Efficacy and safety of lumen-apposing metal stent for benign gastrointestinal stricture

Abstract

Management of benign gastrointestinal (GI) strictures refractory to primary (balloon and savary dilation) and secondary (steroid injection, fully covered self-expanding metal stent, incision therapy) treatment modalities remains a challenge. Lumen-apposing metal stents (LAMSs), originally designed for the management of pancreatic fluid collections, are an attractive option for GI stricture because of their anti-migratory property, attributable to their saddle-shaped design. In this article, we reviewed 70 patients from 12 original studies who received LAMS for refractory (68/70) or treatment-naïve (2/70) benign GI stricture. The technical and clinical success rates were 98.6% (69/70) and 79.7% (55/69), respectively. Endoscopic placement, with or without fluoroscopic guidance, was generally successful, with only a minority requiring endoscopic ultrasound (EUS) guidance where the lumen was completely obscured. The majority of the strictures were short (≤1 cm), but comparable technical and clinical success was noted in isolated cases with long strictures, where 2 overlapping LAMSs were placed. For the overall population, a failure rate of 21.5% (14/69) was noted and was attributed to either lack of follow up, or to persistent or de novo symptoms requiring stent removal/exchange or surgical referral. One perforation (1.4%), five stent migration events (7.1%), two bleeding events (2.9%) and two de novo strictures proximal to the LAMS (2.9%) were reported for the entire study cohort. No mortality was attributable to LAMS placement. Although experience is still evolving, LAMS placement guided by esophagogastroduodenoscopy or EUS is a technically feasible and safe procedure with good clinical outcomes for benign refractory GI strictures.

Lumen-apposing metal stent use to maintain a surgical anastomosis

“…LAMSs have been used in the creation of duodenal jejunostomy to facilitate bile duct clearance after a Roux-en-Y hepaticojejunostomy. 6 , 7 , 8 We report a case of a patient with SMAS with a failed gastrojejunostomy salvaged nonoperatively with an Axios stent.…”

Endoscopic Full-Thickness Defects and Closure Techniques

“…It’s important to note that the stent migration rate is about 30%, thus physicians should consider proximal stent fixation, either with endoscopic suturing or cap mounted clips or with the nasal bridle technique [13,14,28,61,66,67]. When GJA stenosis is present, it is essential to treat distal obstruction, either with CRE balloon (do not over dilate> 15 mm) or luminal stents, including lumen apposing metal stents which are less likely to migrate and theoretically also can be used in the treatment of GJA leaks [68,69].…”

<i>De-novo</i> Gastrointestinal Anastomosis with Lumen Apposing Metal Stent

“…The unique saddle shape of LAMS gives it anti-migratory property and allows it to hold the two GI lumens together. The application of LAMS in this clinical setting is an extension of its known indications, and experience thereof, is still evolving [ 8 - 10 ].…”