Long-term lumen-apposing metal stents in endoscopic ultrasound-guided gallbladder drainage: Late adverse events and stent removal

Table 1 Competing strategies for managing the indwelling stent

Dimension	Strategy A: Elective removal after tract maturation	Strategy B: Scheduled exchange for long-term plastic stent	Strategy C: Permanent indwelling LAMS
Target patient profile	Temporarily unfit for surgery; possible future cholecystectomy	Intermediate; needs ongoing drainage but a metal stent is undesirable long term	Definitively inoperable (never a surgical candidate)
Principal rationale	Preempts late stent-specific events; often combined with cholecystoscopic stone clearance	Maintains a low-profile conduit through an established tract	Avoids repeat instrumentation in frail patients
Supporting evidence	Kamata et al[58] (self-expandable metal stent, not LAMS): Removal at about 4 weeks with no migration or impaction; Choi et al[59] and Walter et al[60]: Long-term outcomes after removal or exchange	Commentary recommendation for patients with extended life expectancy[44]; DRAC-1 protocol[27]; no dedicated trial	Yuste et al[43]; recurrence not increased by retention[36]; most patients die with the stent in situ[44]
Principal risk traded	Recurrent cholecystitis if the cystic duct is obstructed and no conduit is left	Requires repeat endoscopy; uncertain durability	An indefinite, albeit low, risk of burial, erosion, and impaction; it may also complicate subsequent surgery[62,63]
Evidence quality1	Low	Very low	Low to moderate
Basis for the grading	Small single-center series, one using a self-expandable metal stent rather than a LAMS; indirectness of the population; no comparator[58,59]	No study reports the strategy as an intervention; entirely inferential from protocol descriptions and expert opinion[27,44]	Two or more retrospective single-center and multicenter cohorts with follow-up beyond 1 year but serious risk-of-bias from competing mortality and short median follow-up[36,43,44]
Outstanding question	Optimal timing of removal is undefined	Whether exchange outperforms retention	Whether the apparent safety of permanence is real or an artifact of short survival

¹Grading was assigned by the authors using an approach adapted from the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and applied to the body of evidence supporting each strategy, as described in the section “How the evidence was identified”. Low to moderate = two or more cohorts with follow-up beyond 1 year but serious risk-of-bias; Low = single small series or indirect population; Very low = no study reports the strategy as an intervention. No formal GRADE assessment was performed, and no strategy is supported by randomized data. A higher grade reflects the quantity and design of the available evidence and not a stronger recommendation. DRAC-1: Randomized trial of endoscopic ultrasound-guided vs percutaneous gallbladder drainage; LAMS: Lumen-apposing metal stent.