S5317 Expanding the Role of Lumen-Apposing Metal Stents: Off-Label Applications in Gastrointestinal Disease

Introduction: Lumen-apposing metal stents (LAMS) are FDA-approved for the drainage of pancreatic pseudocysts, walled-off necrosis, and gallbladder drainage in high-risk surgical candidates. In clinical practice, LAMS are used off-label in a range of gastrointestinal conditions, including enteral anastomosis, access to excluded anatomy, and management of benign strictures. This case series highlights 3 off-label applications demonstrating the versatility, effectiveness, and safety of LAMS. Case Description: In the first case, a patient with a history of Roux-en-Y gastric bypass presented with abdominal pain, nausea, and vomiting. She was unable to tolerate any oral intake and required total parenteral nutrition. Endoscopy revealed a gastrojejunal anastomotic stricture. A 20 mm LAMS was deployed across the stricture, resulting in resolution of symptoms and return to oral feeding. In the second case, a patient with prior Roux-en-Y bypass presented with abdominal pain and elevated liver-associated enzymes. Imaging demonstrated intra- and extrahepatic biliary dilation, choledocholithiasis, and ampullary stenosis. Initial endoscopic retrograde cholangiopancreatography (ERCP) failed due to altered anatomy. A LAMS was placed via a jejuno-gastric EDGE approach to access the excluded stomach. The stent was dilated to 20 mm and the patient was placed in prone position to permit duodenoscope passage. Balloon dilation and stone extraction were performed with resolution of biliary obstruction. In the third case, a patient with pancreatic cancer and hepatic metastases presented with abdominal pain, nausea, and vomiting. He had a history of biliary stenting for obstructive cholestasis and was being evaluated for chemotherapy. CT showed a distended stomach with an abrupt transition at the second portion of the duodenum. An endoscopic ultrasound -guided gastrojejunostomy was performed using a 20 mm LAMS with rapid symptomatic improvement. Discussion: These cases demonstrate the expanding role of LAMS in therapeutic endoscopy, particularly in off-label settings. While their approved indications remain limited to pancreatic fluid collections and cholecystostomy in select patients, real-world use has extended into areas such as stricture management, transgastric ERCP, and enteral bypass for malignant obstruction. With increasing experience and published outcomes, the need for prospective trials and regulatory consideration is clear. These would help establish safety, standardize technique, and expand access to these innovative therapies.