TECHNICAL ISSUES (TIS) DURING EUS-GUIDED INSERTION OF LUMEN APPOSING METAL STENTS (LAMS): CLASSIFICATION, ANALYSIS OF THEIR EFFECT ON PROCEDURE OUTCOMES, RISK FACTORS AND SALVAGE TECHNIQUES

Aims:

LAMS have been recently introduced, presenting promising results in intraabdominal drainages and endoscopic anastomoses. A variety of TIs might appear but we lack a common terminology to address them and their consequences on outcomes are unknown.

Methods:

All consecutive patients undergoing an endoscopic procedure which included in its planning the deployment of a LAMS between May 2011 and June 2017 at a single tertiary center were prospectively enrolled (table 1). We propose a novel classification of TIs, categorized in dislodgment, access failure, liberation failures and misplacements. We analyzed their incidence, risk factors, management and effect on outcomes

Results:

A total of 289 procedures (47.4% pancreatic fluid collections, 22.2% gallbladder drainages, 13.8% enteric anastomoses, 16.6% others) were analyzed. TI developed in 27% of them, significantly decreasing the technical (99.5% vs. 52.6%, p < 0.001), procedural (100% vs. 82.1%, p < 0.001) and clinical success rates (88% vs. 77.9%, p = 0.03). Distal (25.6%) and proximal flange misplacements (17.9%) and complete liberation failures (17.9%) were the most frequently encountered. Forceps repositioning, placement of coaxial stents and deploying a different type of stent were the most frequent salvage techniques (83.3% of all the TIs). A larger stent saddle (OR: 3.32 (1.05 – 10.56)) and malignant disease (OR: 1.98 (1.07 – 3.65)) were associated to the development of TI on multivariate analysis. Enteric anastomoses (OR 3.42 (1.22 – 9.62)) and malignant disease (OR: 2.8 (1.04 – 7.51)) were associated to the development of distal flange misplacement.

Tab. 1:

Characteristics of the study population and the pr

Age, median (IQR)	71.6 (58.3 – 83.5)
Male sex, n (%)	184 (63.7%)
Malignant disease, n (%)	75 (26%)
Access, n (%) Stomach Duodenum Jejunum Esophagus Missing	215 (74.4%) 63 (21.8%) 6 (2.1%) 3 (1%) 2 (0.7%)
LAMS type, n (%) Hot Cold Missing	170 (58.8%) 116 (40.1%) 3 (1%)

Conclusions:

The transmural insertion of PAL Axios EUS-guided is associated in one of every four cases to various Tis, typically distal flange misplacement in the mobile targets. 83.3% of these Tis can be rescued, mainly through the insertion of another stent.