Lumen-apposing Self-expanding Metal Stent Research Articles

Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy.

Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMSs) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.

Endoscopic Ultrasonography-Guided Gastroenterostomy Techniques for Treatment of Malignant Gastric Outlet Obstruction

Gastric outlet obstruction (GOO) can be caused by periampullary malignancies and often leads to a reduction in a patient’s quality of life. Recently, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed as a minimally invasive and durable endoscopic treatment for GOO. There are three types of EUS-GE technique: (1) the direct technique; (2) device-assisted techniques, such as a balloon catheter, nasobiliary drainage tube, and ultraslim endoscopy; and (3) EUS-guided double balloon-occluded gastrojejunostomy bypass. Previous reports of EUS-GE with LAMS have shown technical and clinical success rates (regardless of technique and etiology) of 87%–100% and 84%–100%, respectively. Studies comparing EUS-GE and surgical gastrojejunostomy have shown similar success rates, reintervention rates, and cost benefits, with a lower rate of early adverse events in EUS-GE. A comparison of EUS-GE and endoscopic enteral stent placement revealed similar technical success rates, but initial clinical success rate was higher and the rate of stent failure requiring reintervention was lower with EUS-GE.

2132 Perivesicular Abscess Drainage With Axios Stent

INTRODUCTION: Pelvic abscesses can occur as sequelae of surgery and are associated with significant morbidity and mortality. The treatment of choice for these abscesses is immediate initiation of broad-spectrum antibiotics and drainage of the collection. We propose that lumen-apposing self-expanding metal stents (LAMS) are a safe treatment option for drainage of pelvic abscesses. LAMS were originally designed for transmural pancreatic fluid collection drainage however have been successfully used for drainage of various extra-luminal fluid collections. CASE DESCRIPTION/METHODS: The patient is an obese 34-year-old female with a PMHx of IDDM, and HTN who had recently underwent ex-lap for a large non-malignant pelvic mass. On POD #5, the patient developed a fever and repeat CT revealed a multiloculated pelvic abscess measuring 5.8 × 4.2 cm. IR was unable to drain the collection in this location between bladder and rectum. Rectal EUS was performed and revealed a septated fluid collection viewed best using 7.5 mHz ultrasound at 10 cm from the anal verge. A 2 cm margin was observed between the abscess and the urinary bladder. A 2 mm margin was seen between the rectal wall and the abscess wall. A 19-gauge non-core needle was used to access the fluid collection which appeared purulent. A 15 mm AXIOS stent was then deployed using the same technique employed with pseudocyst drainage. Drainage was successful. 9 days after placement, the stent was removed using a cold snare. No bleeding resulted from stent pull. The defect was then clipped closed with a 15 mm over the scope clip. The patient tolerated the procedure well, experienced complete resolution of the abscess. DISCUSSION: Manvar et al suggest that EUS-guided LAMS drainage of pelvic abscesses is more efficacious and has a more favorable safety profile when compared to EUS-guided drainage with catheters and plastic stents. It is an efficient and safe alternative for the management of intra-abdominal and pelvic collections. This case demonstrated the novel use of a lumen-apposing self-expanding metal stent for peri-rectal abscess drainage. Although more evidence is needed for its off-label use, we conclude that it should be strongly considered as a viable treatment option if not the initial treatment modality for collections located in the pelvis.

Use of Axios Stent to Relieve Short Malignancy Stricture

Pancreatic cancer is a leading cause of malignant strictures in the upper gastrointestinal tract, caused by a head of the pancreas mass abutting the duodenum. Often, these tumors are not responsive to chemotherapy or radiation leading to supportive care with gastric decompression via endoscopic stenting or operative bypass to relieve obstruction. The lumen-apposing self-expandable metal stent (LASEMS), which is often used to drain pancreatic fluid collections, may serve as a safe and effective option to stent short strictures from pancreatic malignancy. Axios stents, with their short and flared ends, create an anastomotic conduit between two lumens, allowing short strictures to be bypassed. These stents have lumen-apposing and dual anchoring capabilities. The unique design allows for robust pseudocyst drainage and for the passage of an endoscope with a lower risk of stent migration due to anchoring. The ease of deployment and retrieval serves as an advantage over uncovered and partially-covered stents. We present a patient with history of duodenal cancer and recurrent bleeds in which an Axios stent was used to relieve a malignant duodenal stricture. A 57 year old male presented with 4-5 months of decreased oral intake, weight loss, and coffee ground emesis. Endoscopy revealed a near complete, circumferential stricture between the first and second portion of the duodenum, consistent with malignancy (Figure 1). An Axios LASEMS was advanced over a guidewire, across the duodenal stricture (Figure 2). Ampullary exclusion was confirmed endoscopically and patency was confirmed fluoroscopically. An argon plasma coagulation catheter was used to fenestrate the proximal plastic covering of the stent to allow improved mucosal adhesion and was further secured using an over the scope clip (Figure 3).1426_A.tif Figure 1: Near complete, circumferential stricture between the first and second portion of the duodenum1426_B.tif Figure 2: Advancement of a guidewire over the stricture1426_C.tif Figure 3: Axios stent with an over scope clip; argon plasma coagulation catheter was used to fenestrate the proximal plastic covering of the stentSeveral studies have described the use of LASEMS for the management of benign gastrointestinal strictures. The majority of patients who underwent stenting for benign strictures failed prior therapy. Stricture recurrence was seen in those with prior endoscopic balloon dilation or stricturoplasty, and prior placement of covered SEMS had led to migration. In our literature review we were unable to find a case in which Axios stents were used to relieve malignant duodenal strictures. We demonstrated the feasibility and potential safety and efficacy of LASEMS for management of various types of gastrointestinal strictures.

Su1357 A NEW COLLECTION: REMOVAL AND REPLACEMENT OF THE SAME LUMEN-APPOSING METAL STENT FOR MULTIPLE ENDOSCOPIC NECROSECTOMY SESSIONS

The recently approved lumen-apposing self-expandable metal stent (LAMS) provides safe and effective transmural drainage of pancreatic fluid collections (PFC). Large walled-off necrosis (WON) require multiple direct endoscopic necrosectomy (DEN) through the stent. However, the amount of necrotic material extracted is limited by the inner diameter of the stent. Removal of LAMS can facilitate DEN by improving scope maneuverability through the cystogastrostomy and allow removal of larger solid necrotic debris. The aim of this study is to evaluate the feasibility and safety of this novel technique of removal and replacement of the same LAMS to facilitate endoscopic necrosectomy. A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-guided drainage of PFC via cautery-enhanced LAMS was performed. Patients with WON who underwent more than one necrosectomy session with removal and replacement of LAMS from 01/2017 to 11/2017 were included. All patients underwent fluoroless EUS-guided transgastric cautery-enhanced LAMS for perigastric WON in the usual fashion. During subsequent endoscopy for DEN, the LAMS was initially removed using a snare or rat-toothed forceps. The WON cavity was entered through the cystgastrostomy, which provided enhanced access and maneuverability to perform DEN. At the end of session, the same LAMS was manually inserted inside the distal tip of the gastroscope and deployed across the cystogastrostomy at the end of each session (Fig 1). A total of 17 patients (mean age 38.4±14.7 years; 88% males) were included. The mean size of WON was 10.4±3.5 cm by 9±3.7 cm. The mean interval from EUS-guided LAMS placement to first endoscopic necrosectomy session was 20.4±13.3 days. Median number of sessions required was 2 (range 1-5; mean 2.3). Complete resolution was achieved after a median of 2 (range 1-5) DEN sessions with stent retrieval after 8.1±6.4 weeks. This modification provided better visualization of deeper recesses as well as improved scope tip maneuverability even allowing for scope tip retroflexion within the cavity as needed. Snare was used in all sessions with removal of larger necrotic pieces with each pass, leading to less number of passes, shorter duration of procedure, and less number of sessions, compared to the results of a recently published meta-analysis (2.3 vs. 4.09; p <0.05). LAMS was successfully replaced across the cystgastrostomy tract during all sessions (n=39). No stent migration was noted. There was no evidence of stent damage or tissue ingrowth. Our study demonstrates removal and replacement of LAMS during multiple endoscopic necrosectomies is feasible, safe, and facilitates DEN with reduction in procedure duration and number of sessions. Intentional removal of the stent should be considered when a large necrosectomy is done.

Efficacy and Safety of Lumen Apposing Self-Expandable Metal Stents for EUS Guided Cholecystostomy: A Meta-Analysis and Systematic Review.

Background Patients with acute cholecystitis are treated with early cholecystectomy. A subset of patients are unfit for surgery due to comorbidities and late presentation. Prompt gall bladder drainage (GBD) with percutaneous or endoscopic approach remains a viable therapeutic option for nonoperative candidates. Endoscopic ultrasound (EUS) guided transluminal gall bladder drainage (EUS-GBD) continues to evolve as an alternative approach to percutaneous drainage. With continued refinement in stent technology, lumen apposing self-expandable metal stent (LAMS) offers several advantages. We performed a pooled analysis on the efficacy and safety of EUS-GBD with LAMS in nonoperative candidates with acute cholecystitis. Methods Extensive English language literature search was performed in Medline, Embase, Cochrane Central, and Google Scholar using keywords “endoscopic ultrasound”, “stent”, “gallbladder”, “acute cholecystitis”, and “cholecystostomy” from Jan 2000 to Dec 2016. Fixed and random effects models were used to calculate the pooled proportions. Results Data was extracted from 13 studies that met the inclusion criteria (n = 233). Pooled proportion of technical success was 93.86% (95% CI = 90.56 to 96.49) and clinical success was 92.48% (95% CI = 88.9 to 95.42). Overall complication rate was 18.31% (95% CI = 13.49 to 23.68) and stent related complication rate was 8.16% (95% CI = 4.03 to 14.96) in the pooled percentage of patients. Pooled proportion for perforation was 6.71% (95% CI 3.65 to 10.6) and recurrent cholangitis/cholecystitis was noted in 4.05% (95% CI = 1.64 to 7.48). Publication bias calculated using Harbord-Egger bias indicator gave a value of −0.61 (95% CI = −1.39 to 0.16, p = 0.11). The Begg-Mazumdar indicator for bias gave Kendall's tau b value of −0.42 (p ≥ 0.05). Conclusions EUS-GBD with LAMS is a safe and alternative treatment modality for patients needing gallbladder drainage, with acceptable intraprocedural and postprocedural complications. However, due to the limited data and lack of direct comparison with other methods, further controlled trials are necessary to estimate the overall efficacy and safety and the role of EUS-GBD with LAMS in management of nonoperative patients with acute cholecystitis.

The Use of Fully Covered Lumen-Apposing Self-expandable Metallic Stents for Treatment of Benign Strictures of the Upper Gastrointestinal Tract: A Retrospective Case-Controlled Study

Introduction: The AXIOSTM stent (Boston Scientific, Massachusetts, USA) is a fully covered lumen apposing self-expandable metallic stent (fcLASEMS). The stent was developed for transenteric drainage of pancreatic pseudocysts. The dumbbell shaped stent is available in lengths of 10mm or 15mm and can be deployed with or without electrocautery. The aim of this study was to examine the efficacy of fcLASEMSs in the treatment of benign stricture disease of the foregut. Methods: A single center retrospective database of patients who underwent endoscopic treatment of benign strictures was analyzed for this study. A total of 998 endoscopic procedures were identified on these patients between January 2014 and May 2017. Of those, 15 patients underwent endoscopic fcLASEMS placement. The average number of endoscopic dilations prior to stent placement was 2.46. A control group of non-stented patients that underwent 3 or more endoscopic dilations with Savary dilators or controlled radial expansion balloon dilators (n=36) was created. The Mann-Whitney test and twotailed-t test were used to compare the total number of endoscopic interventions between the control and fcLASEMS groups. The patient and stricture characteristics were determined based on review of follow up documentation. Complications were defined as events leading to hospitalization or requiring early removal of the stent. Results: The mean number of endoscopic dilations in the control group was 5.02 (SD 3.873). Whereas the mean number of endoscopic interventions in the fcLASEMS group was 3.385 (SD 0.870). The difference between the 2 groups was statistically significant (t-test (P < 0.0001) and Mann-Whitney test (P=0.017)). The mean duration of fcLASEMS placement was approximately 105 days. fcLASEMS placement provided symptomatic relief in 73% of patients. Stent migration and post procedure complications occurred in 6.6% and 20% of patients respectively. The mean length of follow up for the fcLASEMS and control group was 282 and 225 days respectively. Conclusion: Clinicians should consider the use of fcLASEMSs in patients with recurrently symptomatic benign foregut strictures. Early intervention with an fcLASEMS appears to be a viable option for durable symptomatic relief in patients with persistent benign foregut strictures. The overall number of endoscopic interventions was lower with the use of fcLASEMSs than with standalone serial dilations in patients who required 3 or more endoscopic dilations which may be more cost effective.Table: Table. Results of Fully Covered Lumen-Apposing Self-Expandable Metallic Stents for the Treatment of Benign Strictures of the Upper Gastrointestinal Tract

Endoscopic jejunojejunostomy by use of a lumen-apposing self-expandable metal stent for treatment of obstructed efferent loop after subtotal gastrectomy with Roux-en-Y-reconstruction

Endoscopic jejunojejunostomy by use of a lumen-apposing self-expandable metal stent for treatment of obstructed efferent loop after subtotal gastrectomy with Roux-en-Y-reconstruction

G-Tube Guided Endoscopic Retrograde Cholangiopancreatography; A Lifesaving Procedure

Introduction: Acute cholangitis is a consequence of obstruction and infection of the biliary tract. Endoscopic retrograde cholangiopancreatography (ERCP) is key in the management of choice as acute cholangitis as stone extraction and/or stent insertion establishes biliary drainage and relief of infection. Anatomical variation following Roux-en-Y gastric bypass surgery or patients with esophageal obstructions like in our case are prone to make the early intervention by ERCP a challenge . We describe a case report of septic cholangitis in a patient whom gastrostomy tube (G-tube) access allowed the performance of successful ERCP which was otherwise impossible. Case report: 75-year-old male with multiple comorbidities and esophageal cancer status post G-tube placement for malnutrition who presented with cholangitis. On admission, the patient had fever, nausea and decrease in level of activity. His initial evaluation showed that the patient had a sepsis with a fever of 99.6, leukopenia with WBC of 2.0, elevation in the liver enzymes with alkaline phosphatase of 238, alanine aminotransferase of 48, total bilirubin 1.2 and lactic acid of 3.2. His infectious workup included blood cultures that grew Enterobacter cloacae. His CT scan showed stone in the common bile duct. MRCP demonstrated a 1.3 cm obstructive distal common bile duct stone with extrahepatic and intrahepatic biliary dilatation. ERCP was unsuccessful due to a partially obstructing esophageal mass. After changing to a small pediatric endoscope, the scope was able to be passing the mass and a showed a good visualization of the ampulla but therapeutic intervention was not successful. Patient was brought back for a second attempt using his G-tube. A wire was passed under fluoroscopy adjacent to the G-tube then the G-tube was removed. Then a stent anchoring system was used with 3 anchors being placed. Subsequently, an axios stent (lumen-apposing self-expandable metallic stent) was placed under combined direct vision and fluoro. The stent was then sutured down in order to prevent migration. Following placemen of the stent balloon dilatation was performed inside the stent up to 15 mm in size. Following dilatation over a jag wire the ERCP scope was passed through the stent and used to cannulate the ampulla. A sphincterotomy was performed and the stone was removed with a balloon catheter. Following completion of the stone removal the Axios stent was then removed and a G-tube was replaced and confirmed with contrast for position. The patient tolerated the procedure without any complication, his bilirubin normalized and the patient discharged in stable condition the next day on a total course of 14 days of antibiotics. Conclusion: In cholangitis patient with limited access, G-tube sites provide a useful access value to examine the gastrointestinal track for therapeutic intervention.

Novel Lumen-Apposing Metal Stent for Treatment of a Benign Refractory Stricture from Prior Vertical Banded Gastroplasty

A 67 year old male with prior vertical banded gastroplasty (VBG) presented with recurrent dysphagia due to development of a gastrogastric narrowing at the distal end of the gastric pouch. The narrowing and related symptoms continued to persist despite multiple trials of endoscopic balloon dilatation (EBD). The patient then underwent needle knife stricturoplasty followed by placement of a 14 mm x 10 mm esophageal stent (Alimaxx-ESTM; Merit Medical Endotek, South Jordan, Utah, USA) under endoscopic and fluoroscopic guidance to prevent the complication of bleeding. Three weeks after stricturoplasty and stent placement, the stent was removed, and it was noted that the gastric band from prior VBG had eroded through the area and remained intact in its circular orientation. This band was successfully removed with rat tooth forceps. Five weeks after removal of the gastric band, a stricture 2 mm in diameter was found at the gastrogastric anastomosis. The decision was made to use a lumen-apposing self-expandable metal stent (LAMS) for treatment of the stricture. A through-the-scope (TTS) balloon was utilized for dilation of the stricture to 8 mm. Under endoscopic and fluoroscopic guidance, a 10 mm x 10 mm LAMS (AXIOSTM Stent, Boston Scientific, Marlborough, Massachusetts, USA) was placed across the stricture with good position. At 11-week follow-up, patient was asymptomatic, and the stented area was fully patent with no evidence of migration, erosion or restenosis. At 22 weeks patient continues to do clinically well without dysphagia. Given his clinical improvement and condition of the stent, the decision was made to have the stent remain with serial endoscopic surveillance. The use of LAMS for treatment of refractory benign strictures may serve as a safe and definitive alternative treatment to EBD. Furthermore, the risk of migration, which has been associated with use of traditional fully-covered self-expanding metal stents, is potentially lower with LAMS. Further long term outcome studies with these stents used in benign strictures are warranted.Figure 1Figure 2

Novel Lumen-Apposing Metal Stent for Treatment of a Benign Gastric Stricture after Caustic Injury

A 69 year old female developed extensive mucosal injury (Zargar Grade 2b) of her esophagus and stomach caused by accidental ingestion of a caustic alkali substance. Eight days after injury, EGD showed esophageal fibrosis with a stricture in the mid-esophagus, diffuse erythema of the stomach and a large ulcer encompassing a large portion of the antrum. The patient underwent a percutaneous endoscopic gastrostomy (PEG) with a 16 French PEG tube confirmed to be 5 cm away from the ulcer. Two weeks after PEG tube placement, the patient reported persistent sialorrhea. Endoscopy revealed worsening of the esophageal stricture and via fluoroscopy, the total length was determined to be 10 cm, with a diameter of 3 mm in the narrowest segment. The patient underwent multiple through-the-scope (TTS) guidewire-assisted endoscopic balloon dilations (EBD) of this esophageal stricture. She then began to have intractable nausea and vomiting after each bolus of tube feeds, and serial measurements of gastric residual volume (GRV) were increasingly elevated. Repeat endoscopy showed a tight prepyloric stricture secondary to the healing antral ulcer, and the PEG tube was replaced with a 16 French PEG tube with jejunal extension (PEG-J). Eleven days after placement, due to retrograde migration of the J-tube, the PEG-J tube was removed. The decision was made to place a novel lumen-apposing self-expandable metal stent (LAMS). A guidewire was inserted into the stomach through the existing gastrostomy tract and was advanced beyond the prepyloric stricture. A 10 mm x 10 mm LAMS (AXIOSTM Stent, Boston Scientific, Marlborough, Massachusetts, USA) was advanced over the guidewire and positioned across the prepyloric stricture with endoscopic and fluoroscopic guidance. This was followed by placement of a 16 French PEG tube into the stomach via the existing gastrostomy tract. During the 12 weeks after stent placement, the area remained patent with no evidence of migration or erosion, and the patient has been able to tolerate tube feedings well with appropriate weight gain. The use of LAMS for treatment of benign strictures can serve as a safe alternative treatment to EBD. Furthermore, the risk of migration, which has been associated with use of traditional fully-covered self-expandable metal stents is potentially lower with LAMS.Figure 1Figure 2

Endoscopic ultrasound-guided placement of AXIOS stent for drainage of pancreatic fluid collections.

Pancreatic fluid collections (PFCs) have conventionally been treated with surgery, percutaneous drainage, or with the more recently established endoscopic ultrasound (EUS)-guided drainage modality. Currently, endoscopic plastic or metallic stents are used for PFC drainage. Plastic stents present issues with stent migration and premature occlusion requiring frequent stent exchanges or placement of additional stents. Metallic stents are tubular and may migrate, resulting in inefficient drainage, content leakage, retrieval and replacement, and possible mucosal injury. The aim of this review was to summarize and evaluate the clinical and technical effectiveness of EUS-guided placement of the recently developed AXIOS stent, a lumen-apposing self-expandable metallic stent (LASEMS)for PFC drainage. A literature review was performed to identify the studies describing this technique. In this review article we have summarized case series or reports describing EUS-guided LASEMS placement. The indications, techniques, limitations and complications reported are discussed. A total of 298 patients were included across all studies described thus far in the literature. Overall, a 97% technical success rate and a 96% clinical success rate have been reported. Early and late complications related to the placement or removal of LASEMS have been reported, however few cases have presented life-threatening results. EUS-guided PFC drainage and LASEMS placement can be a safe and effective alternative approach in the management of selected patients.

Endoscopic ultrasound-guided placement of the lumen-apposing self-expandable metallic stent for gallbladder drainage: a promising technique.

Acute cholecystitis and other clinical problems requiring gallbladder removal or drainage have conventionally been treated with surgery, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic drainage of the gallbladder and/or extrahepatic bile duct. Patients unable to undergo these procedures due to functional status or anatomical anomalies are candidates for endoscopic ultrasound (EUS)-guided gallbladder drainage with stent placement. The aim of this review was to evaluate the technical feasibility and efficacy of EUS-guided placement of the recently developed lumen-apposing self-expandable metallic stent (LASEMS). A literature review was performed to identify the studies describing this technique. In this review article we have summarized case series or reports describing EUS-guided LASEMS placement. The indications, techniques, limitations and complications reported are discussed. A total of 78 patients were included across all studies described thus far in the literature. Studies have reported near 100% technical and clinical success rates in selected cases. No major complications were reported. EUS-guided gallbladder drainage and LASEMS placement can be a safe and effective alternative approach in the management of selected patients.

Endoscopic ultrasound-guided gastroenterostomy using a lumen-apposing self-expanding metal stent for decompression of afferent loop obstruction.

Acute afferent loop syndrome following pancreaticoduodenostomy is generally caused by mechanical occlusion due to pancreatic cancer recurrence. Historically, it has been treated with palliative surgical bypass [1–5]. A retrograde endoscopic approach with placement of an enteral metal stent across the afferent limb stricture is often not possible [2]. We report the first case series of endoscopic ultrasound (EUS)-guided gastrojejunostomy using a lumen-apposing, self-expanding, metal stent (LASEMS) for therapy of acute afferent loop syndrome. Three patients who had previously undergone a pancreaticoduodenostomy for pancreatic cancer presented with acute abdominal pain and vomiting. Computed tomography revealed dilation of the afferent loop caused by bowel obstruction due to cancer recurrence (● Fig.1). All three patients underwent successful EUS-guided gastroenterostomy using LASEMS. The dilated afferent limb was located endosonographically by an echoendoscope in the stomach. The obstructed afferent limb was then punctured using a 19-gauge EUS needle. Contrast was injected through the 19-gauge needle into the dilated afferent limb to confirm the position, and a 0.035-inch guidewire was introduced through the needle and coiled into the obstructed afferent limb. Needle-knife cautery was used to make an incision into the fistula tract, and then a 6-mm balloon was used to dilate the tract (● Fig.2,● Video 1). A 15mm×10mm LASEMS (Axios; Boston Scientific Corp., Marlborough, Massachusetts, USA) was then deployed under fluoroscopic guidance across the tract, resulting in apposition between the dilated afferent limb and the stomach wall. A 15-mm balloon was then used to dilate the tract within the lumen of the LASEMS to create an endoscopic gastrojejunostomy for drainage of the obstructed afferent limb (● Fig.3,● Video 1). All three patients had resolution of clinical symptoms (● Fig.4) and were discharged. This series demonstrates that EUS-guided gastroenterostomy involving LASEMS placement offers a safe, technically feasible, and clinically successful endoscopic method of management for acute afferent loop obstruction.

Pancreatic endotherapy and necrosectomy.

There has been a paradigm shift in the management of pancreatic necrosis from open surgical debridement of infected necrosis to minimally invasive interventional radiologic, laparoscopic, and endoscopic drainage/debridement techniques. A step-up approach from less invasive to the more invasive modalities is recommended. An important distinction to make is between pseudocysts and walled-off necrosis (WON), as the interventions for each are different. Endoscopic or other interventions should be delayed for at least 4weeks for collections to encapsulate. Direct endoscopic necrosectomy (DEN) is an effective, minimally invasive option. Several variations in the technique, including the use of esophageal fully covered self-expanding metal stents (SEMS) and lumen-apposing SEMS have recently been described. The incremental effectiveness of these stents over conventional techniques needs to be studied. Dual-modality drainage with endoscopic transmural stent placement and lavage through percutaneous drains is also an effective option with low mortality and morbidity. Several minimally invasive surgical options, including video-assisted retroperitoneal debridement and sinus tract endoscopy are available and may be preferable to open surgical necrosectomy. An algorithmic, multidisciplinary management is warranted for successful outcomes. Disconnected pancreatic duct syndrome in the setting of necrotizing pancreatitis is challenging; long-term endoscopic transmural stent placement and/or distal pancreatectomy are potential treatment options.

Endoscopic ultrasonography‐guided cholecystogastrostomy using a lumen‐apposing metal stent as an alternative to extrahepatic bile duct drainage in pancreatic cancer with duodenal invasion

Various approaches to biliary drainage, especially endoscopic ultrasonography (EUS)-guided drainage, have become commonly used as an alternative method for biliary decompression for malignant biliary obstruction. Occasionally, however, duodenal obstruction and non-dilated intrahepatic bile duct impede conventional EUS-guided biliary drainage. Herein, we describe a case of cholecystogastrostomy successfully carried out using a newly developed fully covered lumen-apposing self-expandable metallic stent (SEMS). EUS-guided cholecystogastrostomy should be considered an option for biliary decompression. This is a particularly ideal alternative if the patient has duodenal strictures with or without a duodenal metal stent and a non-dilated intrahepatic bile duct, which suggests the impossibility of choledochoduodenostomy and hepaticogastrostomy. Furthermore, the newly developed fully covered lumen-apposing SEMS seems ideal for EUS-guided cholecystoenterostomy.