Safety and efficacy of coaxial lumen-apposing metal stents in the management of refractory gastrointestinal luminal strictures: a multicenter study
submitted 09 March 2017
accepted after revision 29 May 2017
12 September 2017 (online)
Background and aims Benign gastrointestinal (GI) strictures are often refractory to standard endoscopic interventions. Fully covered coaxial lumen-apposing metal stents (LAMS) have emerged as a novel therapy for these strictures. The aim of this study was to evaluate the safety and efficacy of LAMS for refractory GI strictures.
Patients and methods A retrospective analysis was performed for patients who underwent LAMS placement for benign luminal strictures in three US centers between January 2014 and December 2016. The primary outcomes were technical success and initial clinical success of LAMS placement. Secondary outcomes were stent migration, rate of re-intervention, and adverse events.
Results A total of 49 patients underwent 56 LAMS placement procedures. Previous treatment had failed in 39 patients (79.6 %), and anastomotic strictures were the indication in 77.6 % (38/49), with the most common site being gastrojejunal (34.7 % [17/49]). Technical success was achieved in all procedures and initial clinical success was achieved in 96.4 % of all procedures (54/56). Patient initial clinical success was 95.9 % (47/49). Stent migration occurred in 17.9 % of procedures, and was more likely to occur at sites in the lower GI tract (P = 0.02). The mean stent dwell time was 100.6 days, and the mean follow-up was 169.8 days. Minor adverse events, not requiring hospitalization, occurred in 33.9 % of procedures, including subsequent stricture progression (10.7 %). In cases where LAMS were removed, mean follow-up time was 102.2 days. The re-intervention rate was 75 % at 300 days follow-up after stent removal. Of the LAMS placed at anastomotic strictures, 36.4 % required re-intervention, with approximately two-thirds of these re-interventions requiring placement of a new stent or surgery.
Conclusion LAMS placement was successful for the management of refractory GI strictures, with good technical and initial clinical success rates. However, re-intervention rates after LAMS removal were high, and many strictures were not resolved by an extended period of stenting with these coaxial stents. LAMS placement offers additional therapeutic options and in selected cases might be considered a destination therapy for patients with recalcitrant benign strictures.
- 1 Ramage Jr JI, Rumalla A, Baron TH. et al. A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures. Am J Gastroenterol 2005; 100: 2419-2425
- 2 Samanta J, Dhaka N, Sinha SK. et al. Endoscopic incisional therapy for benign esophageal strictures: technique and results. World J Gastrointest Endosc 2015; 7: 1318-1326
- 3 de Wijkerslooth LR, Vleggaar FP, Siersema PD. Endoscopic management of difficult or recurrent esophageal strictures. Am J Gastroenterol 2011; 106: 2080-2091
- 4 Agnew SR, Pandya SP, Reynolds RP. et al. Predictors for frequent esophageal dilations of benign peptic strictures. Dig Dis Sci 1996; 41: 931-936
- 5 Choi WJ, Park JJ, Park J. et al. Effects of the temporary placement of a self-expandable metallic stent in benign pyloric stenosis. Gut Liver 2013; 7: 417-422
- 6 Walter D, Will U, Sanchez-Yague A. et al. A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study. Endoscopy 2015; 47: 63-67
- 7 Adler DG. Esophageal placement of a lumen-apposing metal stent in a patient with a chronic anastomotic stricture. Gastrointest Endosc 2017; 85: 1291-1293
- 8 Fujii LL, Bonin EA, Baron TH. et al. Utility of an endoscopic suturing system for prevention of covered luminal stent migration in the upper GI tract. Gastrointest Endosc 2013; 78: 787-793
- 9 Thomas T, Abrams KR, Subramanian V. et al. Esophageal stents for benign refractory strictures: a meta-analysis. Endoscopy 2011; 43: 386-393
- 10 Suzuki T, Siddiqui A, Taylor LJ. et al. Clinical outcomes, efficacy, and adverse events in patients undergoing esophageal stent placement for benign indications: a large multicenter study. J Clin Gastroenterol 2016; 50: 373-378
- 11 Dan D, Gannavarapu B, Lee J. et al. Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures (RBES). Dis Esophagus 2014; 27: 511-517
- 12 Wadhwa RP, Kozarek RA, France RE. et al. Use of self-expandable metallic stents in benign GI diseases. Gastrointest Endosc 2003; 58: 207-212
- 13 Repici A, Small AJ, Mendelson A. et al. Natural history and management of refractory benign esophageal strictures. Gastrointest Endosc 2016; 84: 222-228
- 14 Pasricha S, Li N, Bulsiewicz WJ. et al. Sex and race and/or ethnicity differences in patients undergoing radiofrequency ablation for Barrett’s esophagus: results from the U.S. RFA Registry. Gastrointest Endosc 2015; 82: 276-284