What is the ideal indwelling time for metal stents after endoscopic ultrasound‐guided gastrojejunostomy? Case report of delayed iatrogenic perforation with a review of the literature

Abstract

Several recent studies have described the feasibility, efficacy and safety of the placement of lumen‐apposing metal stents (LAMS) for the treatment of gastrointestinal strictures. However, the optimum stent indwelling time is unclear. We reviewed the literature on endoscopic gastroenterostomy (GE) with a focus on the stent indwelling time and we described the first reported case of iatrogenic perforation six months after Axios stent placement. In the literature review (n = 239), the composite technical success rate and clinical success rate were 93.7% and 87.9%, respectively. The mean follow‐up period was 191 days, and the mean stent indwelling time was 88 days. Among 13 studies (n = 202), the mean rate of complications was 13.4%. The principal complication was mis‐deployment of the stent (4.5%). We report a case report of delayed iatrogenic perforation. A 59‐year‐old male patient with cystic dystrophy of the duodenum has been followed for several years. He presented with anorexia following duodenal obstruction and underwent endoscopic ultrasound‐guided gastrojejunostomy. Six months later, he was referred to our center due to septic shock, and abdominal computed tomography revealed peritonitis secondary to a perforation of the small intestine, opposite the Axios stent. The mean LAMS indwelling time after GE was 88 days. To minimise the rate of adverse events, such as ulceration and mucosal overgrowth, regular abdominal computed tomography and endoscopy can be performed to evaluate the local effect of the stent. When the disease has resolved, the LAMS must be removed as soon as possible.

Endoscopic ultrasound-guided gastroenterostomy using large-diameter (20 mm) lumen apposing metal stent (LLAMS)

“…This may be further extended to patients with significant comorbidities and limited life expectancy. The challenge in patients with benign GOO is determining the optimal time and criteria for removal of the LAMS, especially given reports of delayed perforation occurring 6 months after creation of EUS-GE 24 . Considering the relatively recent adaptation of this technique long term data is not yet available.…”

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…Results from clinical experience with this technique are detailed in Table 7 s. Published cohorts of more than 10 cases have been described in 15 studies (with partial cohort overlap), all but one of these being retrospective [140,[145][146][147][148][149][157][158][159][160][161][162][163][164][165]. The results from these studies were included in five recent pooled analyses and systematic reviews including almost 300 patients [144,[166][167][168][169]. The technical and clinical success rates of EUS-GE are reported to range from 91 % to 94 % and 88 % to 90 %, respectively [147,164].…”

“…In this study, LAMS placement was associated with a low risk of symptom recurrence due to food obstruction. If food impaction occurred, it could be easily resolved endoscopically (10 %) [159,161,169]. The most frequent AE identified that needed revision was ulceration at the stent site [169].…”

Early Lumen-Apposing Metal Stent Dysfunction Complicating Endoscopic Ultrasound-Guided Gastroenterostomy: A Report of Two Cases

“…13 Some authors therefore suggested regular evaluation of the LAMS after EUS-GE, either by CT-scan or repeated endoscopies, to reduce the incidence of adverse events such as tissue overgrowth and ulcerations. 14 The gastro-colonic fistula, which occurred 11 weeks after the LAMS placement, might have resulted from suboptimal deployment and subsequent lengthening of the stent, causing prolonged pressure erosions due to friction between the transverse colon and the flanges of the gastro-jejunal LAMS. The mechanism might be similar to when LAMS is impinging adjacent vasculature causing friction and bleeding, when used for draining PFC.…”