Management After LAMS Removal Following EUS-Guided Cystogastrostomy and Necrosectomy

Introduction to LAMS Removal

The American Gastroenterological Association recommends removing the LAMS within 4-6 weeks after initial placement, once the collection has resolved, and exchanging it for double pigtail plastic stents to maintain fistula patency long-term 1, 2

The American College of Gastroenterology suggests that the optimal timing for LAMS removal is typically 4-6 weeks after initial LAMS placement, allowing adequate time for fistula tract maturation while minimizing stent-related complications 1
The World Journal of Emergency Surgery recommends removing the LAMS within 4 weeks to avoid food impaction and subsequent complications, as a well-formed fistula develops between the collection and gastrointestinal tract within this timeframe 3, 4

The American Gastroenterological Association recommends performing simultaneous exchange to double pigtail plastic stents at the time of LAMS removal to maintain the cystogastrostomy tract and prevent fistula closure 1, 2
The European Society of Gastrointestinal Endoscopy suggests placing one or two 7 Fr double pigtail plastic stents through the established fistula tract at the time of LAMS removal 5, 6, 2

The American College of Gastroenterology recommends performing routine follow-up peroral cholecystoscopy/gastroscopy at 4-6 weeks after initial drainage to assess for complete clearance of any residual necrotic debris, patency of the fistula tract, and need for additional interventions 1, 7
The American Gastroenterological Association suggests assessing for spontaneous passage of debris, which occurs in approximately 56% of cases, and performing direct endoscopic debridement using stone-retrieval baskets or other extraction devices if residual solid material persists 1

The American Gastroenterological Association recommends maintaining plastic stents with routine exchanges every 2-4 weeks until the cavity has contracted to <2 cm in size 2
The European Society of Gastrointestinal Endoscopy suggests continuing prophylactic antibiotics covering enteric gram-negative organisms and enterococci during the post-removal period 5, 8

The American College of Gastroenterology recommends that in frail patients or those refusing a second procedure, the LAMS may be left in place permanently with acceptable long-term outcomes, including 3-year stent patency of 86% and delayed adverse events occurring in only 7.1% of cases 1, 3

The American Gastroenterological Association recommends actively surveilling for delayed adverse events during the post-removal period, including recurrent collection formation, which occurs in 2.6% with proper stent maintenance vs 20% without, and fistula closure if plastic stents are not maintained 1
The World Journal of Emergency Surgery suggests monitoring for buried stent syndrome if LAMS is left too long 5, 6

The American College of Gastroenterology recommends that if the patient becomes a surgical candidate after LAMS removal, fistula repair will be required at the time of surgery to prevent postoperative leak, and surgical consultation before LAMS placement is ideal to clarify future surgical plans 7