• Humans
• Drainage/methods
• Drainage/instrumentation
• Drainage/adverse effects
• Stents/adverse effects
• Endosonography/methods
• Ultrasonography, Interventional
• Pancreatic Pseudocyst/surgery
• Metals
• Treatment Outcome

• Adverse events
• Endoscopic ultrasound
• Lumen-apposing metal stent

• Humans
• Male
• Middle Aged
• Female
• Retrospective Studies
• Aged
• Device Removal/methods
• Stents
• Drainage/methods
• Time Factors
• Metals
• Endosonography

• Humans
• Male
• Female
• Middle Aged
• Drainage/methods
• Drainage/instrumentation
• Stents/adverse effects
• Endosonography/methods
• Pancreatitis, Acute Necrotizing/surgery
• Pancreatitis, Acute Necrotizing/therapy
• Electrocoagulation/methods
• Electrocoagulation/adverse effects
• Electrocoagulation/instrumentation
• Plastics
• Adult
• Aged
• Treatment Outcome
• Metals
• Ultrasonography, Interventional

• J.H.M. SoonChunHyang University Research Fund

• Acute necrotizing pancreatitis
• Chronic
• Endosonography
• Fat necrosis, Pancreatic pseudocyst
• Pancreatitis
• Peripancreatic

• Cystic pancreatic lesions
• Endoscopic ultrasound
• Pancreatic fluid collection
• Pancreatic pseudocyst
• Pancreatitis

• Consensus
• Diagnosis and treatment
• Pancreatic pseudocyst
• Walled-off necrosis

• Biliary tract
• Dilation, injection, stenting
• Endoscopic ultrasonography
• Endoscopy Upper GI Tract
• Intervention EUS
• Performance and complications
• Portal hypertension and variceal bleeding
• Quality and logistical aspects

• CT
• EUS
• Lumen-apposing metal stents
• MRI
• Pancreatic walled-off necrosis

• Humans
• Drainage/methods
• Male
• Middle Aged
• Female
• Stents/adverse effects
• Retrospective Studies
• Pancreatitis, Acute Necrotizing/diagnostic imaging
• Pancreatitis, Acute Necrotizing/surgery
• Pancreatitis, Acute Necrotizing/pathology
• Adult
• Aged
• Endosonography/methods
• Treatment Outcome
• Tomography, X-Ray Computed/methods
• Magnetic Resonance Imaging/methods
• Aged, 80 and over
• Young Adult

• EUS drainage
• necrotizing pancreatitis
• walled-off necrosis

• Endoscopic ultrasound
• Lumen-apposing metal stents
• Meta-analysis
• Pancreatic fluid collections
• Self-expanding metal stents

• Humans
• Treatment Outcome
• Pancreatic Diseases/surgery
• Pancreatic Diseases/etiology
• Endosonography/methods
• Stents/adverse effects
• Drainage/methods
• Metals/adverse effects
• Ultrasonography, Interventional

• 2021YJ0198 Sichuan Province Science and Technology Support Program
• 2021XHNJ19 Sichuan Federation of Social Science Associations
• YYZX2020036 Chengdu University of Traditional Chinese Medicine

The introduction of lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings. Nevertheless, the procedure may conceal unexpected pitfalls. LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences. Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. To date, no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.

To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (EUS-PFC) and to describe the endoscopic rescue strategies adopted under the circumstance.

We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022. The search was carried out using the exploded medical subject heading terms “lumen apposing metal stent”, “LAMS”, “endoscopic ultrasound” and “choledochoduodenostomy” or “gallbladder” or “pancreatic fluid collections”. We included in the review on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. Only those publications reporting EUS-guided LAMS positioning were considered. The studies reporting a technical success rate of 100% and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment, while studies not reporting the causes of technical failure were excluded. Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques. The following data were collected from each study: Author, year of publication, study design, study population, clinical indication, technical success, reported number of misdeployment, stent type and size, flange misdeployed and type of rescue strategy.

The overall technical success rate of EUS-CDS, EUS-GBD and EUS-PFC was 93.7%, 96.1%, and 98.1% respectively. Significant rates of LAMS misdeployment have been reported for EUS-CDS, EUS-GBD and EUS-PFC drainage, respectively 5.8%, 3.4%, and 2.0%. Endoscopic rescue treatment was feasible in 86.8%, 80%, and 96.8% of cases. Non endoscopic rescue strategies were required only in 10.3%, 16% and 3.2% for EUS-CDS, EUS-GBD, and EUS-PFC. The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%, 8% and 64.5% and stent-in-stent in 23.5%, 60%, and 12.9%, respectively for EUS-CDS, EUS-GBD, and EUS-PFC. Further therapeutic option were endoscopic rendezvous in 11.8% of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1% of EUS-PFC.

LAMS misdeployment is a relatively common adverse event in EUS-guided drainages. There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario, anatomical characteristics, and local expertise. In this review, we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used, with the aim of providing useful data for endoscopists and to improve patient outcomes.

• Lams misdeployment
• Endoscopic ultrasound-guided drainage
• Lams maldeployment
• Biliary drainage
• Gallbladder drainage
• Pancreatic fluid collections
• Lumen-apposing metal stents

• Humans
• Treatment Outcome
• Endosonography/adverse effects
• Endosonography/methods
• Stents/adverse effects
• Pancreatic Diseases
• Ultrasonography, Interventional/adverse effects
• Ultrasonography, Interventional/methods
• Drainage/adverse effects
• Drainage/methods

• Humans
• Pancreatic Diseases/surgery
• Endoscopy
• Drainage/methods

Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.

• Endoscopic
• Drainage
• Necrosectomy
• Infected necrotizing pancreatitis
• Progress
• Challenge

• EUS
• Hot AXIOS system
• evaluation
• pancreatic fluid collection drainage

• Biliary strictures
• ERCP
• EUS
• Next-generation DNA sequencing
• cholangiocarcinoma
• cholangioscopy

• EUS
• LAMS
• adverse events
• guideline
• interventional EUS

• electro-cautery lumen apposing metal stents
• endoscopic ultrasound-guided biliary drainage
• endoscopic ultrasound-guided gastroenterostomy
• interventional endoscopic ultrasound
• pancreatic fluid collection

• Humans
• Middle Aged
• Aged
• Pancreatitis/etiology
• Pancreatitis/surgery
• Retrospective Studies
• Acute Disease
• Treatment Outcome
• Pancreatic Pseudocyst/diagnostic imaging
• Pancreatic Pseudocyst/surgery
• Pancreatic Pseudocyst/etiology
• Drainage/methods
• Necrosis/etiology
• Necrosis/surgery
• Ultrasonography, Interventional

• Cholecystitis
• Gastric outlet obstruction
• Obstructive jaundice
• Pseudocyst
• Stents
• Stricture

• Drainage
• pancreatic fluid collection
• pancreatitis
• stents
• walled-off necrosis (WON)

EUS-guided drainage of pancreatic fluid collections (PFCs) has been increasingly performed using lumen-apposing metal stents (LAMS). However, recent data have suggested higher adverse event rates with LAMS compared to double pigtail plastic stents (DPS) alone. To decrease risks, there has been anecdotal use of placing DPS through the LAMS. We aimed to determine whether the placement of DPS through cautery-enhanced LAMS at time of initial placement decreases adverse events or need for reintervention.

We performed a multicenter retrospective study between January 2015 and October 2017 examining patients who underwent EUS-guided drainage of pseudocysts (PP), walled-off necrosis (WON), and postsurgical fluid collection using a cautery enhanced LAMS with and without DPS.

There were 68 patients identified at 3 US tertiary referral centers: 44 PP (65%), 17 WON (25%), and 7 PFSC (10%). There were 35 patients with DPS placed through LAMS (Group 1) and 33 with LAMS alone (Group 2). Overall technical success was 100%, clinical success was 94%, and adverse events (bleeding, perforation, stent occlusion, and stent migration) occurred in 28% of patients. Subgroup analysis compared specific types of PFCs and occurrence of adverse events between each group with no significant difference detected in adverse event or reintervention rates.

This multicenter study of various types of PFCs requiring EUS-guided drainage demonstrates that deployment of DPS across cautery-enhanced LAMS at the time of initial drainage does not have a significant effect on clinical outcomes, adverse events, or need for reinterventions.

• endoscopic ultrasound
• lumen-apposing metal stents
• pancreatic fluid collections
• pancreatitis

• acute necrotizing pancreatitis
• endoscopic sequestrectomy

• Drainage
• Endosonography
• Humans
• Pancreas
• Pancreatic Diseases/surgery
• Plastics
• Stents
• Treatment Outcome

To compare fully covered bi-flanged metal stents (BFMS) and lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainage/debridement of pancreatic walled-off necrosis (WON).

Patients with WON managed by EUS-guided therapy were divided into those who underwent: 1) drainage using BFMS; and 2) drainage using LAMS and scheduled direct endoscopic necrosectomy (DEN). Clinical success (resolution of the WON), technical success (successful stent placement), and adverse events (AEs) were evaluated.

387 patients underwent WON endoscopic drainage, 205 using BFMS and 182 using LAMS. The clinical success in the BFMS or LAMS groups were similar (197 [96.1%] vs. 174 [95.6%]; P=0.81). Median number of procedures required for WON resolution was significantly lower in BFMS compared to LAMS (2 vs. 3, P<0.001). Technical success for stent placement was similar in BFMS and LAMS groups (203 [99%] vs. 180 [99%], P=0.90). Procedure-related AEs were similar in the BFMS and LAMS groups (19 [9.3%] vs. 20 [10.9%], P=0.61). Stent dysfunction with occluding debris was higher in the BFMS group compared to LAMS group (21 [10.2 %] vs. 11 [5.9%], P=0.04). The migration rate was higher in the BFMS group than in the LAMS group (15 [7.3%] vs. 3 [1.6%]; P<0.001). DEN was required in 23 [11.2%] patients in the BFMS group after lack of WON resolution by conservative means.

BFMS with a “step-up approach” and LAMS with scheduled DEN are both safe and effective for EUS-guided drainage/debridement of WON.

• Pancreatic walled off necrosis
• acute pancreatitis
• bi-flanged metal stents
• endosonography
• lumen-apposing metal stents

• endoscopic ultrasonography
• pancreatic fluid collection
• pancreatitis
• pediatric
• pediatric gastroenterologists

•

There is increasing use of endoscopic ultrasound-guided drainage stents.

Pancreatic fluid collections are a common complication of acute pancreatitis. They are classified as acute peripancreatic fluid collections and pancreatic pseudocysts. There has been an increase in the use of endoscopic ultrasound-guided drainage stents for management of these collections. As a result, complications such as stent migration are becoming more prevalent.

A 47-year-old male presented to the emergency department with upper abdominal pain, nausea and vomiting, and intermittent fevers. The patient had a known history of a pancreatic pseudocyst. He had undergone an endoscopic cyst-gastrostomy and placement of an AXIOS and Compass stents for drainage prior to the current presentation. The patient was investigated with a computed tomography (CT) scan that demonstrated acute pancreatitis, and migration of his AXIOS/Compass stent complex into the transverse colon. The patient was managed conservatively, and ultimately passed the stent through his bowel motions without issue. Follow up abdominal x-ray confirmed the passage of the stent.

Stent migration is a recognised complication of stent placement but is infrequently described for lumen-apposing metal stents like the AXIOS stent. The AXIOS stent has a dumbbell configuration designed to reduce the rate of migration compared to the original double-pigtail plastic stents. Despite this, stent migration still occurs, as in this case.

Complications of AXIOS stents can also include migration of the stent despite their specific design to prevent this. Conservative management is feasible rather than endoscopic retrieval and can be considered if there are no complicating features.

• AXIOS stent
• Case report
• Lumen-apposing metal stent
• Pancreatitis
• Pseudocyst

• EUS-guided drainage
• lumen-apposing metal stent
• solid debris
• walled-off necrosis

Fluoroscopy is often used during the endoscopic drainage of pancreatic-fluid collections (PFCs). An electrocautery-enhanced coaxial lumen-apposing, self-expanding metal stent (ELAMS) facilitates a single-step procedure and may avoid the need for fluoroscopy. This study compares the treatment outcomes using ELAMS with and without fluoroscopy.

Patients with PFCs who had cystogastrostomy from January 2014 to February 2017 were enrolled. Two groups were studied based on fluoroscopy use. Technical success was defined as uneventful insertion of ELAMS at time of procedure. Clinical success was defined as (i) clinical resolution of symptoms after the procedure and (ii) >75% reduction in cyst size on computed tomography 8 weeks after stent placement. Adverse events including bleeding, stent migration, and infection were recorded.

A total of 21 patients (13 males) had PFCs drainage with ELAMS in the study period. The mean age was 51.6 ± 14.2 years. Thirteen patients had walled-off necrosis while eight had a pancreatic pseudocyst. The mean size of the PFCs was 11.3 ± 3.3 cm. Fluoroscopy was used in seven cases (33%) and was associated with a longer procedure time compared to non-fluoroscopy (43.1 ± 10.4 vs 33.3 ± 10.5 min, P = 0.025). This association was independent of the size, location, or type of PFCs. Fluoroscopy had no effect on the technical success rates. In fluoroless procedures, the clinical resolution was 91% as compared to 71% in fluoroscopy procedures (P = 0.52) and the radiologic resolution was 57% as compared to 71% in fluoroscopy procedures (P = 0. 65). Three cases of stent migration/displacement occurred in the fluoroless procedures.

ELAMS may avoid the need for fluoroscopy during cystogastrostomy. Procedures without fluoroscopy were significantly shorter and fluoroscopy use had no impact on the technical or clinical success rates.

Endoscopic ultrasound (EUS)-guided interventions provide easy access to structures adjacent to the gastrointestinal tract, effectively targeting them for therapeutic purposes. They play an important role in the management of pancreatic fluid collections (PFC) and bile duct (BD) and pancreatic duct (PD) drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) or gallbladder (GB) drainage. Specially designed stents and delivery systems for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. In fact, EUS-guided drainage has emerged as the treatment of choice for the management of PFC, and recent innovations such as fully covered metal stents (including lumen-apposing metal stents) have improved outcomes in patients with walled-off necrosis. Similarly, EUS-guided BD and PD drainage with specially designed stents can be beneficial for patients with failed ERCP due to an inaccessible papilla, gastric outlet obstruction, or surgically altered anatomy. EUS-guided GB drainage is also performed using dedicated stents in patients with acute cholecystitis who are not fit for surgery. Although the field of dedicated stents for interventional EUS is rapidly advancing with increasing innovations, the debate on the most appropriate stent for EUS-guided drainage has resurfaced. Furthermore, some important questions remain unaddressed, such as which stent improves clinical outcomes and safety in EUS-guided drainage. Herein, the current status and problems of the available stents are reviewed, including the applicable indications, long-term clinical outcomes, comparison between each stent, and their future prospects.

• drainage
• endoscopic ultrasound
• intervention
• stents
• therapeutic

• Endoscopy
• Flexible gastrointestinal endoscopy
• Gastrointestinal endoscopy
• Gastroscopy

• Adverse Events
• Endoscopy
• Infection
• Prophylaxis

Endoscopic ultrasonography (EUS)-guided transmural drainage has been accepted as a modality of choice in peripancreatic fluid collection and acute cholecystitis. Each type of stent, including double-pigtail plastic stents, tubular self-expandable metal stents (SEMS), and lumen-apposing metal stents, for these procedure has its own advantages and disadvantages. To overcome their disadvantages, this animal study evaluated the feasibility of a newly designed twisted fully covered SEMS with spiral coiled ends. We performed the EUS-guided cholecystogastrostomy with a newly developed metal stent in eight mini pigs with surgically induced gallbladder distension. This novel stent is a twisted fully covered SEMS with spiral coiled ends, a diameter of 8 mm, and a length of 6 cm. The stent has been maintained for four to seven weeks after EUS-guided cholecystogastrostomy. The primary outcome was the technical success rate, and the secondary outcomes were adverse events, stent dysfunction, stent removability, and fistula formation. The stent was placed successfully between the gallbladder and the stomach in all cases without any adverse event. We observed neither stent migration nor dysfunction during the study period, and all the stents were removed easily as scheduled. We confirmed successful cholecysto-gastric fistula formation at endoscopic and histologic level in all cases. EUS-guided transmural drainage and fistula formation using a new twisted fully covered metal stent with spiral coiled ends was technically feasible without any adverse event in this animal study. Further clinical studies are needed to evaluate its efficacy and safety in real practice.

The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.

• Lumen apposing metal stents
• Walled off necrosis
• Gallbladder drainage
• Biliary drainage
• Gastric access temporary for endoscopy
• Gastric outlet obstruction
• Therapeutic endoscopy

• Drainage/instrumentation
• Drainage/methods
• Endoscopy/instrumentation
• Endoscopy/methods
• Endosonography
• Fluoroscopy
• Gastrointestinal Diseases/therapy
• Humans
• Stents