Safety and rate of delayed adverse events with lumen-apposing metal stents (LAMS) for pancreatic fluid collections: a multicenter study

 

 Permissions and Reprints

Abstract

Background and study aims Endoscopic drainage with dedicated lumen-apposing metal stents (LAMS) is routinely performed for symptomatic pancreatic fluid collections (PFCs), walled-off necrosis (WON) and pseudocyst (PP). There has been increasing concern regarding delayed adverse events associated with the indwelling LAMS. 

Patients and methods Multicenter retrospective analysis of consecutive patients who underwent endoscopic ultrasound (EUS)-guided LAMS placement for PFC from January 2010 to May 2017. Main outcomes included: (1) resolution of the PFC, (2) rate of delayed adverse events at follow-up, and (3) predictors of treatment failure and delayed adverse events on logistic regression.

Results A total of 122 patients (mean age 50.9 years, 68 % male) underwent LAMS insertion for 64 WON (98.4 %) and 58 PP (98.3 %). PFC mean size was 10.6 cm. PFC resolution was significantly lower for WON (62.3 %) vs. PP (96.5 %) (P < 0.001) on imaging at a median of 4 weeks. Stent occlusion was identified in 18 (29.5 %) and 10 (17.5 %) patients with WON and PP, respectively (P = 0.13). There were no cases of delayed bleeding or buried stent on follow-up endoscopy. Use of electrocautery-enhanced LAMS was the only factor associated with treatment failure of WON (OR = 13.2; 95 % ci: 3.33 – 51.82, P = 0.02) on logistic regression. There were no patient, operator, or procedure-related factors predictive of stent occlusion.

Conclusions EUS-guided LAMS for PFC is associated with a low incidence of delayed adverse events. While nearly all PPs resolve at 4 weeks permitting LAMS removal shortly thereafter, many WON persist, with use of electrocautery-enhanced LAMS being the sole predictor of treatment failure.

• References

• 1 Varadarajulu S, Bang JY, Sutton BS. et al. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology 2013; 145: 583-590
  CrossrefPubMedGoogle Scholar
• 2 Van Brunschot S, van Grinsven J, van Santvoort HC. et al. Endoscopic or surgical step-up approach for infected necrotizing pancreatitis: a multicentre randomized trial. Lancet 2018; 39: 51-58
  CrossrefPubMedGoogle Scholar
• 3 Yang D, Draganov PV. EUS-Guided transmural drainage of pancreatic fluid collections: keeping it close. Pancreat Disord Ther 2016; 6: e144
  CrossrefPubMedGoogle Scholar
• 4 Shah RJ, Shah JN, Waxman I. et al. Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered self-expanding metal stent. Clin Gastroenterol Hepatol 2015; 13: 747-752
  CrossrefPubMedGoogle Scholar
• 5 Siddiqui AA, Adler DG, Niejo J. et al. EUS-guided drainage of peripancreatic fluid collections and necrosis using a novel lumen-apposing stent: a large retrospective multicenter U.S. experience (with videos). Gastrointest Endosc 2016; 83: 699-707
  CrossrefPubMedGoogle Scholar
• 6 Sharaiha RZ, Tyberg A, Khashab MA. et al. endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol 2016; 14: 1797-1803
  CrossrefPubMedGoogle Scholar
• 7 Siddiqui AA, Kowalski TE, Loren DE. et al. Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc 2017; 85: 758-765
  CrossrefPubMedGoogle Scholar
• 8 Fabbri C, Luigiano C, Marsico M. et al. A rare adverse even resulting from the use of a lumen-apposing metal stent for drainage of a pancreatic fluid collection: “the buried stent”. Gastrointest Endosc 2015; 82: 585-587
  CrossrefPubMedGoogle Scholar
• 9 Seerden TC, Vleggaar FP. Endoscopic removal of buried lumen-apposing metal stents used for cystogastrostomy and cholecystogastrostomy. Endoscopy 2016; 48 (Suppl. 01) E179
  Article in Thieme ConnectPubMedGoogle Scholar
• 10 Altonbary AY, Hakim H. The buried stent: a rare complication of endoscopic ultrasound-guided pancreatic necrosectomy using a lumen-apposing metal stent. Endoscopy 2017; 49: E84-E85
  Article in Thieme ConnectPubMedGoogle Scholar
• 11 Sanchez-Ocana R, Peňas-Herrero I, Santons-Santamarta F. et al. EUS-guided removal of a buried lumen-apposing metal stent caused by delayed inward migration after cyst-gastrostomy. Gastrointest Endosc 2017; 86: 229
  CrossrefPubMedGoogle Scholar
• 12 Brimhall BB, Han S, Tatman PD. et al. Lumen apposing metal stents compared with double pigtail plastic stents in the management of pancreatic pseudocysts and walled-off necrosis: a 5 year single center study. Gastrointest Endosc 2017; 85: AB90
  CrossrefPubMedGoogle Scholar
• 13 Bang JY, Hasan M, Navaneethan U. et al. Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual. Gut 2016; 66: 2054-2056
  CrossrefPubMedGoogle Scholar
• 14 ASGE Standards ofPractice Committee, Khashab MA, Chithadi KV. et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015; 81: 81-89
  CrossrefPubMedGoogle Scholar
• 15 Anderson MA, Ben-Menachem T, Gan SI. et al. ASGE Standards of Practice Committee. management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070
  CrossrefPubMedGoogle Scholar
• 16 Banks PA, Bollen TL, Dervenis C. et al. Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2012; 62: 102-111
  CrossrefPubMedGoogle Scholar
• 17 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 450-454
  CrossrefPubMedGoogle Scholar
• 18 Penn DE, Draganov PV, Wagh MS. et al. prospective evaluation of the use of fully covered self-expanding metal stents of EUS-guided transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 2012; 76: 679-684
  CrossrefPubMedGoogle Scholar
• 19 Siddiqui A, Li Z, Kowalski TE. et al. Computed tomography or magnetic resonance imaging characteristics of pancreatic walled-off necrosis accurately predicts the clinical outcomes of endoscopic transmural drainage using lumen-apposing fully covered self-expanding metal stents: a multicenter experience. Gastrointest Endosc 2017; 85: AB216
  CrossrefPubMedGoogle Scholar
• 20 Aburajab M, Smith Z, Khan A. Safety and efficacy of lumen-apposing metal stents with and without simultaneous double-pigtail plastic stents for draining pancreatic pseudocysts. Gastrointest Endosc 2018; 87: 1248-1255
  CrossrefPubMedGoogle Scholar
• 21 Rana SS, Sharma V, Sharma R. et al. Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a “step-up” approach: a single center experience. Pancreatology 2017; 17: 203-208
  CrossrefPubMedGoogle Scholar
• 22 Cosgrove N, Loren DE, Siddiqui AA. et al. Effect of scheduled vs. “step up” necrosectomy for walled-off pancreatic necrosis on hospital admission and necrosis resolution. Gastrointest Endosc 2017; 85: AB101
  CrossrefPubMedGoogle Scholar
• 23 Lakhatakia S, Basha J, Talukdar R. et al. Endoscopic “step-up approach” using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos). Gastrointest Endosc 2016; 85: 1243-1252
  CrossrefPubMedGoogle Scholar
• 24 Guo J, Saftoui A, Vilmann P. et al. A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy. Endosc Ultrasound 2017; 6: 285-291
  CrossrefPubMedGoogle Scholar