Introduction:
Benign GI strictures lead to significant morbidity and overall reduced quality of life for patients. These lesions are often refractory to first-line treatment interventions such as endoscopic balloon dilation (EBD). Thus, lumen-apposing metal stents (LAMS) have emerged as an off-label treatment option. This study aimed to characterize the clinical outcomes, safety, and efficacy of non-cautery-enhanced LAMS in the treatment of benign GI strictures as well as provide future considerations for management.

Methods:
This is an IRB-approved retrospective review of all patients who underwent LAMS placement for benign strictures from 06/2017 to 07/2023 at a single center. The primary outcomes were technical success, early clinical success (ECS), late clinical success (LCS), and sustained post-LAMS clinical success (SPLCS). Secondary outcomes included stent dwell time, change in stenosis diameter, adverse events (AEs), reintervention rates, and symptom evaluation via a standardized follow-up instrument.

Results:
A total of 35 patients underwent placement of 42 LAMS (74% female, mean age of 54.2 ± 11.7). Anastomotic strictures accounted for 64% of cases (N=27, 45% at the gastrojejunal anastomosis) (Fig 1.). The average stent dwell time was 111.1 ± 102 days. Technical success was obtained in all cases. ECS and LCS were achieved in 86% of anastomotic strictures versus 69% of non-anastomotic strictures (p=0.22). ECS and LCS were associated with a change in stenosis diameter of 8.6 mm versus 5.3 mm in those who did not though this was not significant (p=0.064). SPLCS was achieved in 47% (N=15) of cases. The overall reintervention rate was 63% (LAMS replacement in 9, EBD in 12, EBD + stricturoplasty in 3) and the average time to it was 75 days. Migration occurred in 24% of cases, which was not affected by LAMS size (p=0.96) or reintervention (p=0.61). AEs irrespective of migration occurred in 5% (N=2) of cases. Follow-up was completed in 83% of cases with an average interval of 689.7 days. Overall symptom improvement occurred in 79% (N=27) during indwelling LAMS versus 58% and 56% at 30- and 60-days post-removal, respectively. Overall stent dwell time, including time > 60 days, are strong predictors for ECS and LCS [(OR=1.08; 95% CI=[1.01-1.15]; p=0.02)( OR=16.80; 95% CI=[1.53-184.92]; p=0.02)] (Table 1).

Discussion:
Our study better characterizes symptom outcomes during and after LAMS placement alongside patient-driven clinical success rates. LAMS placement for benign GI strictures is associated with high technical and early/late clinical success rates, positive quality-of-life metrics, and a low rate of AEs. The overall recurrence of symptoms and relatively high reintervention rates post-LAMS removal reinforce the difficulty in the management of benign GI strictures but also argue for consideration of LAMS as a destination therapy in selected cases.

Fig 1. Localization of benign GI strictures of the included patients. GEJ: gastroesophageal junction; EJA: esophagojejunal anastomosis; GJA: gastrojejunal anastomosis.

Table 1. Predictors for Early Clinical Success (ECS) and Late Clinical Success (LCS).

Usman Barlass

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