Introduction

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound (EUS). LAMSs were initially developed for drainage of pancreatic fluid collections, but in the last decade its use for off-label indications has increased significantly. One of the most common off-label indications is treatment of gastrointestinal outflow obstruction.

Aims & Methods

This study aims to evaluate the effectiveness and safety of LAMS in creating EUS-guided gastro-enterostomy (EUS-GE) and entero-enterostomy (EUS-EE) anastomoses for the treatment of gastrointestinal (GI) outflow obstruction.
We collected data on all LAMS procedures conducted in patients with gastrointestinal (GI) outflow obstructions, including malignant gastric outlet obstruction (mGOO), benign gastric outlet obstruction (bGOO), candy cane syndrome, and afferent loop syndrome, between October 2019 and November 2023 at the University Hospital of Ghent. We used our prospective LAMS database and retrieved missing data from retrospective analysis of the medical patient records. The main outcome data of interest were technical success, clinical success, and adverse events. Technical success was defined as a successful placement of LAMS in the desired position. Clinical success was defined as either successful re-initiation of oral food intake in patients with mGOO and bGOO, or achievement of the intended therapeutic goal for the remaining conditions. Adverse events were classified according to the AGREE criteria.

Results

A total of 72 LAMS procedures were performed for GI outflow obstructions. The indications included 50 (69.4%)cases of mGOO, 19 (26.4%) cases of bGOO, 2 (2.8%) cases of afferent loop syndrome, and 1 (1.4%) case of candy cane syndrome. The overall technical and clinical success rates were very high (97.2% and 94.4%, respectively). Adverse events were observed in 9/72 (12.5%) cases, including 4 (5.6%) minor events (AGREE < 3) and 5 (6.9%) major events (AGREE ≥ 3). Major events included persisting fistula (N=1), and bleeding (N=4). All could be successfully managed, and there were no procedure-related deaths. Loss of LAMS patency occurred in 3/72 (4.2 %) cases and could be endoscopically managed in all cases.

Conclusion

In conclusion, our study shows that EUS-GE and EUS-EE offer an effective and safe approach when performed by experts. With high technical (97.2%) and clinical (94.4%) success rates, LAMS proves beneficial for treating GI outflow obstruction. Adverse events (12.5%) were manageable, with no procedure-related mortality. The extended patency duration and low re-intervention rate highlight LAMS as a minimally invasive and durable therapeutic option. Further prospective studies are needed.

Introduction

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound (EUS). In the last decade, its utilization for off-label indications has markedly increased, particularly among patients with surgically altered anatomy to establish access in the excluded segment of the gastrointestinal tract. Indications for anastomosis creation include EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE), EUS-directed transgastric intervention (EDGI), or endoscopic reversal of Roux-en-Y gastric bypass (RYGB) for specific indications (see below).

Aims & Methods

This study aims to evaluate the effectiveness and safety of LAMS in patients with surgically altered anatomy for EDGE, EDGI, and reversal of RYGB. We collected data on all LAMS procedures conducted in patients with surgically altered anatomy, between October 2019 and February 2024 at the University Hospital of Ghent.
We used our prospective LAMS database and retrieved missing data from retrospective analysis of the medical patient records. The main outcome data of interest were technical success, clinical success, and adverse events. Technical success was defined as a successful placement of LAMS in the desired position. Clinical success was defined as either successful endoscopic access to the intended excluded gastrointestinal segment or achievement of the intended therapeutic goal when RYGB reversal was necessary. Adverse events were classified according to the AGREE criteria.

Results

A total of 73 LAMS procedures were performed: 70 cases of EUS-guided gastro-gastrostomy in patients with RYGB and 3 cases of EUS-guided gastro-enterostomy in patients with hepaticojejunostomy. Indications for LAMS procedures included 55 (75.3%) cases of EDGE, 13 (17.8%) cases of EDGI (such as gastroduodenoscopy and EUS), and 5 (6.8%) cases of RYGB reversal. Reversal of RYGB was required for one cachectic patient due to metastatic cholangiocarcinoma, three patients with hyperinsulinemic hypoglycemia, and one patient with therapy-resistant small intestinal bacterial overgrowth (SIBO).
The overall technical and clinical success rates were very high at 97.3% and 95.9%, respectively. Adverse events were observed in 11 out of 73 (15.1%) cases, including 7 (9.6%) minor events (AGREE score < 3) and 4 (5.5%) major events (AGREE score ≥ 3). Major events included stent migration (N=1), persistent fistula (N=2), and respiratory desaturation (N=1). All events could be successfully managed, and there were no procedure-related deaths. In 69.9% of cases, our method involved a dual-step approach, strategically implemented to await fistula maturation and reduce the risk of perforation. The median LAMS dwell time was 38 days (range 7, 431). LAMS was removed in 72.6% of the cases. Loss of LAMS patency occurred in 1 out of 73 (1.4%) cases and was endoscopically managed.

Conclusion

In conclusion, our study demonstrates that EUS-GG and EUS-GE offer an effective and safe approach to create anastomoses between gastrointestinal (GI) segments when performed by experts. With high technical (97.3%) and clinical (95.9%) success rates, LAMS proves beneficial for accessing excluded GI segments and reversing RYGB. Adverse events (15.1%) were mostly minor and manageable, with no procedure-related mortality. The extended patency duration and low re-intervention rate highlight LAMS as a minimally invasive and durable option in therapeutic endoscopic ultrasound procedures. Further prospective studies are required.

Introduction

Lumen-apposing metal stents (LAMS) have increasingly been used for the management of gastrojejunal anastomotic strictures following Roux-en-Y gastric bypass, although through-the-scope balloon dilation (TTS-BD) remains the first-line therapy.

Aims & Methods

This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of LAMS for gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass using a single-arm meta-analysis. Additionally, we conducted pairwise meta-analyses of studies comparing LAMS and TTS-BD. We systematically searched PubMed, Embase, and the Cochrane Librarydatabases. The primary outcome was clinical success. Secondary outcomes included the need for surgery, overall adverse events, and the most common adverse event. Pooled estimates with 95% confidence intervals (CIs) were calculated for single-arm analyses. For the pairwise meta-analysis of comparative studies, pooled risk ratios (RRs) with 95% CIs were calculated for binary outcomes.

Results

We included nine studies, comprising 189 patients treated with LAMS for gastrojejunal anastomotic strictures following Roux-en-Y gastric bypass. Most patients were female, with the mean age ranging from 43.6 to 62.0 years. The pooled clinical success rate with LAMS was 76.39% (95% CI 61.67–86.67%). The pooled rates for need for surgery and overall adverse events were 15.03% (95% CI 7.46–27.97%) and 18.93% (95% CI 11.21–30.16%), respectively. Stent migration was the most frequently reported adverse event associated with LAMS, occurring in 14.83% of cases (95% CI 7.49–27.25%).Among the included studies, four compared LAMS with TTS-BD, encompassing a total of 200 patients (92 treated with LAMS and 108 with TTS-BD). LAMS was associated with a higher clinical success rate (RR 1.49; 95% CI 1.07–2.07; P=0.02; I2=0%) and a higher risk of overall adverse events (RR 4.31; 95% CI 1.03–17.97; P=0.04; I2=37%) compared to TTS-BD. The need for surgery was similar between groups (RR 0.82; 95% CI 0.05–12.68; P=0.89; I2=88%).

Conclusion

LAMS placement showed to be an effectivetreatment for gastrojejunal anastomotic strictures following Roux-en-Y gastric bypass. However, compared to TTS-BD, LAMS was associated with a higher rate of overall adverse events, most commonly stent migration.

Table 1. LAMS size

References

1. Agrawal R, et al. Safety and Efficacy of LAMS for Management of Late Refractory Gastro-jejunal Strictures in Patients with Roux-en-Y Gastric Bypass. Dig Dis Sci. 2025.
2. Hathorn K, et al. Gastrojejunal Anastomotic Stenosis: A Matched Cohort Study Comparing Efficacy and Safety of LAMS Placement to Standard Balloon Dilation. Gastrointest Endosc. 2020.
3. Ichkhanian Y. Balloon Dilation vs. Lumen Apposing Metal Stent for the Management of Post RYGB Gastro-jejunal Anastomotic Stricture (GJAS): A Multicenter Comparative Study. Gastrointest Endosc. 2022.
4. Jirapinyo P, et al. Efficacy of LAMS in the Treatment of Gastrojejunal Anastomotic Stenosis. Gastrointest Endosc. 2018.
5. Packey C. Role for LAMS in the Management of Short-Length Gastrointestinal Strictures. Gastrointest Endosc. 2018.
6. Samuels JM, et al. Use of LAMS in Treating Gastrojejunal Anastomotic Strictures in Bariatric Patients. Surg Endosc. 2023.
7. Sawas T. Endoscopic Stenting for Symptomatic Gastrojejunal Anastomotic Stricture Provides Durable Clinical Response After Failed Balloon Dilation. Gastrointest Endosc. 2020.
8. Shamaa O. Management of Gastro-Jejunal Anastomotic Strictures: Comparing Endoscopic Outcomes in Primary vs Conversion Roux-en-Y Gastric Bypass Patients. Am J Gastroenterol. 2024.
9. Skidmore AP. Use of LAMS in the Management of Gastro Jejunostomy Stricture Following Roux-en-Y Gastric Bypass for Obesity: A Prospective Series. BMC Surg. 2021.

Clinical Case Summary

A 66-year-old patient underwent cephalic pancreaticoduodenectomy on 05/2021 for moderately differentiated adenocarcinoma of the distal bile duct (R1 pT3 pN1). He underwent 8 cycles of adjuvant chemoradiotherapy with Capecitabine, which ended on 12/2021. On 09/2022, locoregional recurrence was detected and the disease was considered unresectable. At this time, he started systemic therapy with Cisplatin+Gemcitabine+Durvalumab (TOAZ trial 1). Prior to the beginning of the third cycle, the patient began to suffer from food intolerance with vomiting. A CT scan showed locoregional progression of the disease with extension to the stomach and infiltration of the gastro-jejunal anastomosis. In the endoscopic comparison, the anastomotic stenosis was confirmed, only transposable with the pediatric gastroscope, leaving the efferent loop permeable. Given the unequivocal progression of the disease, an assumed palliative strategy and, in line with this decision, a minimally invasive – endoscopic – approach was chosen to protect the gastric outlet tract. Once the efferent loop has been isolated, a nitinol guidewire was advanced under direct vision through which a metal prosthesis with luminal apposition (Spaxus®) 16x20 mm was submitted by backload, released simultaneously under control under fluoroscopic control and endoscopic vision. At the end of the procedure, luminal patency was confirmed with contrast injection. One week after stent placement, the patient continues to tolerate the oral diet, was discharged and will be reassessed in a Medical Oncology consultation with the aim of starting second-line chemotherapy (FOLFOX).
Locoregional recurrence after Whipple’s procedure is high.Lumen-apposing metal stents, originally designed for the management of pancreatic fluid collections, have been shown to be option for gastrointestinal strictures due to their anti-migratory design. This report shows its application in cases of short strictures requiring preventive migration measures.

Clinical Case Summary

Background: Silastic-Ring Vertical Gastroplasty (SRVG) was popular in the 1980-90s, but ring-related stenosis and dysphagia are frequent and may demand removal via surgery or endoscopy⁵. Infective endocarditis (IE) after upper-GI endoscopy is considered exceptionally rare, so current ESC and AHA guidelines no longer recommend routine antibiotic prophylaxis - a measure that, prior to 2007, was advised for numerous indications, including endoscopic procedures.¹ ².
Case: A 60-year-old woman with a mechanical mitral valve (warfarin), HFpEF and APS presented 29 years post-SRVG with progressive dysphagia and daily emesis. Gastroscopy showed critical ring stenosis. After shared decision-making an endoscopic strategy was chosen: a 20 mm LAMS was placed across the ring to induce erosion, and both stent and ring were removed eight weeks later without peri-procedural complications. Three weeks after the the removal she developed transient dysarthria, right hemiparesis, fever and a vasculitic rash. Three blood-culture sets grew Gemella morbillorum; transthoracic echo was inconclusive, but CT revealed splenic infarcts, and modified Duke criteria confirmed definite IE. She received six weeks of intravenous ceftriaxone and recovered fully. No other portal of entry was identified.
Discussion: This is the first report of G. morbillorum IE following advanced bariatric endoscopy. Although endoscopic procedures can produce bacteremia in up to 22 % of cases, overt IE is seldom described, and everyday activities such as tooth-brushing yield higher bacteremia rates³. This patient combined two converging risks: a prosthetic valve and a deeply invasive, multi-stage intervention (LAMS placement, ring extraction). Current ASGE/ESGE guidance on primary bariatric endoscopic therapies addresses only surgical-site infection prophylaxis⁴ and is silent on IE. Prospective data are needed to clarify whether complex endoscopic procedures in high-risk hosts warrant targeted antibiotic prophylaxis.

References

1. ESC Scientific Document Group.2023 ESC Guidelines for the management of endocarditis. Eur Heart J. 2023 Oct 14;44(39):3948-4042. doi: 10.1093
2. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2;143(5):e35-e71. doi: 10.1161
3. ASGE Standards of Practice Committee; Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc. 2015 Jan;81(1):81-9. doi: 10.1016
4. Storm AC, Pimentel-Nunes P, et al. Primary bariatric endoscopic therapies: joint ASGE/ESGE guideline 2024. Gastrointest Endosc. 2024 Jun;56(6):437-456. doi: 10.1055
5. Luchtenstein A, Fishman 2025.Z, Shnell M, Reicher T, et al. Endoscopic removal of non-eroding gastric bands post-SRVG using lumen-apposing metal stents: a viable alternative to traditional endoscopic and surgical methods [abstract]. ESGE Week, Barcelona, April