Alternative uses of lumen apposing metal stents

Table 1 Clinical pearls when performing procedures with lumen apposing metal stent

Type of procedure	Summary of keys to success
Pancreatic fluid collection and walled-off necrosis	Transgastric approach is typically recommended
	Ensure collection is within one cm of the gastric wall
	May be less effective for large collections extending into the paracolic gutters
EUS-guided gallbladder drainage	Ensure the echoendoscope is advanced into the gastric antrum or duodenal bulb
	Transgastric or transduodenal approach is recommended (transgastric preferred)
	Freehand placement or over a wire after fine needle injection and dilation of tract
EUS-guided choledochoduodenostomy	Use of a pigtail stent through LAMS to decrease risk of sump syndrome
	Reserve LAMS use for optimal candidates for traditional metal stent placement
Gastric access temporary for endoscopy	Avoid penetration of the diaphragm to minimize patient discomfort
	Avoidance of gastric staple line to reduce risk of persistent gastro-gastric fistula
	Consider gastro-gastric fistula to decrease risk of LAMS dislodgement
EUS-guided gastroenterostomy	Prone/swimmer’s positioning prior to beginning procedure
	Distention of the bowel with dilute contrast and sterile water
	Use of glucagon to decrease motility of the bowel
	Placement of a wire may push small bowel away from the stomach
Benign gastrointestinal strictures	First traverse entire length of stricture (if possible)
	Use of a guidewire is also important to prevent trauma
Post-surgical fluid collections	Favorable collection locations include adjacent to stomach, duodenum, or rectum

EUS: Endoscopic ultrasound; LAMS: Lumen apposing metal stent.