Lumen-apposing Metal Stent Removal Research Articles

Revolutionizing outcomes: endoscopic ultrasound-guided gallbladder drainage using innovative electrocautery enhanced-lumen apposing metal stents for high-risk surgical patients

This study retrospectively evaluated the outcomes of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using novel electrocautery-enhanced lumen-apposing metal stents (LAMS) in high-risk patients with acute cholecystitis (AC). Between January 1, 2021, and November 30, 2022, 58 high-risk surgical patients with AC underwent EUS-GBD with the novel electrocautery-enhanced LAMS. The technical success rate was 94.8% (55/58), with one case of duodenal perforation requiring surgery with complete stent migration and two of partial stent migration into the gallbladder. However, the clinical success rate was 100% (55/55). Recurrent AC occurred in 3.6% of the cases (2/55), managed with double pigtail plastic stents through the LAMS. Early AEs observed in 1.8% (1/55) due to stent obstruction. Late AEs occurred in 5.4% (3/55), including two cases of cholangitis and one of stent obstruction. For 33 patients followed over 6 months, LAMS maintenance was sustained in 30 cases. Two patients underwent double-pigtail plastic stent replacement after LAMS removal, and one underwent LAMS removal during surgery following tumor stage regression after chemotherapy for cholangiocarcinoma. The novel electrocautery-enhanced LAMS demonstrated high technical and clinical success rates in high-risk surgical patients with AC, maintaining effective gallbladder drainage with minimal AEs during long-term follow-up, thus highlighting its efficacy and safety in challenging patients.

Primary anastomosis closure after endoscopic ultrasound-directed transgastric intervention.

Background and study aims Endoscopic ultrasound-directed transgastric intervention (EDGI) is a technique that creates an anastomosis between the gastric pouch or jejunum to the excluded stomach in Roux-en-Y gastric bypass (RYGB) anatomy to allow access to the pancreaticobiliary system. Thus far, management of anastomosis closure at the time of lumen-apposing metal stent (LAMS) removal has varied widely. This study aimed to assess the efficacy of primary closure at the time of LAMS removal using athrough-the-scope (TTS) tack-based suture system. Patients and methods This was a two-center retrospective study of RYGB patients who underwent single-stage EDGI using a 20-mm LAMS and subsequent primary anastomosis closure with the X-tack system at the time of stent removal. Patient demographics, procedure details, clinical outcomes, and imaging findings are reported. Results Nineteen patients (median age 63 years, 84% female) underwent single-stage EDGI with a median follow-up of 31.5 months. Adverse events occurred in two patients (11%) who had abdominal pain requiring hospitalization. The median LAMS dwell time was 32 days (range 16-86). All patients (100%) who underwent follow-up studies after LAMS removal had confirmed anastomosis closure (n = 18). Most patients had documented weight loss at the time of LAMS removal and at last follow-up (68%, n = 13). Conclusions Single-stage EDGI is an effective approach to managing RYGB patients with pancreaticobiliary pathology. Thus far, endoscopic TTS tack-based suturing appears to have a high success rate in anastomosis closure after LAMS removal and should be considered as a primary method for preventing chronic fistulae.

Safety and efficacy of early versus late removal of LAMS for pancreatic fluid collections.

Background and study aims Optimal timing for removal of lumen-apposing metal stents (LAMS) for effective drainage of pancreatic fluid collections (PFC) while minimizing adverse events (AE) is unknown. Outcomes of early (≤ 4 weeks) or delayed (> 4 weeks) LAMS removal on both clinical efficacy and the incidence of AE were assessed. Patients and methods This was a retrospective analysis of a prospectively maintained registry of PFC drainage between November 2016 and September 2021. Clinical success was defined as a 75% decrease in fluid collection volume with no need for reintervention at 6 months. AE were defined using the American Society for Gastrointestinal Endoscopy lexicon. Multiple logistic regression analysis was performed to determine variables associated with clinical success and AE. Results A total of 108 consecutive PFCs were included. LAMS deployment was technically successful in 103 of 108 cases (95.4%). Failure was associated with collection diameter ≤ 4 cm (odds ratio [OR] 24.0, P = 0.005) and presence of more than 50% necrotic material (OR 20.1, P = 0.01). Stents were left in place for a median of 48 days. Patients with early stent removal (< 4 weeks) had clinical success in 70.0% of cases, which was significantly less than in the group with delayed stent removal (96.4%, P = 0.03). On multiple regression analysis, clinical failure was associated with early stent removal (OR 25.5, P = 0.003). AEs occurred in 8.7% of cases (9/103). There were no predictors of AE. Notably, delayed stent removal did not predict the occurrence of AE. Conclusions Early LAMS removal (< 4 weeks) did not prevent AEs but did lead to increased clinical failure.

EUS-guided transluminal drainage using lumen-apposing metal stents with or without coaxial plastic stents for treatment of walled-off necrotizing pancreatitis: a prospective bicentric randomized controlled trial.

Lumen-apposing metal stents (LAMSs) have proven to be effective for drainage of pancreatic walled-off necrosis (WON), although associated adverse events (AEs) have been reported. Anchoring coaxial double-pigtail plastic stents (DPSs) within LAMSs have been proposed to prevent LAMS-related AEs but have not been assessed in prospective studies. We aimed to evaluate the utility of such measures with a randomized controlled trial. We randomly assigned consecutive patients with WON indications for drainage to EUS-guided transluminal drainage using LAMSs with (group A) or without (group B) DPSs. All LAMSs were to be removed after 3 weeks had elapsed from the index procedure with a preceding CT to decide whether additional steps needed to be taken (eg, transluminal necrosectomy or placing transluminal plastic stents in patients with incomplete resolution of WON). The main outcomes were failure of the index method, defined as necessity of reintervention (endoscopic, percutaneous, or surgical) before LAMS removal because of LAMS-related AEs and/or clinical deterioration; AE rates; and mortality with LAMS in place. Variables were evaluated using the Mann-Whitney U test, χ2 test, or Fisher exact test as appropriate. P< .05 was considered significant. Sixty-seven patients (37.3% women; mean age, 54 ± 14.4 years) underwent LAMS placement with (n= 34) or without (n= 33) DPS placement in 2 tertiary centers. Baseline characteristics including demographics, etiology, comorbidity, and clinical presentation (sterile vs infected necrosis) were comparable between both groups. The technical success rate in placing LAMSs and DPSs was 100%. The global rate of AEs was significantly lower in group A versus group B (20.7% vs 51.5%, respectively; P= .008). Stent occlusion was the most frequently observed AE (14.7% vs 36.3%, P= .042). Failure of the index method was lower in group A versus group B (29.4% vs 48.5%, respectively; P= .109); however, the difference did not achieve statistical significance. The same applied to the mortality rate with LAMSs in place (2.9% vs 12.1%, P= .197). The addition of a coaxial DPS within a LAMS was associated with a significantly lower global rate of AEs and stent occlusion rate in EUS-guided drainage of WON. (Clinical trial registration number: NCT03923686.).

Endoscopic ultrasound-directed transgastric ERCP (EDGE): A multicenter US study on long-term follow-up and fistula closure.

Background and study aims Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a safe and efficacious procedure to treat pancreaticobiliary diseases in Roux-en-Y gastric bypass (RYGB). This multicenter study aimed to determine the long-term outcomes of EDGE focusing on fistula persistence rates and post-procedure weight change. Patients and methods Information about patients with Roux-en-Y gastric bypass anatomy who underwent EDGE between 2015 and 2021 from 10 institutions was captured in a registry. Patient demographics, procedural details, and clinical outcomes were analyzed. Results One hundred seventy-two patients were included in the study (mean age 60, 25 % male). Technical success of lumen-apposing metal stent (LAMS) placement was 171 of 172 (99.4 %) while clinical success of intervention was 95%. The mean procedure time was 65 minutes. The most commonly reported complication was stent dislodgement/migration (n = 29, 17). Mean length of time of LAMS duration was 69 days. Mean follow-up time was 6 months. Endoscopic fistula closure was performed in 40 % of patients (69/172) at the time of LAMS removal. Persistence of fistula was observed in 19 of 62 patients (31 %) assessed. Length of LAMS indwell time (days) was a predictor of persistent fistula. The average weight gain while the LAMS was in place was 12 lb in 63 patients (36.6 %); 59.4 % of patients gained < 5 lb. Conclusions EDGE is a safe and efficacious procedure for RYGB patients requiring ERCP. Post-procedure evaluation and management of the enteral fistula varies widely among centers currently and would benefit from further standardization. Fistula persistence appears to be uncommon and can be managed endoscopically but may be related to length of indwell times of the LAMS.

Self-assembling peptide gel application to achieve endoscopic hemostasis for fistula bleeding after lumen apposing metal stent removal.

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Temporary EUS-guided gastrojejunostomy for gastric outlet obstruction caused by severe acute pancreatitis (with videos).

Gastric outlet obstruction (GOO) due to duodenal stricture after acute pancreatitis occurs in 5.7%, with two peaks, during the early phase or after 4 weeks.[1] Patients may require enteral and parenteral nutrition or surgical therapy when conservative treatment fails.[1] EUS-guided gastrojejunostomy (EUS-GJ) has emerged as an alternative for malignant GOO and a bridge therapy for benign causes,[23] including after acute pancreatitis as an unusual indication.[24] We present the case of a 73-year-old male with a history of severe acute pancreatitis 8 weeks earlier, with percutaneous drainage of 70 mm × 50 mm pancreatic fluid collection. He complained of oral intolerance. A computed tomography scan revealed a large gastric retention with two small pancreatic fluid collections [Figure 1]. Gastroscopy confirmed impassable duodenal inflammatory stenosis leading to severe gastric outlet gastrointestinal edema (GOGE) [Figure 2]. A nasojejunal tube was inserted downstream the jejunum but failed to achieve enteral nutrition so parenteral nutrition was initiated. He was referred to our unit to address GOO. A 0.035 mm guidewire was inserted through the duodenal stenosis downstream the jejunum using a gastroscope. After exchange for linear echoendoscope and distension of jejunum with water and contrast, the gastric wall was punctured and free-hand deployment of a cautery-enhanced 15 mm × 10 mm lumen-apposing metal stent (LAMS) was performed [Video 1]. However, an unplanned procedure event occurred as free perforation due to distal flange misdeployment outside the jejunum [Figure 3]. The LAMS was removed using rat-tooth forceps [Figure 4] and the procedure was repeated without finding the previous puncture site. Hence, a 15 mm × 10 mm LAMS was inserted allowing the EUS-GJ [Video 2]. Oral feeding was tolerated the next day, and the patient was discharged 6 days after uneventfully. A barium-meal radiography performed 54 days after confirmed adequate gastric emptying [Figure 5]. The LAMS was removed 3 months later and the patient underwent cholecystectomy 9 months later. He remained with any GOO symptoms throughout a 12-month follow-up.Figure 1: A computed tomography scan showing a large gastric distension together with a small fluid collection in the pancreatic headFigure 2: Endoscopic view of impassable duodenal inflammatory stenosis due to severe acute pancreatitisFigure 3: Endoscopic view of the misdeployed distal lumen-apposing metal stent flange after the first EUS-guided gastrojejunostomy attempt. Notice that the peritoneum can be observed across the lumen-apposing stentFigure 4: Radiological view of lumen-apposing metal stent removal using a rat-tooth forceps after misdeployment of distal flangeFigure 5: Radiological view of barium meal. An adequate gastric emptying is observed as the first and second image are compared. (a) The arrow indicates the pylorus. Notice that only a small amount of contrast pass to the duodenum with a second and third portion stenosis. The asterisk refers to the EUS-guided gastro-jejunal anastomosis. (b) Also, the lumen-apposing metal stent can be observed in situ in the right imageThis case suggests that temporary EUS-GJ is feasible and safe in some patients with GOGE after acute pancreatitis[3] as an alternative to indefinite LAMS placement.[5] Distal flange misdeployement noted intraprocedurally was successfully managed by immediate LAMS removal and repeat LAMS insertion across a new puncture tract. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest Dr. Manuel Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic and M.I.Tech. He is also an Editorial Board Member of the journal. This article was subject to the journal’s standard procedures, with peer review handled independently of this editor and his research group.

Lumen-apposing metal stents for the treatment of benign gastrointestinal tract strictures: a single-center experience and proposed treatment algorithm.

Lumen-apposing metal stents (LAMS) are an alternative therapeutic option for benign gastrointestinal (GI) tract strictures. Our study aimed to evaluate the safety and efficacy of LAMS for the management of benign GI strictures. Consecutive patients who underwent a LAMS placement for benign luminal GI strictures at a tertiary care center between January 2014 and July 2021 were reviewed. Primary outcomes included technical success, early clinical success, and adverse events (AEs). Other outcomes included rates of stent migration and re-intervention after LAMS removal. One hundred and nine patients who underwent 128 LAMS placements (67.9% female, mean age of 54.3 ± 14.2years) were included, and 70.6% of the patients had failed prior endoscopic treatments. The majority of strictures (83.5%) were anastomotic, and the most common stricture site was the gastrojejunal anastomosis (65.9%). Technical success was achieved in 100% of procedures, while early clinical success was achieved in 98.4%. The overall stent-related AE rate was 25%. The migration rate was 27.3% (35/128). Of these, five stents were successfully repositioned endoscopically. The median stent dwell time was 119days [interquartile range (IQR) 68-189days], and the median follow-up duration was 668.5days [IQR: 285.5-1441.5days]. The re-intervention rate after LAMS removal was 58.3%. LAMS is an effective therapeutic option for benign GI strictures, offering high technical and early clinical success. However, the re-intervention rate after LAMS removal was high. In select cases, using LAMS placement as destination therapy with close surveillance is a reasonable option.

Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study

EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure. This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon. Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips+ endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P= .02) and more patients had≥5% total body weight gain (33.3% vs 10.3%, P= .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P= .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%). Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.

S1718 Delayed Gastrointestinal Hemorrhage From Visceral Artery Pseudoaneurysm in Necrotizing Pancreatitis After LAMS Removal

Introduction: Delayed bleeding from visceral artery pseudoaneurysm (PA) formation is an uncommon complication of lumen-apposing metal stent (LAMS) placement. Risk factors for gastrointestinal bleeding (GIB) in patients with LAMS remain largely undefined. We report a case of delayed GIB due to rupture of a splenic artery PA 16 months after LAMS removal. Case Description/Methods: A 34-year-old female with a history of severe necrotizing pancreatitis presented to our hospital with massive hematemesis. 23 months prior to presentation, she underwent uncomplicated placement of a 15x10 mm LAMS and 2 7 Fr x 4 cm double pigtail plastic stents for drainage of walled-off pancreatic necrosis. She was briefly lost to follow-up and returned for LAMS removal 5 months later. Contrast was injected into the residual cyst cavity and contrast filling was noted of what appeared to be a splenic vessel without active bleeding (Figure A). CT angiogram showed no PA but proximity of the splenic hilar vasculature to the LAMS (Figure B). The LAMS was successfully removed 2 months later without complication. On presentation, she was tachycardic but normotensive. Laboratory studies were notable for hemoglobin 8.8 g/dL (baseline 14 g/dL). Upper endoscopy showed brisk bleeding in the proximal gastric body near the area of prior LAMS. Her bleeding was refractory to endoscopic hemostatic maneuvers, and she underwent emergent mesenteric angiography. Angiography revealed active arterial extravasation arising from the inferior segmental branch of the splenic artery ( Figure C) which was successfully embolized with no further bleeding. Discussion: Visceral artery PA development after LAMS placement is thought to occur due to friction of the inner flange against regional vasculature surrounding the necrotic cavity as it collapses. Close anatomical proximity of LAMS to regional vasculature increases the risk of PA development. In our case, the LAMS was placed near the rich vascular supply of the splenic hilum. Most reported bleeding events related to LAMS have occurred within 8 weeks of placement. Our case is notable for the prolonged delay between LAMS removal and bleeding presentation. Adherent scar tissue between the gastric wall and vasculature could potentially cause delayed PA development after LAMS removal. This case reinforces that high clinical suspicion for PA bleeding is necessary for patients who have previously undergone distant LAMS removal who present with massive GIB.Figure 1.: (A) Fluoroscopic image of contrast injection into residual cyst cavity demonstrating opacification of likely splenic vasculature; (B) Coronal images demonstrating the proximity of the LAMS to the vasculature of the splenic hilum (yellow arrow); (C) Super-selective angiography demonstrating active extravasation into the lateral aspect of the stomach from a pseudoaneurysm (White arrow) involving an inferior segmental branch of the splenic artery.

S1093 Assessment of Physical and Mental Health Before and After Protocolized Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis in a Prospective Multi-Center Trial

Introduction: A regulatory FDA IDE prospective multi-center clinical trial (G170261-NCT03525808) was performed to evaluate rigorous protocolized management of walled off necrosis (WON) ≥ 6 cm in size with > 30% necrotic material using endoscopic ultrasound (EUS) guided lumen apposing metal stent (LAMS) placement with/without endoscopic necrosectomy. Few studies have examined changes in health related quality of life (HRQOL) before and after endoscopic management for WON. The SF-12 is a validated measure of HRQOL containing 12 items which yield a Mental Components Score (MCS) and a Physical Components Score (PCS). Higher scores correspond to a greater perceived quality of life. Methods: The pre-specified target sample of 40 consecutive eligible patients was enrolled by multiple centers from September 2018 to March 2020. Patients with radiographic WON resolution (as demonstrated by size ≤ 3 cm on CT or MRI) and/or 60 days LAMS indwell time had stent removal followed by an end of study visit 6 months later. SF-12 quality of life questionnaires were completed by patients at baseline, stent removal and at the end of study visit. Results: Mean SF-12 Physical Components Score (PCS) was 27.5±21.1 at baseline, 54.4±19.5 at the time of LAMS removal, and 77.9±22.3 at end of study. Mean SF-12 Mental Components Score (MCS) was 44.9±20.1 at baseline, 64.7±16.5 at the time of LAMS removal, and 79.0±17.2 at end of study. The mean improvement in PCS score from baseline to LAMS removal was 26.0±24.8 (p< 0.0001), with the mean improvement in score from baseline to end of the study being 49.1±29.6 (p< 0.0001). The mean improvement in MCS was 19.6±20.1 from baseline to LAMS removal (p< 0.0001) and 32.0±22.3 from baseline to the end of study (p< 0.0001). The mean improvement from the time of stent removal to the end of study was 25.2±18.0 (PCS, p< 0.0001) and 15.5±18.5 (MCS, p=0.0002) (Figure). Conclusion: These data suggest that patients undergoing protocolized endoscopic necrosectomy for walled-off pancreatic necrosis experience significant improvement in both physical and mental HRQOL. Improvement in the physical score domain appeared to be greater than for the mental score domain. HRQOL indicators continued to improve over a mean follow-up of 180 days.Figure 1.: SF-12 Physical and Mental Components Score.

S1727 Endoscopic Ultrasound-Guided Transgastric Drainage of an Infected Biloma After Cholecystectomy: A Case Report

Introduction: A biloma is a well-defined collection of bile outside the biliary tree typically caused by iatrogenic disruption of a bile duct. Percutaneous drainage is the traditional treatment modality with surgery reserved for refractory cases. Endoscopic ultrasound (EUS) guided transenteric drainage has emerged as a suitable alternative. We present a case of an infected post-cholecystectomy biloma treated using EUS-guided drainage with a transgastric LAMS. Case Description/Methods: A 57-year-old female presented with fevers, abdominal pain, nausea, and vomiting following a laparoscopic cholecystectomy for acute cholecystitis 12 days prior. Labs noted a leukocytosis with normal liver chemistries. CT scan of the abdomen showed a peripherally enhancing gas and fluid collection in the subhepatic space measuring 14.5 x 7 x 8 cm, resulting in a mass effect on the antrum and proximal duodenum. Gastroenterology was consulted for the management of suspected bile leak and infected biloma. Endoscopic retrograde cholangiography (ERC) revealed a bile leak with contrast extravasation from the cystic duct stump. This was treated with biliary sphincterotomy and placement of a 10 Fr x 7 cm plastic biliary stent. Same session EUS demonstrated a large fluid collection abutting the antrum with a well-defined wall. EUS-guided drainage of the biloma was performed using a 15 x 10 mm electrocautery enhanced LAMS via a transgastric approach. Approximately 1 L of purulent fluid was evacuated from the cavity. A subsequent CT scan confirmed the correct positioning of the LAMS with marked cavity decompression (Figure). The patient’s symptoms resolved. Endoscopy with LAMS removal and placement of 2 10 Fr x 4 cm double pigtail stents (DPT) was performed 1 week later. CT 1 week after DPT placement noted near-complete resolution of the fluid collection. Six weeks after the index procedure, ERC showed resolution of the cystic duct leak and the biliary stent was removed. Both DPTs were removed 2 weeks later. The patient has remained well clinically. Discussion: EUS-guided transenteric biloma drainage is a safe and effective alternative to percutaneous drainage. Initial cases were performed using plastic stents but more recently, transduodenal drainage with a LAMS was reported. Endoscopic drainage also enables same session identification and treatment of the culprit bile leak which is essential to prevent biloma recurrence. Our case is the first reported EUS-guided transgastric drainage of an infected biloma using a LAMS.Figure 1.: A. CT scan illustrating a large subhepatic fluid and gas-containing collection (Black arrow) with resultant gastric outlet obstruction (red arrow). B. Successful placement of a transgastric lumen apposing metal stent (LAMS) into the biloma cavity with immediate drainage of purulent fluid. C. Post-drainage CT scan demonstrating biloma cavity decompression and appropriate positioning of the LAMS (green arrow).

S1164 Lumen-Apposing Metal Stents for Pancreatic Fluid Collections Reduce 90-Day Readmission Rates

Introduction: Management of symptomatic mature pancreatic fluid collections (PFCs) such as pancreatic pseudocysts or walled-off necrosis now involve the use of lumen-apposing metal stents (LAMS) under endoscopic ultrasound (EUS) guidance. LAMS appear to be superior compared to traditional plastic stents however require close follow up. Numerous studies have shown a benefit of LAMS for short-term (e.g., 4-week) outcomes. However, there is a lack of data evaluating longer term outcomes. Our aim was to investigate 90-day readmission rates after LAMS placement over an 8-year period. Methods: We identified all patients ≥ 18 years who underwent deployment of a LAMS from 01/01/2014 to 06/01/2021 at our urban, safety net hospital. We subsequently collected demographic data, cyst characteristics, and stent information. Follow-up upper endoscopies and imaging were examined to determine stent removal date and assess for complications. Hospital admission rates 90 days before and after stent placement were collected. Admissions were stratified into gastrointestinal (GI)-related or other. Results: We identified 27 patients who underwent LAMS for drainage of mature PFCs. Of these, 18 were simple pancreatic pseudocysts (PP), 6 walled-off necrosis (WON), and 3 mixed collections. Mean age was 52.1 ± 11.0 years, 66.7% male, 66.7 % non-white, and 59.3% reported alcohol use. The average collection was 6.6 ± 2.0 cm. Stents were removed in 81.5% of patients at a median of 37.5 days. 7.4% were lost to follow up, and 22.2% of patients had stent complications during follow-up: 2 bleeding, 2 stent migration, and 2 stent occlusions. Patients on average had 1.00 ± 0.20 hospital admissions in the 90 days prior to stent placement vs 0.48 ± 0.17 admissions 90 days after placement (mean difference 0.52 ± 0.17, p< 0.05). Of these patients, 64.7% of pre-stent hospitalizations were due to GI complaints vs 22.2% of post-stent hospitalizations (p< 0.05). Neither cyst size nor time to stent removal were significantly related to complications. Conclusion: LAMS for the management of mature pancreatic fluid collections were effective at reducing 90-day readmission rates especially in the setting of GI-related complaints. Although there was a delay in LAMS removal with a median of 38 days, it did not appear to translate into higher complication rates. Perhaps an extended use of LAMS beyond 4 weeks may prove to be safe and efficacious, however larger studies are required.

EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience

Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n= 16) and management of pancreatic fluid collections (n= 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n= 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n= 28) and EUS-guided cystgastrostomy (n= 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P= .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.

Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series.

Aim:Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS).Methods:All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence.Results:Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9).Conclusions:Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.

Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study.

BACKGROUNDEndoscopic drainage of walled-off necrosis (WON) is still a challenge due to stent-associated problems. We explored endoscopic gastric fenestration (EGF) as an innovative alternative intervention.AIMTo assess the feasibility, efficacy and safety of EGF for WON.METHODSBetween March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound (EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy.RESULTSEGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min (EUS assessment, 32.3 min; initial fenestration, 28.8 min; expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent (LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients.CONCLUSIONEGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

S2321 Use of a Lumen-Apposing Metal Stent for a Colo-Colonic Stricture in the Time of COVID-19

INTRODUCTION: Anastomotic strictures are a known complication of colon resections. Risk factors include neoadjuvant chemo-radiation, anastomotic leak, diverting stoma and stapled anastomosis. Endoscopic balloon dilation is the first line intervention for anastomotic strictures but often requires several treatment sessions and associated healthcare system exposure. We describe a case of a colorectal anastomotic stricture treated with a lumen apposing metal stent (LAMS) with the purpose of decreasing frequency of endoscopic therapy during the initial outbreak of COVID-19. CASE DESCRIPTION/METHODS: A 51 year old female presented for management of a colo-colonic anastomotic stricture. She underwent a low anterior resection for stage III rectal cancer, complicated by an anastomotic leak requiring a diverting loop ileostomy. She then completed adjuvant XRT and FOLFOX therapy. She presented for evaluation 6 months after the creation of her loop ileostomy to consider reversal. During endoscopy, a severe stricture was found which could not be traversed even with a 15 Fr gastroscope. Initial dilation to 10mm with a balloon dilator was successful. One week later, the stricture was improved but still severe. A 15 mm by 10 mm LAMS was placed with the intent of decreasing the number of required procedures and healthcare system exposure during the initial outbreak of COVID-19. The stent was removed 6 weeks later, and the underlying stricture was markedly improved to a diameter of 15 mm, easily traversable with a gastroscope. The patient did not experience any complications while the stent was in place and was able to proceed with planning for ostomy reversal. DISCUSSION: Endoscopic balloon dilation is the initial intervention for anastomotic strictures. Serial balloon dilations usually require multiple procedures to achieve a durable response. With the uncertainty caused by the recent outbreak of COVID-19, many physicians and patients are looking for ways to decrease exposure to healthcare centers. Although LAMS are approved for the management of pancreatic fluid collections, they have been described as an alternative therapy for luminal GI strictures. This case demonstrates early adoption of LAMS with successful luminal dilation of an anastomotic stricture during the COVID-19 pandemic in an effort to decrease healthcare exposure and PPE use during an unprecedented time.Figure 1.: Colo-colonic anastomotic stricture prior to dilation.Figure 2.: LAMS 6 weeks after initial placement.Figure 3.: Stricture after LAMS removal.

Management of adverse events of EUS-directed transgastric ERCPprocedure.

Background and AimsAccessing the pancreatobiliary region in patients with a history of Roux-en-Y gastric bypass (RYGB) can be challenging. Traditionally, techniques such as percutaneous biliary drainage, enteroscopy-assisted ERCP, and laparoscopy-assisted ERCP have been used. However, each technique has its limitations. EUS–directed transgastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has emerged as a novel endoscopic technique for ERCP in patients who have undergone RYGB. The aim of this case series was to highlight LAMS-related shortcomings and adverse events during the periprocedural period.MethodsThis was a retrospective review of 4 patients with RYGB anatomy who underwent EDGE for the management of pancreaticobiliary disease and experienced LAMS-related adverse events. Techniques for managing and avoiding these events are discussed.ResultsFour patients underwent EDGE with both technical and clinical success. Slight LAMS migration with partial mucosal overgrowth was encountered in 1 case and was managed by LAMS removal. A large, bleeding, distal marginal ulcer after the EDGE procedure was encountered in the second case and was managed with proton pump inhibitor and removal of the LAMS, with fistula treatment with argon plasma coagulation used to enhance closure. The third case was complicated by moderate intraprocedural bleeding after LAMS dilation, which was managed by applying balloon tamponade and placing a through-the-scope esophageal stent across the LAMS. Last, preferential food passage to the excluded stomach was noted in the fourth case and resulted in symptomatic distention. The symptomatic distention was managed by another de novo jejunogastrostomy using a LAMS for drainage.ConclusionsDespite its feasibility and acceptable safety profile, the use of LAMSs during EDGE could be associated with several procedure-specific adverse events, which can be avoided or managed endoscopically with no further consequence.

Protocol of early lumen apposing metal stent removal for pseudocysts and walled off necrosis avoids bleeding complications

Background: EUS-guided drainage of pancreatic fluid collections (PFCs; pancreatic pseudocyst (PPC) or walled-off necrosis (WON)) using lumen apposing metal stents (LAMSs) is now standard of care. We adopted a protocol of early LAMS removal and prospectively followed patients to determine if this protocol avoids bleeding complications.Methods: Prospective, consecutive case series of all patients with PPC and WON who underwent drainage with LAMS at a tertiary care referral center from July 2016 to November 2018. LAMS was removed within 4 weeks for PPC and within 6 weeks for WON. Patients with residual necrosis after 6 weeks underwent removal of initial LAMS and replacement with new LAMS every 6 weeks until resolution. Patients were followed within protocol while monitoring for bleeding complications and clinical success. We also performed a literature review to determine rates of LAMS related bleeding at various timepoints.Results: Forty patients (PPC n = 19, WON n = 21) underwent drainage with LAMS. Median time for LAMS removal was 21.0 days for PPC and 33.5 days for WON. Technical success and clinical success were achieved in 40/40 patients with zero cases of delayed bleeding. A literature review of 21 studies and 1378 patients showed 52/1378 (3.8%) bleeding events with 24/52 (46.2%) events occurring within 1 week of LAMS placement.Conclusions: An early removal LAMS protocol for PFC is highly efficacious and prevents delayed bleeding. Based on analysis of published cases, half of LAMS related bleeding occurs within the first week suggesting procedural factors rather than stent dwell time impact risk of bleeding.

EUS-guided gastroenteric anastomosis as a bridge to definitive treatment in benign gastric outlet obstruction

Benign gastric outlet obstruction (GOO) has typically been managed surgically. However, many patients are poor operative candidates because of comorbidities. EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) has previously demonstrated efficacy as a definitive treatment for benign and malignant GOO; however, limited data exist on use as a bridge to resolution of the obstruction in an attempt to avoid or delay definitive surgery. A retrospective series of consecutive patients who underwent EUS-GE between January 2013 and July 2019 for benign GOO at a tertiary referral center were included in the study. The primary outcome was the rate of definitive surgery; secondary outcomes included technical success and rate of adverse events. During the study period, 22 patients with benign GOO underwent EUS-GE (40% female; mean age, 54.2 years). The mean procedure time was 66 minutes, and technical success was achieved in 21. Five patients developed recurrent GOO while the LAMS was in place after a mean dwell time of 228 days; 1 patient was converted to surgical GE. LAMSs were removed electively in 18 patients after GOO resolution and a mean dwell time of 270 days; 1 patient developed a recurrent GOO after LAMS removal and was converted to surgical GE. The rate of recurrent GOO after LAMS removal was 5.6%. Three severe adverse events occurred in the cohort. EUS-GE was able to prevent surgery for GOO in 83.3% of cases. LAMSs needed to stay in place for a mean of 8.5 months to allow resolution of GOO, and there was a low rate of recurrent GOO (5.6%) after LAMS removal. Prospective, randomized trials comparing surgical and endoscopic anastomoses are needed in patients with benign causes of GOO.