Role of endoscopic-ultrasound-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction

In this editorial,we discuss the article by Peng et al in the recent issue of the World Journal of Gastrointestinal Surgery,focusing on the evolving role of endoscopicultrasound-guided biliary drainage(EUS-BD)with electrocautery lumen apposing metal stent(LAMS)for distal malignant biliary obstruction.Therapeutic endoscopy has rapidly advanced in decompression techniques,with growing evidence of its safety and efficacy surpassing percutaneous and surgical approaches.While endoscopic retrograde cholangiopancreatography(ERCP)has been the gold standard for biliary decompression,its failure rate approaches 10.0%,prompting the exploration of alternatives like EUS-BD.This random-effects meta-analysis demonstrated high technical and clinical success of over 90.0% and an adverse event rate of 17.5%,mainly in the form of stent dysfunction.Outcomes based on stent size were not reported but the majority used 6 mm and 8 mm stents.As the body of literature continues to demonstrate the effectiveness of this technique,the challenges of stent dysfunction need to be addressed in future studies.One strategy that has shown promise is placement of double-pigtail stents,only 18% received the prophylactic intervention in this study.We expect this to improve with time as the technique continues to be refined and standardized.The results above establish EUS-BD with LAMS as a reliable alternative after failed ERCP and considering EUS to ERCP upfront in the same session is an effective strategy.Given the promising results,studies must explore the role of EUS-BD as first-line therapy for biliary decompression.

Alternative uses of lumen apposing metal stents

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 for pancreatic fluid collections:Recognition and management of complications

For patients recovering from acute pancreatitis,the development of a pancreatic fluid collection (PFC) predicts a more complex course of recovery,and introduces difficult management decisions with regard to when,whether,and how the collection should be drained.Most PFCs resolve spontaneously and drainage is indicated only in pseudocysts and walled-off pancreatic necrosis when the collections are causing symptoms and/or local complications such as biliary obstruction.Historical approaches to PFC drainage have included surgical (open or laparoscopic cystgastrostomy or pancreatic debridement),and the placement of percutaneous drains.Endoscopic drainage techniques have emerged in the last several years as the preferred approach for most patients,when local expertise is available.Lumen-apposing metal stents(LAMS) have recently been developed as a tool to facilitate potentially safer and easier endoscopic drainage of pancreatic fluid collections,and less commonly,for other indications,such as gallbladder drainage.Physicians considering LAMS placement must be aware of the complications most commonly associated with LAMS including bleeding,migration,buried stent,stent occlusion,and perforation.Because of the patient complexity associated with severe pancreatitis,management of pancreatic fluid collections can be a complex and multidisciplinary endeavor.Successful and safe use of LAMS for patients with pancreatic fluid collections requires that the endoscopist have a full understanding of the potential complications of LAMS techniques,including how to recognize and manage expected complications.

Off label use of lumen-apposing metal stent for persistent gastro-jejunal anastomotic stricture

We are reporting a novel "off-label" use of lumen apposing metal stent(LAMS) for management of refractory gastro-jejunal(GJ) anastomotic stricture after Roux-en-y gastric bypass(RYGB). With increasing prevalence of obesity, bariatric surgery is performed more frequently than ever. RYGB is one of the most commonly performed bariatric procedures. GJ anastomotic stricture is a late complication of this procedure. Our patient, seven years after RYGB developed GJ anastomotic ulcer and subsequently a stricture not amendable to repeated pneumatic dilations. Instead of using the conventional fully covered self-expanding metal stent(fc SEMS) we deployed the relatively new LAMS keeping in mind its novel dumbbell shaped design. Our patient's symptoms were controlled successfully and she remained asymptomatic on follow-up. Despite initial approval for pancreatic pseudocyst drainage, LAMS has been used with increased frequency at various locations within gastrointestinal tract including GJ anastomotic strictures. Future randomized control trials are warranted to compare the efficacy of fcSEMS to LAMS.

Endoscopic ultrasound-guided pancreatic fluid collection drainage: Where are we?

Pancreatic fluid collections(PFCs)result from injury to the pancreas from acute or chronic pancreatitis,surgery,or trauma.Management of these collections has evolved over the last 2 decades.The choice of interventions includes percu-taneous,endoscopic,minimally invasive surgery,or a combined approach.Endoscopic drainage is the drainage of PFCs by creating an artificial communication between the collection and gastrointestinal lumen that is maintained by placing a stent across the fistulous tract.In this editorial,we endeavored to update the current status of endoscopic ultrasound-guided drainage of PFCs.

Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE in patients with GOO.METHODS This study was a retrospective,observational,multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected.We analyzed technical success,clinical success,adverse events,and survival.Technical success was defined as adequate positioning and deployment of the stent.Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure.Postprocedural adverse events were recorded.RESULTS Eleven procedures in 10 patients with GOO were included.The mean age of the patients was 67.5 years(range:56-77 years).Malignant GOO was present in 9 patients.Technical success was achieved in 9/11 procedures(82%).Among them,clinical success was achieved in 9 patients(100%).Adverse events occurred in 1 patient(9%).The median survival was 3 months(n=7;range:1-8 months).CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.

Endoscopic ultrasonography drainage and debridement of an infected subcapsular hepatic hematoma:A case report

BACKGROUND Endoscopic ultrasonography(EUS)has evolved in the last years making it not only a diagnostic modality but a therapeutic procedure.EUS is now used as an alternative technique to percutaneous and surgical drainage.Even though EUS is a challenging procedure and not always suitable compared to percutaneous drainage,there is a need for developing new therapeutic approaches to the liver for when percutaneous drainage is not feasible.CASE SUMMARY We present the case of a 82 years old male who developed an infected subcapsular hepatic hematoma(SHH)of the left lobe following percutaneous biliary drainage.After 2 failed attempts of percutaneous drainage of the SHH and because the patients couldn’t withstand surgery,we conducted a EUS drainage and debridement of the SHH.Using a lumen apposing metal stent(LAMS)by a transgastric approach,we were able to gain endoscopic access to the SHH.With our experience in the debridement of walled off pancreatic necrosis using this technique,we were confident it was the right approach.After four debridement sessions,the computed tomography scan showed a clear regression of the SHH.CONCLUSION To our knowledge,this is the first case of successful endoscopic debridement of a SHH using a LAMS which appear to be feasible and safe in this specific case.