Pancreaticoduodenectomy after endoscopic ultrasound-guided lumen apposing metal stent (LAMS): A case series evaluating feasibility and short-term outcomes

Abstract

Introduction: Endoscopic ultrasound (EUS)-guided lumen-apposing metal stents (LAMS) represent a novel tool in therapeutic endoscopy. However, the presence of LAMS may dissuade surgeons from operations with curative-intent. We report three clinical scenarios with deployment of LAMS in patients that subsequently underwent pancreaticoduodenectomy (PD).

Methods: Six patients identified from our IRB-approved pancreas cancer database had EUS-LAMS placement prior to PD. Patient, tumor, treatment-related variables, and outcomes are herein reported.

Results: Two patients underwent a LAMS gastrojejunostomy (GJ) for duodenal obstruction. Another patient underwent LAMS choledochoduodenostomy (CDS) for malignant biliary obstruction. In three patients, a LAMS gastrogastrostomy or jejunogastrostomy was deployed post Roux-en-Y gastric bypass (RYGB) for a EUS-directed transgastric ERCP (EDGE) procedure. The hospital length of stay after LAMS placement was 0-3 days without morbidity. Patients subsequently proceeded to either classic PD (n = 5) or PPPD (n = 1). Interval from LAMS insertion to surgery ranged from 28 to 194 days. Mean PD operative time and EBL were 513 minutes and 560 mL, respectively. Post-PD hospital length of stay was 4-17 days. Clavien-Dindo IIIb morbidity required percutaneous drainage of intra-abdominal collections in two patients. In cases involving LAMS-GJ and CDS, the LAMS directly impacted the surgeon's preference not to perform pylorus preservation.

Conclusions: In this case series, PD following EUS-LAMS was feasible with acceptable morbidity. Additional studies with larger patient populations are needed to evaluate LAMS as a bridge to PD with curative-intent.

Keywords: Advanced endoscopy; Lumen-apposing metal stent; Pancreatic cancer; Pancreaticoduodenectomy.

Fig. 1

A: Structural depiction of bi-flanged covered lumen apposing metal stent (LAMS). B: Schematic of electrocautery-enhanced LAMS deployment. (Credit for this figure is given to Boston Scientific – AXIOS™ stent).

Fig. 2

CT and Endoscopic Images stratified by clinical scenario (CS). A: CS 1: EUS-guided LAMS gastrojejunostomy. B: CS 2: EUS-guided LAMS choledochoduodenostomy. C: CS 3: EUS-guided LAMS gastrogastrostomy* CT: computed tomography; EUS: endoscopic ultrasound; LAMS: lumen apposing metal stent; EDGE procedure: endoscopic ultrasound directed transgastric ERCP *gastrogastrostomy from gastric pouch to remnant stomach.

Fig. 3

Clinical Scenario 1: A: EUS-guided LAMS gastrojejunostomy for malignant duodenal obstruction and subsequent classic PD (LAMS left in situ) (Patient 1). B: EUS-guided LAMS gastrojejunostomy for malignant duodenal obstruction with subsequent classic PD (LAMS removed with specimen) (Patient 2). EUS: Endoscopic Ultrasound; LAMS: lumen apposing metal stent; PD: pancreaticoduodenectomy; CBD: common bile duct.

Fig. 4

Clinical Scenario 2: EUS-guided LAMS choledochoduodenostomy with double-pigtail stents with subsequent classic PD (LAMS removed with specimen) (Patient 3). EUS: endoscopic ultrasound; LAMS: lumen apposing metal stent; PD: pancreaticoduodenectomy; CDS: choledochoduodenostomy.

Fig. 5

Clinical Scenario 3: Roux-en-Y gastric bypass anatomy. A: EUS-guided LAMS jejunogastrostomy* for completion of EDGE procedure with subsequent gastric remnant PPPD (LAMS left in situ) (Patient 4). B: EUS-guided LAMS gastrogastrostomy for completion of EDGE procedure with subsequent gastric remnant classic PD (LAMS left in situ) (Patients 5–6). EUS: endoscopic ultrasound; LAMS: lumen apposing metal stent; EDGE procedure: endoscopic ultrasound directed transgastric ERCP; PPPD: pylorus-preserving pancreaticoduodenectomy; PD: pancreaticoduodenectomy *jejunogastrostomy from proximal alimentary limb to remnant stomach.