Dear Editor,
Pancreatic cysts represent a significant clinical entity in gastroenterology, frequently arising as sequelae of acute or chronic pancreatitis. These cysts are categorized based on the presence of necrotic material, which can be effectively identified through cross-sectional imaging techniques. Fluid-filled collections encapsulated by fibrous or granulation tissue are classified as pseudocysts, whereas collections with necrotic content are termed walled-off necrosis (WON). Clinical management becomes particularly critical when these cysts are symptomatic—manifesting as intractable pain, nausea, or vomiting—or when complications such as antimicrobial-resistant infections or mass effects on surrounding structures, including the biliary tract, are present.
Endoscopic drainage is the cornerstone of treatment, with plastic and metallic stents serving as the primary tools. Economic constraints and clinical considerations often dictate the choice of stents, with plastic stents being the preferred option in resource-limited settings due to their cost-effectiveness and favorable clinical outcomes. Although metallic stents, such as lumen-apposing metal stents (LAMS), provide technical advantages—primarily their larger diameter for drainage—plastic stents have demonstrated comparable efficacy in many scenarios, particularly when the number of stents is optimized.
Advantages of Dual Plastic Stenting
Recent studies have underscored the advantages of dual plastic stent placement over single stenting for managing pancreatic pseudocysts [1]. Dual stenting offers several distinct benefits that enhance clinical outcomes and procedural safety.
The primary advantage is the reduction of additional endoscopic interventions. When one stent becomes occluded by necrotic debris or viscous fluid, the second stent serves as a safeguard, maintaining drainage and reducing the need for repeated procedures [2].
A second notable benefit of dual stent placement is the stabilization of the newly formed fistulotomy tract in cases of stent migration. Larger pseudocysts, due to their size and intraluminal pressures, are particularly prone to this issue when managed with a single stent. If migration occurs, re-accessing the endoscopically created fistula tract for re-stenting can be challenging and may require a new puncture. Dual stent placement significantly reduces migration risk, enhances tract stability, and minimizes the need for unnecessary interventions [1].
Supporting Evidence
Ghoneem et al. demonstrated the technical and clinical success of single wide-caliber plastic stents for pseudocyst drainage, albeit with stent occlusion as a potential limitation [2]. Similarly, Giri et al. reported superior drainage efficiency and a lower incidence of complications with dual stent placement [1]. Furthermore, a meta-analysis by Saunders et al. comparing plastic and metallic stents for pancreatic fluid collections revealed that while metallic stents offer certain advantages, plastic stents remain highly effective, especially in resource-constrained settings [3].
Although LAMS is gaining traction due to its ease of placement and larger luminal diameter, randomized trials have not consistently demonstrated its superiority over plastic stents [4]. These findings highlight the importance of cost-effectiveness and accessibility in stent selection, particularly in resource-limited environments where dual plastic stenting is a practical yet effective enhancement of standard techniques.
Practical Considerations
While dual stenting offers clear advantages, the procedure demands technical expertise. Ensuring proper positioning of the first stent before placing the second is crucial, as inadvertent migration during the procedure can complicate the intervention. This emphasizes the need for specialized training and experience among endoscopists managing pancreatic pseudocysts.
CONCLUSION
We advocate for the judicious use of plastic stents in managing pseudocysts, with dual stenting providing enhanced clinical outcomes and procedural safety. Further research comparing single and dual stenting strategies in diverse patient populations, along with randomized trials evaluating the long-term efficacy of plastic versus metallic stents, would offer invaluable insights.
