Introduction
Endoscopic stenting is considered the mainstay of biliary treatment for benign biliary strictures [1]; temporary insertion of multiple plastic stents or of a fully covered self-expandable metal stent (FC-SEMS) are the preferred methods due to their favorable results [2]. However, there is a not-negligible rate of stricture recurrence and spontaneous stent migration, the latter being a leading cause of treatment failure [3]. Lumen-apposing metal stents (LAMS), developed for transluminal drainages, have a unique design with short length, large diameter and wide flanges which make them less prone to migration [4]. LAMS have recently been proposed as a novel modality for treating short benign gastrointestinal strictures [5].
Aims & Methods
Aim of our study was to describe the intraluminal use of LAMS to treat short benign biliary strictures. This was a retrospective, single-arm, single Centre study. All consecutive patients who underwent retrograde LAMS placement for benign biliary strictures, from October 2016 to July 2022, were included. Clinical data, including stricture etiology, previous upper-GI or hepatobiliary surgery, previous treatments for biliary stricture and type of LAMS used were collected from medical records. Primary outcomes were technical success and stricture resolution; secondary outcomes were stricture recurrence, number of endoscopic retrograde cholangiopancreatography (ERCP), stent migration.
Results
During the study period, seventy patients (35 male, mean age 67, range 27-90 years) underwent retrograde LAMS placement for benign biliary strictures; distal biliary stricture was the most common etiology (n=36), followed by anastomotic stricture (n=31) and proximal non-anastomotic stricture (n=3). LAMS placement was a second-line therapy, after failure of other methods, in 38 patients (54.2%). A 16-mm LAMS was used in 44 patients and a 12-mm LAMS in 26 (NAGI stent, Taewoong Medical, South Korea). Technical and clinical success were obtained in 100% and 83% of patients, respectively. Stent migration occurred in 9 (12,8%) of cases, 3 of which determined treatment failure. Stricture recurred in 9 patients within a mean of 16 months onset (range 3-30 months). We found a statistically significant higher success if the treatment was performed as a second line therapy than as a first attempt, with success rate of 91.1% and 79.3%, respectively (p=0.04). No statistically significant differences were seen between 16-mm LAMS and 12-mm LAMS placement (87% vs 76%, p=0.23).
Conclusion
LAMS placement could be a safe and effective alternative for short, benign biliary strictures, especially as a second line therapy in patients who experienced a previous endoscopic treatment failure.
References
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2. Dumonceau JM, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017. Endoscopy. 2018 Sep;50(9):910-930. doi: 10.1055/a-0659-9864. PMID: 30086596.
3. Park JS, et al. Long-term outcomes of covered self-expandable metal stents for treating benign biliary strictures. Endoscopy. 2016 May;48(5):440-7. doi: 10.1055/s-0042-101406. PMID: 26919262.
4. Sharma P, et al. Alternative uses of lumen apposing metal stents. World J Gastroenterol. 2020 Jun 7;26(21):2715-2728. doi: 10.3748/wjg.v26.i21.2715. PMID: 32550749.
5. Larson B, Adler DG. Lumen-apposing metal stents for gastrointestinal luminal strictures: current use and future directions. Ann Gastroenterol. 2019 Mar-Apr;32(2):141-146. doi: 10.20524/aog.2018.0337. PMID: 30837786;
