Published online Jun 7, 2023. doi: 10.3748/wjg.v29.i21.3341
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
Processing time: 153 Days and 23.5 Hours
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 (EUS)-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.
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.
The overall technical success rate of EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (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.
We conducted a systematic review of the literature on PubMed searching for studies published up to October 2022 about on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. 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”.
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, 5.8%, 3.4%, and 2.0%, respectively. 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.
Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. In accordance with our results endoscopic rescue techniques are feasible in most cases (up to 96.8%). Three endoscopic rescue strategies have been identified: Gaining wire access to the target through the created fistula and completing the procedure; placement of a new stent through the misdeployed LAMS to the target (“stent-in-stent”) and repeated drainage procedures (ex novo or rendezvous).
LAMS misdeployment is the main cause of technical failure of EUS-drainages and it is potentially harmful to the patient. Knowledge of risk factors, classification of misdeployment and of endoscopic rescue techniques is useful to improve patient outcome and the safety of the procedure. Further prospective studies describing these issues are expected.