Systematic Reviews
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 7, 2023; 29(21): 3341-3361
Published online Jun 7, 2023. doi: 10.3748/wjg.v29.i21.3341
Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: A systematic review focusing on issues and rescue management
Elia Armellini, Flavio Metelli, Andrea Anderloni, Anna Cominardi, Giovanni Aragona, Michele Marini, Fabio Pace
Elia Armellini, Flavio Metelli, Fabio Pace, Department of Gastroenterology, ASST-Bergamoest, Seriate 24068, Bergamo, Italy
Andrea Anderloni, Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia 27100, Italy
Anna Cominardi, Giovanni Aragona, Department of Gastroenterology, “Guglielmo da Saliceto” Hospital, Piacenza 29121, Italy
Michele Marini, Department of General Surgery, ASST-Bergamoest, Seriate 24068, Italy
Author contributions: Armellini E contributed to the concept, design, drafting of the article, and approved final revision; Metelli F and Marini M involved in the acquisition, statistical analysis, or interpretation of data for biliary duct and pancreatic fluid collection section, and contribution to drafting the article; Cominardi A and Aragona G contributed to the acquisition and statistical analysis, or interpretation of data for gallbladder section; Anderloni A and Pace F revised the manuscript critically for intellectual content; and all the authors approved the version to be published.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article. Andrea Anderloni is consultant for BSCI, Olympus.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Elia Armellini, MD, Department of Gastroenterology, ASST-Bergamoest, Via Paderno 21, Seriate 24068, Bergamo, Italy.
Received: December 29, 2022
Peer-review started: January 1, 2023
First decision: January 10, 2023
Revised: February 1, 2023
Accepted: May 6, 2023
Article in press: May 6, 2023
Published online: June 7, 2023

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.

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

Core Tip: Scant data are available about rescue techniques in cases of lumen-apposing metal stents (LAMS) misdeployment which is the main cause of technical failure in endoscopic ultrasound-guided drainage procedures. We performed a systematic review of the literature about LAMS misdeployment and rescue techniques in the biliopancreatic setting, focusing on technical aspects and success rate of endoscopic maneuvers. In accordance with our results endoscopic rescue techniques are feasible in most cases (up to 96.8%). Three endoscopic rescue strategies have been identified. The choice of the endoscopic rescue maneuver is based on the clinical scenario, type of misdeployment and expertise of the endoscopic team.