Lumen apposing metal stents in drainage of pancreatic walled-off necrosis, are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections

Abstract

Lumen-apposing metal stents (LAMS) are increasingly being used in the drainage of pancreatic walled-off necrosis (WON). Best choice of stent is subject to argument, and studies are varied in the reported outcomes between LAMS and plastic stents (PS) to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception through July 2018) to identify studies that reported on the use of LAMS and PS in WON drainage. Studies published since the release of the revised Atlanta classification for pancreatic fluid collections (2014 to current) were included in the analysis. The outcomes were to estimate and compare the pooled rates of clinical success, and adverse-events. A total of 9 studies (737 patients) for LAMS and 6 studies (527 patients) for PS were included in the analysis. The pooled rate of clinical-success with LAMS was 88.5% (95% CI 82.5-92.6, I 2 = 71.7) and with PS was 88.1% (95% CI 80.5-93.0, I 2 = 78.1) and the difference was not statistically significant, P = 0.93. No difference was noted in the pooled rates of all adverse-events, LAMS: 11.2% (6.8-17.9, I 2 = 82.0); vs PS: 15.9% (8.4-27.8, I 2 = 78.8); P = 0.38. Based on our meta-analysis, LAMS and PS demonstrate equal clinical outcomes and equal adverse-events in the drainage of pancreatic WON.

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections

“…Furthermore, 2 systematic reviews, including comparative studies between plastic and metal stents (FCSEMS and/or LAMS) [23, 25], also demonstrated a higher rate of clinical success and a lower rate of adverse events with metal stents for both pseudocysts and WON. In contrast, 2 other systematic reviews [24, 33] showed no difference in overall treatment success or rates of adverse events between PS and metal stents.…”

Endoscopic Management of Pancreatic Fluid Collections: An Update

“…In three of the published systematic reviews and meta-analyses, metal stents were found superior to plastic stents for both pseudocysts as well as WON in terms of clinical success and adverse events [34,36,32]. On the contrary, two other systematic reviews and meta-analyses did not find a difference in the outcomes between metal or plastic stents [33,37]. It must be emphasized that the paucity of randomized trials is the major limitations of these reviews.…”

“…In addition, the treatment cost (LCMS: US$12155 vs. plastic stents: US$6609) and stent related adverse events were higher in the LCMS group (32.3 vs. 6.9%, p = 0.01) [24]. Several systematic reviews and meta-analyses draw conflicting conclusions while comparing plastic stents vs. metal stents for ETD of PFCs [32][33][34][35][36][37]. In three of the published systematic reviews and meta-analyses, metal stents were found superior to plastic stents for both pseudocysts as well as WON in terms of clinical success and adverse events [34,36,32].…”

The role of endoscopic therapy in the minimally invasive management of pancreatic necrosis

“…Recent data suggests that this risk of adverse events with LAMS may be ameliorated by the placement of a coaxial double pigtail stent to prevent mechanical agitation of intra-cystic vessels and stent occlusion by necrosis or tissue overgrowth [ 36 , 37 ]. A recent systematic review of 737 patients from nine studies found similar rates of clinical success (88.5% vs. 88.1%, p = 0.93) and adverse events (11.2% vs. 15.9%, p = 0.38) compared to DPPS [ 38 ]. Based on this data, while LAMS offer technical advantages for the endoscopic management of WON, it is unclear that this technology translates to superior outcomes for patients.…”