L. T. Meredith3, D. Baek2, A. Agarwal2, T. Kowalski4, A. Kumar4, A. Schlachterman4, C. Yeo1, H. Lavu1, A. Nevler1, W. Bowne1 1Thomas Jefferson University, Jefferson Pancreas, Biliary And Related Cancer Center, Department Of Surgery, Philadelphia, PA, USA 2Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PENNSYLVANIA, USA 3Thomas Jefferson University, Department Of Surgery, Philadelphia, PA, USA 4Thomas Jefferson University, Department Of Gastroenterology, Philadelphia, PENNSYLVANIA, USA
Introduction:
Endoscopic ultrasound (EUS)-guided lumen-apposing metal stents (LAMS) represent a novel tool in therapeutic endoscopy providing means for diagnosis and/or palliation of malignant obstruction. Placement of LAMS can generate a perception of greater disease severity and negatively impact surgeons’ perception of patient candidacy for surgical resection. In our case series, we present several clinical scenarios with deployment of LAMS in patients that later underwent pancreaticoduodenectomy (PD).
Methods:
We identified six patients from our institutional IRB-approved pancreas cancer database who underwent LAMS placement prior to undergoing a PD or pylorus-preserving PD (PPPD). Patient, tumor and treatment related variables, and outcomes are reported.
Results:
Among our patient cohort, two patients underwent endoscopic LAMS gastrojejunostomy for duodenal obstruction. One patient underwent LAMS choledochoduodenostomy for malignant distal biliary obstruction. Three patients who had a prior Roux-en-Y gastric bypass (RYGB) underwent LAMS gastrogastrostomy during an endoscopic ultrasound-directed transgastric ERCP (EDGE) procedure to gain endoscopic access to the duodenum. The length of stay after LAMS placement ranged from 0 to 4 days. There were no complications related to the LAMS procedure, with no stent migration or bleeding events. Two patients received neoadjuvant chemotherapy after LAMS placement. In all cases, patients proceeded with PD (five cases) or PPPD (one case). The time from LAMS insertion to surgery ranged from 28 to 194 days. Mean operative time was 513 minutes. Mean EBL was 560 mL. The initial post-PD length of stay ranged from 4 to 7 days. Post-operative fluid collections were managed with percutaneous drainage and medical management in two cases. In one case of PD after LAMS gastrojejunostomy for duodenal obstruction, dense adhesions were described in the region of the LAMS requiring one hour of lysis of adhesions. In the three cases involving LAMS gastrojejunostomy or choledochoduodenostomy, the LAMS was directly related to the inability to perform pylorus preservation. In the three patients who had a prior RYGB, the gastro-gastric LAMS placed during the EDGE procedure did not affect operative reconstruction.
Conclusion:
Pancreaticoduodenectomy after EUS-LAMS is feasible with acceptable morbidity, although it may limit the ability to perform pylorus preservation. LAMS as a bridge to definitive surgical resection can be considered in highly select patients.
