método: Estudio retrospectivo, observacional, entre 2016-2018. Resultados: 17 pacientes en total. Ocho casos fueron PQ sintomáticos y 9 NE. Edad 12-72 años (12 casos en hombres). Indicaciones: dolor abdominal 5 casos e infección 11. Los 8 casos de PQ fueron drenados exitosamente con PP, sin efectos adversos. En relación con el drenaje de NE, 3 casos fueron manejados con PP y 6 con LAMS. En 5 casos se requirió necrosectomía endoscópica complementaria. Un paciente con LAMS requirió aseo quirúrgico complementario por colecciones alejadas al LAMS. En relación con las complicaciones, un caso de PP presentó oclusión del pigtail con sobreinfección y otro presentó migración al estómago. Respecto a LAMS, un caso presentó sangrado autolimitado y otro caso obstrucción de la prótesis con sobreinfección, que fue manejada endoscópicamente y con antibióticos. Conclusión: El manejo endoscópico de las CP es efectiva y segura, tanto con prótesis plásticas como metálicas (LAMS). La elección de la prótesis depende de las características de la lesión (líquido vs sólido), experiencia del centro y costos.

De-novo Gastrointestinal Anastomosis with Lumen Apposing Metal Stent

Gastric outlet obstruction, afferent or efferent limb obstruction, and biliary obstruction among patients with altered anatomy often require surgical intervention which is associated with significant morbidity and mortality. Endoscopic dilation for benign etiologies requires multiple sessions, whereas self-expandable metal stents used for malignant etiologies often fail due to tumor in-growth. Lumen apposing metal stents, placed endoscopically with the intent of creating a de-novo gastrointestinal anastomosis bypassing the site of obstruction, can potentially achieve similar efficacy, with a much lower complication rate. In our study cohort (n=79), the composite technical success rate and clinical success rate was 91.1% (72/79) and 97.2% (70/72), respectively. Five different techniques were used: 43% (34/79) underwent the balloon-assisted method, 27.9% (22/79) underwent endoscopic ultrasound-guided balloon occluded gastro-jejunostomy bypass, 20.3% (16/79) underwent the direct technique, 6.3% (5/79) underwent the hybrid rendezvous technique, and 2.5% (2/79) underwent natural orifice transluminal endoscopic surgery (NOTES)-assisted procedure. All techniques required an echoendoscope except NOTES. In all, 53.2% (42/79) had non-cautery enhanced Axios stent, 44.3% (35/79) had hot Axios stent, and 2.5% (2/79) had Niti-S spaxus stent. Symptom-recurrence was seen in 2.8%, and 6.3% had a complication (bleeding, abdominal pain or peritonitis). All procedures were performed by experts at centers of excellence with adequate surgical back up.

Lumen apposing metal stents: A review of current uses and outcomes

Lumen-apposing metal stents (LAMS) represent a new innovation in gastrointestinal endoscopy. These devices have a saddle-shaped design and larger inner lumen diameter than either plastic or metal biliary stents, which should decrease the risk of migration and allows for an endoscope to pass into pancreatic fluid collections as well as the ability to perform direct endoscopic necrosectomy. LAMS were originally conceived and designed for transmural pancreatic fluid collection drainage but are currently also being used for many off label indications. There are three different LAMS available at this time around the globe. This manuscript will review the current state of the art with regards to LAMS and their indications, usage, and outcomes.