Managing dysfunctions and reinterventions in endoscopic ultrasound‐guided choledochoduodenostomy with lumen apposing metal stents: Illustrated technical review (with videos)

Abstract

Endoscopic ultrasound‐guided choledochoduodenostomy (EUS‐CDS) with lumen apposing metal stent (LAMS) is emerging both as a rescue strategy and a primary treatment for distal malignant biliary obstruction (dMBO). The large‐scale diffusion of the procedure and improved overall survival of patients with pancreatobiliary neoplasms is resulting in a growing population of long‐term EUS‐CDS LAMS carriers.Recent studies have reported a need for reintervention during follow‐up as higher as 55%, and the Leuven‐Amsterdam‐Milan Study Group (L.A.M.S) Classification has been developed, identifying 5 mechanisms of stent dysfunction and 11 possible rescue strategies aimed at restoring biliary drainage.This illustrated technical review aims to further dissect the recent classification through a comprehensive analysis of nine illustrative cases, offering insights into the pathophysiology underlying dysfunction and clinical reasoning behind rescue interventions, as well as technical considerations and practical tips and tricks.By exploring mechanisms of dysfunction, this review also assists clinicians in selecting the ideal candidates for EUS‐CDS while identifying patients deemed high risk for dysfunction or clinical failure.

How to prevent and treat biliary lumen‐apposing metal stent dysfunction?

“…In view of these factors, it is clear that the number of patients fitted with this type of device will increase, as will the number of patients with LAMS dysfunction. While self-expandable metal stent (SEMS) obstruction and its endoscopic management is now part of the daily routine for interventional endoscopists, LAMS obstructions are a relatively recent problem for which the publication by Vanella et al 6 in this issue of Digestive Endoscopy is particularly relevant.…”

“…This important article by the Leuven-Amsterdam-Milan Study Group also demonstrates the high technical level required in interventional endoscopy for the management of stent dysfunction, which should not be overshadowed by the relative facility of initial LAMS insertion. 6…”

“…Then, how to treat it? In this issue of Digestive Endoscopy, Vanella et al 6 propose different management strategies for LAMS dysfunction according to their proposed classification of dysfunction. The Leuven-Amsterdam-Milan team should be congratulated for their valuable work on an increasingly frequent problem.…”