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

Abstract

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.

Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives

“…These devices are self-expanding metal stents equipped with wide flanges that ensure a strong lumen-to-lumen apposition, anti-migratory properties, and sealing of the fresh transmural tract, minimizing the risk of extraluminal leakage. Initially used for EUS-guided drainage of peripancreatic fluid collections, indications have rapidly expanded to include EUS-guided biliary drainage, gallbladder drainage, and enteric anastomoses [28][29][30][31]. Currently, guidelines suggest the use of either LAMS or dedicated SEMS for EUS-GBD [32].…”

“…However, no definitive evidence is yet available on transgastric vs. transduodenal LAMS patency rates, and preliminary data suggest that the outcomes across both subgroups are fairly comparable [35]. In this regard, it is unclear if the placement of coaxial DPS, which has been proposed in different clinical settings involving LAMS drainage, may reduce the risk of stent dysfunction [30,32,[36][37][38]. On the other hand, transgastric EUS-GBD may be the preferred approach in patients with a possible future cholecystectomy, as the gastric fistula is perceived as less challenging to manage during laparoscopic cholecystectomy compared to the transduodenal fistula of a cholecystoduodenostomy (see below).…”

Lumen-apposing metal stent-induced perforation during endoscopic ultrasound-directed transgastric retrograde cholangiopancreaticography managed with an endoscopic suturing device

“…Owing to the patient's previous sleeve gastrectomy, the LAMS had to be placed between the jejunum and the excluded antrum. As per recently published international expert recommendations, the ERCP was scheduled 2 weeks post-LAMS placement to allow for tract maturation [1]. Nevertheless, the proximal flange of the LAMS dislocated during duodenoscope introduction and ended up in the peritoneal cavity (▶ Fig.…”