Lumen-apposing metal stenting (LAMS) appears to be effective in preventing multiple procedures for resolution of strictures and increase rates of stricture resolution compared to dilatation alone following RYGB, according to researchers from Australia. The investigators also reported that the procedure can be undertaken without radiology and can be done as an outpatient procedure. The findings were featured in the paper, ‘Use of lumen-apposing metal stents (LAMS) in the management of gastro jejunostomy stricture following Roux-en-Y Gastric Bypass for obesity: a prospective series’, published in BMC Surgery.
The authors note that chronic strictures following Roux-en-Y Gastric Bypass (RYGB) are a troublesome complication that can cause significant morbidity. However, Lumen apposing metal stents (LAMS) do not require X-ray and are easy to deploy with a short learning curve. Therefore, they decided to investigate the use of the AXIOS (Boston Scientific) stent to treat post RYGB strictures and explore their safety and efficacy.
LAMS are designed for deployment through a therapeutic forward viewing endoscope and the technique used in this study was similar to deployment used in pancreatic pseudocysts. In this series a 15mm stent was deployed and in most cases the endoscopist directly visualised the stricture to assess the size and length. In instances where the lumen could not be traversed by the endoscope, the stent was placed after introduction of a guide wire. Radiology was not required in any of the reported cases. Stricture size was documented by the endoscopist and recorded for analysis.
A total of 14 patients (from 421 patients, 3%) undergoing RYGB presented with a post-operative gastro jejunostomy stricture requiring dilatation, with twelve presenting within the first six weeks. All 14 patients all underwent insertion of a LAMS stent in preference to dilatation alone. On average the stent remained in for 44 days (10–161 days) until removal. A total of 26 stents were placed in these 14 patients.
Five patients required re-insertion of their stent, with two having a formal revision of their gastro jejunostomy. The remaining three patients strictures resolved after removal of the second stent. Five (from 26, 19%) of the stents placed migrated distally and passed spontaneously. This was proven by repeat endoscopy and abdominal X-ray or CT scan and none of these required any intervention to remove them after migration.
They found no immediate or late complications after insertion of LAMS. Two patients had removal of the stent secondary to chest pain and one of these patients the stent had migrated proximally in a short pouch to straddle the gastroesophageal junction. Finally, there were no immediate complications such as bleeding or ulceration.
Importantly, weight loss did not seem to be significantly affected by insertion of the stent and this findings appears to be comparable with patients on the database with no evidence of stricture or insertion of stent.
The design of LAMS compared to SEMS makes them an attractive option for management of post-operative strictures in patients who have undergone RYGB, as the dumb bell shape allows the stent to remain relatively fixed across a short stricture, the authors noted.
“LAMS are a safe and effective method to manage post RYGB strictures. They have a high rate of resolution of strictures and can be safely deployed across strictures with no immediate complication,” they conclude. “Migration does still appear to be a problem, however, does not appear to affect patient outcome or increase morbidity. Insertion is straightforward and doesn’t appear to be associated with a long learning curve.”
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