INTRODUCTION: The study aimed to develop international consensus recommendations on the safe use of lumen-apposing metal stents (LAMSs) for on- and off-label indications. METHODS: Based on the available literature, statements were formulated and grouped into the following categories: general safety measures, peripancreatic fluid collections, endoscopic ultrasound (EUS)-biliary drainage, EUS-gallbladder drainage, EUS-gastroenterostomy, and gastric access temporary for endoscopy. The evidence level of each statement was determined using the Grading of Recommendations Assessment, Development, and Evaluation methodology. International LAMS experts were invited to participate in a modified Delphi process. When no 80% consensus was reached, the statement was modified based on expert feedback. Statements were rejected if no consensus was reached after the third Delphi round. RESULTS: Fifty-six (93.3%) of 60 formulated statements were accepted, of which 35 (58.3%) in the first round. Consensus was reached on the optimal learning path, preprocedural imaging, the need for airway protection and essential safety measures during the procedure, such as the use of Doppler, and measurement of the distance between the gastrointestinal lumen and the target structure. Specific consensus recommendations were generated for the different LAMS indications, covering, among others, careful patient selection, the preferred size of the LAMS, the need for antibiotics, the preferred anatomic location of the LAMS, the need for coaxial pigtail placement, and the appropriate management of LAMS-related adverse events. DISCUSSION: Through a modified international Delphi process, we developed general and indication-specific experience- and evidence-based recommendations on the safe use of LAMS.

Background and aims: Lumen-apposing metal stents (LAMSs) are increasingly used both for on- and off-label indications. We continuously adapt our step-by-step protocol to optimize the safe deployment of LAMSs for the different indications. The aim of this study was to evaluate the impact of this approach over time. Methods: We conducted a single-center study on consecutive patients who underwent LAMS placement for on- and off-label indications between June 2020 and June 2022. Endpoints included technical success, clinical success and adverse event rates. We compared the results with our previously published early experience with LAMSs (N = 61), between March 2018 and May 2020. Results: This cohort consisted of 168 LAMSs in 153 patients. Almost half of them (47.6%) were placed for off-label indications (gastro-enterostomy, temporary access to the excluded stomach in patients with previous gastric bypass, drainage of postsurgical collections, stenting of short refractory gastrointestinal strictures). While the technical and clinical success rates were similar to those in our previously published cohort (97% and 93.5% versus 93.4% and 88.5%, respectively), the adverse event rate dropped from 21.3% to 8.9%. Conclusions: Our results demonstrate the impact of a learning curve in LAMS placement, with a clinically relevant drop in LAMS-related adverse events over time.

Background and Purpose: Hepatic encephalopathy (HE) is a neuropsychiatric syndrome associated with liver cirrhosis (LC) that often results in cognitive impairment. Minimal HE (mHE), a subtle form of the condition, significantly affects patients’ quality of life. Advanced imaging techniques, such as quantitative susceptibility mapping (QSM), provide new insights into the brain changes associated with HE. Materials and Methods: The study included 28 patients (17 with mHE and 11 without) with alcohol-induced LC and 25 healthy controls. MR imaging, including QSM, was utilized to assess microstructural tissue changes and iron deposition in the brain. Cognitive function was assessed through a neuropsychological test battery. QSM quantified magnetic susceptibility in deep gray matter, while enlarged perivascular spaces (EPVS) were evaluated using T2-weighted images. Statistical analyses, including non-parametric tests and linear regression, assessed differences in susceptibility and their correlation with cognitive performance and EPVS. Results: Significant differences in cognitive performance and brain susceptibility were observed between patients and controls. Patients exhibited lower susceptibility in the caudate nucleus with the accumbens (CNA); mHE patients, in particular, had a significant reduction in CNA susceptibility. Additionally, EPVS grade correlated positively with cognitive decline, suggesting that EPVS may play an essential role in the pathophysiology of mHE. Conclusions: This study demonstrates that QSM can detect subtle brain changes in LC patients, with decreased susceptibility in the CN (caudate nucleus) linked to cognitive impairment in mHE. The role of EPVS in HE warrants further investigation, as it may affect the efficacy of current diagnostic and therapeutic approaches. These findings highlight the potential of QSM to improve HE assessment.