Double pigtail stent placement as an adjunct to lumen-apposing metal stents for drainage of pancreatic fluid collections may not affect outcomes

Abstract

Background and Objectives: EUS-guided drainage of pancreatic fluid collections (PFCs) has been increasingly performed using lumen-apposing metal stents (LAMS). However, recent data have suggested higher adverse event rates with LAMS compared to double pigtail plastic stents (DPS) alone. To decrease risks, there has been anecdotal use of placing DPS through the LAMS. We aimed to determine whether the placement of DPS through cautery-enhanced LAMS at time of initial placement decreases adverse events or need for reintervention. Methods: We performed a multicenter retrospective study between January 2015 and October 2017 examining patients who underwent EUS-guided drainage of pseudocysts (PP), walled-off necrosis (WON), and postsurgical fluid collection using a cautery enhanced LAMS with and without DPS. Results: There were 68 patients identified at 3 US tertiary referral centers: 44 PP (65%), 17 WON (25%), and 7 PFSC (10%). There were 35 patients with DPS placed through LAMS (Group 1) and 33 with LAMS alone (Group 2). Overall technical success was 100%, clinical success was 94%, and adverse events (bleeding, perforation, stent occlusion, and stent migration) occurred in 28% of patients. Subgroup analysis compared specific types of PFCs and occurrence of adverse events between each group with no significant difference detected in adverse event or reintervention rates. Conclusion: This multicenter study of various types of PFCs requiring EUS-guided drainage demonstrates that deployment of DPS across cautery-enhanced LAMS at the time of initial drainage does not have a significant effect on clinical outcomes, adverse events, or need for reinterventions.

Does a coaxial double pigtail stent reduce adverse events after lumen apposing metal stent placement for pancreatic fluid collections? A systematic review and meta-analysis

“…The search strategy yielded 468 records, out of which eight studies 6,7,[10][11][12][13][14][15] were included in the final analysis. Figure 1 shows the PRISMA diagram for the study selection and inclusion process.…”

“…Supplemental Figure 1 shows the risk of bias assessment for individual studies. Of the included studies, four had moderate, 6,11,14,15 and four had a high risk of bias. 7,10,12,13 Clinical success A total of five studies (n = 302) compared the clinical success between both groups.…”

“…7,10,12,13 Clinical success A total of five studies (n = 302) compared the clinical success between both groups. 6,7,[12][13][14] The pooled clinical success rate with LAMS alone and LAMS-DPS was 88.5% (95% CI: 81.3-95.8) and 87.0% (95% CI: 74.7-99.4), respectively TherapeuTic advances in Gastrointestinal endoscopy (Table 2). Clinical success was comparable between both groups (RR 1.00, 95% CI: 0.87-1.14; I 2 = 62%) (Figure 1).…”

Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges

“…Endoscopists attempt to reduce LAMS-related adverse events by additionally placing DPPS through LAMS. However, a recent multicenter retrospective study revealed that deployment of DPS through LAMS had no significant effect on clinical outcomes, adverse events, or the need for re-interventions[ 64 ]. Thus, given the relatively higher cost[ 65 ], various possible complications, and the lack of significant differences with DPPS in outcomes, the non-clinical-trial application of SEMS and LAMS is not recommended for pancreatic PPC drainage by the Asian EUS group RAND/UCLA expert panel[ 18 ].…”

Analysis of adverse events with lumen apposing metal stents for drainage of pancreatic fluid collections

“…A strategy that has been reported in the literature to decrease the risk of stent migration is placing a double-pigtail stent within the LAMS to help anchor the stent [18,19]. Shamah et al in a retrospective analysis of 68 patients comparing 35 patients with LAMS and DPS versus 33 pa-▶ tients with LAMS alone found no significant difference in AEs or clinical outcomes between the two groups [20]. In a recent randomized controlled trial by Vanek et al comparing 67 patients with WON drained with LAMS alone or LAMS with DPS, it was seen that the addition of coaxial DPS within a LAMS was associated with lower rates of AE and stent occlusion [21].…”