Long-term transmural plastic stenting after metal stent removal in disconnected pancreatic duct: is the debate over?

Rana, Surinder Singh; Gupta, Rajesh

doi:10.1055/a-1857-5600

Cited by 3 publications

(3 citation statements)

References 5 publications

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“…This was not significantly associated with plastic stents replacement in both intention-to-treat analyses and per-protocol analyses. The trial has some limitations however, as postulated in three letters to the editor [28][29][30]. Firstly, the follow-up period stopped after one year, potentially missing an important part of follow-up as previous studies have shown that PFC recurrence mostly occurred in the first two years.…”

Section: Discussionmentioning

confidence: 99%

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis

Voermans,

de Jonge,

de Jong

et al. 2024

Endoscopy

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Background and study aims: Endoscopic transmural drainage (ETD) using double pigtail stents (DPS) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPS left indwelling versus those where stents were removed or migrated. Patients and methods: This retrospective, multicenter cohort study included patients with WON who underwent ETD using DPS between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariate. Results: Among 320 patients (median age 58, 36% female), DPS were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal in 39 (25.5%), after migration in 4 (14.8%) and in patients with indwelling DPS in 14 patients (10%). In 25 patients (7.8%) drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (HR: 3.45, 95%CI: 1.37–8.70) and presence of a disconnected pancreatic duct (HR: 3.45, 95%CI: 1.84–14.0). Conclusions: Among patients who undergo ETD of WON, leaving DPS in situ seems to lower the risk on recurrent fluid collections, without any long term DPS-related complications. These results suggest that DPS should not be routinely removed and can be safely left indwelling indefinitely.

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Section: Discussionmentioning

confidence: 99%

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis

Voermans,

de Jonge,

de Jong

et al. 2024

Endoscopy

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“…Besides, there were some cases in which the DPS was hanging in the gastric lumen anchored only by the pigtail - which should not provide adequate drainage. As Rana et al argued in a letter about this RCT, besides the time after drainage to deploy DPS, other reasons should be considered, such as the amount of functional pancreatic parenchyma left upstream of the disconnection that influences the possibility of PFC recurrence [ 36 ]. DPDS is still an underdiagnosed and challenging condition, many aspects regarding endoscopic management after EUS-drainage are still unanswered, such as the perfect time to replace metal stent to DPS, the clinical impact and safety of long-term indwelling DPS and when to remove or not the indwelling DPS [ 37 ].…”

Section: Discussionmentioning

confidence: 99%

Self-Expandable Metal Stent (SEMS) Versus Lumen-Apposing Metal Stent (LAMS) for Drainage of Pancreatic Fluid Collections: A Randomized Clinical Trial

Santos¹,

Proença²,

Ribeiro³

et al. 2023

Cureus

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Background and aimEndoscopic ultrasound (EUS)-guided drainage is the gold standard approach for the treatment of encapsulated pancreatic collections (EPCs) including pseudocyst and walled-off pancreatic necrosis (WON), and is associated with an equivalent clinical efficacy to surgical drainage with fewer complications and less morbidity. Drainage may be achieved via several types of stents including a fully covered self-expandable metallic stent (SEMS) and lumen-apposing metal stent (LAMS). However, to date there have been no randomized trials to compare these devices. This study aimed to compare the efficacy and safety of the SEMS versus LAMS for EUS-guided drainage of EPCs. MethodsA phase IIB randomized trial was designed to compare the SEMS versus LAMS for the treatment of EPCs. Technical success, clinical success, adverse events (AEs), and procedure time were evaluated. A sample size of 42 patients was determined. ResultsThere was no difference between the two groups in technical (LAMS 80.95% vs 100% SEMS, p=0.107), clinical (LAMS 85.71% vs 95.24% SEMS, p=0.606) or radiological success (LAMS 92.86% vs 83.33% SEMS, p=0.613). There was no difference in AEs including stent migration rate and mortality. The procedure time was longer in the LAMS group (mean time 43.81 min versus 24.43 min, p=0.001). There was also a difference in the number of intra-procedure complications (5 LAMS vs 0 SEMS, p=0.048). ConclusionSEMS and LAMS have similar technical, clinical, and radiological success as well as AEs. However, SEMS has a shorter procedure time and fewer intra-procedure complications compared to non-electrocauteryenhanced LAMS in this phase IIB randomized controlled trial (RCT). The choice of the type of stent used for EUS drainage of EPCs should consider device availability, costs, and personal and local experience.

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“…29 The remnant pancreatic tissue above the disrupted pancreatic duct might predict PFC recurrence, although this was not investigated in the aforementioned studies. 86 Long-term PSs appear safe, with 3.5% local complications and 3.5% migration. 87…”

Section: Clinical Outcomes Of Eus Drainagesmentioning

confidence: 93%

Endoscopic ultrasound drainage of pancreatic fluid collections: do we know enough about the best approach?

Seicean

Pojoga

Rednic

et al. 2023

Therap Adv Gastroenterol

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Pancreatic fluid collection often occurs as a local complication of acute pancreatitis, and drainage is indicated in symptomatic patients. The drainage may be surgical, percutaneous, or endoscopic ultrasound (EUS) guided. In symptomatic collections older than 4 weeks and localized in the upper abdomen, EUS-guided drainage is the first choice of treatment. Lumen-apposing metal stents are useful in cases of walled-off necrosis, facilitating access to the cavity; however, they do not reduce the number of necrosectomy sessions required. In most pancreatic pseudocysts requiring drainage, plastic stents remain the first choice of treatment. This review aimed to summarize the principles and techniques of step-up therapy of pancreatic fluid collections, including preprocedural and postprocedural assessment and practical approaches of drainage and necrosectomy, making available evidence more accessible to endoscopists aiming to train for this procedure. Successful and safe EUS drainage connotes early recognition and treatment of complications and the presence of a multidisciplinary team for optimal patient management. However, the best time for necrosectomy, modality of drainage method (lumen-apposing metal stents or plastic stents), and duration of antibiotherapy are still under evaluation.

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Long-term transmural plastic stenting after metal stent removal in disconnected pancreatic duct: is the debate over?

Cited by 3 publications

References 5 publications

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis

Self-Expandable Metal Stent (SEMS) Versus Lumen-Apposing Metal Stent (LAMS) for Drainage of Pancreatic Fluid Collections: A Randomized Clinical Trial

Endoscopic ultrasound drainage of pancreatic fluid collections: do we know enough about the best approach?

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