Over-the-Wire Lumen-Apposing Metal Stent Exchange for Management of a Long-Term Choledochoduodenostomy Dysfunction

Vanella, Giuseppe; Dell’Anna, Giuseppe; Mariani, Alberto; Lauri, Gaetano; Casadei‐Gardini, Andrea; Arcidiacono, Paolo Giorgio

doi:10.14309/ajg.0000000000001730

Cited by 5 publications

(9 citation statements)

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“…Even though the dumbbell shape of LAMS should prevent stent migration, spontaneous LAMS dislodgement has been described in fluid collection, 28 gallbladder, 29 and EUS‐guided gastroenterostomy 30 . In these cases, a new LAMS release using the same fistula, 31 a new EUS‐CDS, or other (EUS‐guided) biliary drainage strategies are viable options.…”

Section: Discussionmentioning

confidence: 99%

Classification, risk factors, and management of lumen apposing metal stent dysfunction during follow‐up of endoscopic ultrasound‐guided choledochoduodenostomy: Multicenter evaluation from the Leuven‐Amsterdam‐Milan Study Group

Vanella

Bronswijk

Dell’Anna

et al. 2022

Digestive Endoscopy

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Objectives Long‐term outcomes of endoscopic ultrasound‐guided choledochoduodenostomy (EUS‐CDS) performed with lumen apposing metal stents (LAMS) have been poorly evaluated in small or retrospective series, leading to an underestimation of LAMS dysfunction. Methods All consecutive EUS‐CDS performed in three academic referral centers were included in prospectively maintained databases. Technical/clinical success, adverse events (AEs), and dysfunction during follow‐up were retrospectively analyzed. Kaplan–Meier analysis was used to estimate dysfunction‐free survival (DFS), with Cox proportional hazard regression to evaluate independent predictors of dysfunction. Results Ninety‐three patients were included (male 56%; mean age, 70 years [95% confidence interval (CI) 68–72]; pancreatic cancer 81%, metastatic disease 47%). In 67% of procedures, 6 mm LAMS were used. Technical and clinical success were achieved in 97.8% and 93.4% of patients, respectively, with AEs occurring in 9.7% (78% mild/moderate). Dysfunction occurred in 31.8% of patients after a mean of 166 days (95% CI 91–241), with an estimated 6 month and 12 month DFS of 75% and 52%, respectively; mean DFS of 394 (95% CI 307–482) days. Almost all dysfunctions (96%) were successfully managed by endoscopic reintervention. Duodenal invasion (hazard ratio 2.7 [95% CI 1.1–6.8]) was the only independent predictor of dysfunction. Conclusions Endoscopic ultrasound‐guided choledochoduodenostomy shows excellent initial efficacy and safety, although stent dysfunctions occurs frequently during long‐term follow‐up. Almost all stent dysfunctions can be managed successfully by endoscopic reinterventions. We propose a comprehensive classification of the different types of dysfunction that may be encountered and rescue procedures that may be employed under these circumstances. Duodenal invasion seems to increase the risk of developing EUS‐CDS dysfunction, potentially representing a relative contraindication for this technique.

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Section: Discussionmentioning

confidence: 99%

Classification, risk factors, and management of lumen apposing metal stent dysfunction during follow‐up of endoscopic ultrasound‐guided choledochoduodenostomy: Multicenter evaluation from the Leuven‐Amsterdam‐Milan Study Group

Vanella

Bronswijk

Dell’Anna

et al. 2022

Digestive Endoscopy

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“…If clinically possible, swiping of the LAMS should be delayed until a permanent fistula is developed (usually 10-15 days after the initial placement) because of the risk of dislocating the LAMS. 9 Coaxial double-pigtail plastic stenting Prophylactic coaxial double-pigtail plastic stenting (DPPS) placement during the index procedure is still debated. 10 Conversely, coaxial DPPS (rescue strategy A) 6 has been extensively used in case of LAMS dysfunction because it can: (i) prevent stent reocclusion, especially by food impaction; (ii) reduce the risk of ascending cholangitis; (iii) redirect the LAMS in case of compression/invasion; and (iv) prevent migration by anchoring the LAMS.…”

Section: Balloon Swipes Through the Lamsmentioning

confidence: 99%

“…If clinically possible, swiping of the LAMS should be delayed until a permanent fistula is developed (usually 10–15 days after the initial placement) because of the risk of dislocating the LAMS 9 …”

Section: Procedures and Techniquesmentioning

confidence: 99%

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

Vanella,

Dell'Anna,

van Wanrooij

et al. 2023

Digestive Endoscopy

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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.

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“…Bile leakage and capnoperitoneum are prevented by the compressive properties of the bi-flanged fully-covered LAMS design. The silicone membrane also facilitates stent exchange/removal if the need should arise [ 34 ]. A CBD dilation >12 mm (ideally >15 mm) is usually required for a free-hand LAMS deployment [ 32 ].…”

Section: Introductionmentioning

confidence: 99%

“…Very rarely, the EUS-CDS LAMS can spontaneously migrate, especially after the fistula has consolidated. In these cases, a new stent can be placed through the open fistula [ 34 , 56 ]. An interesting recent retrospective series by Ishiwatari et al , comparing EUS-HGS with or without additional antegrade stenting in patients with dMBO, suggested that associating antegrade stenting with EUS-HGS might prolong the time to biliary recurrence (P=0.036 on log-rank test) and independently predict a reduced recurrent biliary obstruction (hazard ratio 0.2, 95%CI 0.1-0.9); despite the non-different risk of AEs, fewer cases of peritonitis and cholangitis (but more frequent pancreatitis) were observed in the double procedure than in EUS-HGS alone [ 57 ].…”

Section: Introductionmentioning

confidence: 99%

Endoscopic ultrasound-guided biliary drainage and gastrointestinal anastomoses: the journey from promising innovations to standard of care

Vanella

Dell’Anna

Bronswijk

et al. 2022

aog

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Biliary obstruction (BO) and gastric outlet obstruction (GOO) are frequent complications of pancreatobiliary and gastroduodenal neoplasia, which can severely impact oncological outcomes, patient survival and quality of life. Although endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for biliary drainage, this may fail or be unfeasible because of duodenal/papillary infiltration or surgically-altered anatomy. Percutaneous transhepatic biliary drainage (PTBD) has been the standard rescue therapy in this setting, but is burdened by high morbidity and reduced quality of life. As for GOO, surgical gastroenterostomy and enteral stenting are limited by invasiveness and suboptimal long-term outcomes, respectively. Endoscopic ultrasound (EUS) has evolved from a diagnostic to a therapeutic modality, providing a safe and effective alternative for draining the pancreatobiliary tract into the stomach or duodenum. EUS-guided biliary drainage (EUS-BD) has already demonstrated similar efficacy, greater safety and fewer reinterventions compared to PTBD, and can be performed in the same session after ERCP failure. Further development of lumen apposing metal stents has paved the way towards the creation of EUS-guided anastomoses. EUS-guided gastroenterostomy (EUS-GE) is nowadays increasingly used to treat GOO, combining the minimal invasiveness of endoscopy with surgical-range efficacy. This review summarizes the technical details, current evidence and society recommendations contributing to EUS-BD and EUS-GE gaining ground in everyday practice or tertiary referral centers and becoming crucial in improving the multidisciplinary management of cancer-related symptoms.

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Over-the-Wire Lumen-Apposing Metal Stent Exchange for Management of a Long-Term Choledochoduodenostomy Dysfunction

Cited by 5 publications

References 0 publications

Classification, risk factors, and management of lumen apposing metal stent dysfunction during follow‐up of endoscopic ultrasound‐guided choledochoduodenostomy: Multicenter evaluation from the Leuven‐Amsterdam‐Milan Study Group

Classification, risk factors, and management of lumen apposing metal stent dysfunction during follow‐up of endoscopic ultrasound‐guided choledochoduodenostomy: Multicenter evaluation from the Leuven‐Amsterdam‐Milan Study Group

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

Endoscopic ultrasound-guided biliary drainage and gastrointestinal anastomoses: the journey from promising innovations to standard of care

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