From lumen-apposing metal stents to plastic stents: going backward may be progress

Abstract

Abdallah et al1Abdallah M. Vantanasiri K. Young S. et al.Visceral artery pseudoaneurysms in necrotizing pancreatitis: risk of early bleeding with lumen-apposing metal stents.Gastrointest Endosc. 2022; 95: 1150-1157Abstract Full Text Full Text PDF Scopus (1) Google Scholar reported an earlier development of pseudoaneurysm (PSA), seen in patients with lumen-apposing metal stents (LAMSs). Because research focusing on PSA in patients with necrotizing pancreatitis (NP) is limited, this study fittingly enriched the existing literature on PSA, which may have an important impact on NP management. In comparison with plastic stents (PSs), the deployment of LAMSs is technically easy, and the large diameter facilitates rapid drainage of necrotic contents. Thus, LAMSs are increasingly preferred over PSs for the drainage of pancreatic fluid collection (PFC). However, serious LAMS-related adverse events reported by Bang et al2Bang J.Y. Hasan M. Navaneethan U. et al.Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual.Gut. 2017; 66: 2054-2056Crossref PubMed Scopus (134) Google Scholar arouse great concern. In their study, PSA was confirmed in all 3 patients who presented with severe GI bleeding. It was postulated that friction between LAMSs and the vasculature surrounding the necrotic cavity may predispose to PSA formation, and the hypothesis was well testified by Abdallah et al1Abdallah M. Vantanasiri K. Young S. et al.Visceral artery pseudoaneurysms in necrotizing pancreatitis: risk of early bleeding with lumen-apposing metal stents.Gastrointest Endosc. 2022; 95: 1150-1157Abstract Full Text Full Text PDF Scopus (1) Google Scholar inasmuch as the close anatomic proximity of PSA and LAMSs was seen in most patients. Given the widespread use of LAMSs and the lethal stent-related bleeding, we cannot help thinking about the question whether the indications for using LAMSs in patients with NP should be rigorously established. First, the only published randomized controlled trial demonstrated nonsuperiority of LAMSs over PSs for drainage of walled-off necrosis except for procedure duration.3Bang J.Y. Navaneethan U. Hasan M.K. et al.Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial.Gut. 2019; 68: 1200-1209Crossref PubMed Scopus (121) Google Scholar Our study and a meta-analysis also supported equal clinical outcomes and adverse events in the drainage of PFC.4Wang Z. Zhao S. Meng Q. et al.Comparison of three different stents for endoscopic ultrasound-guided drainage of pancreatic fluid collection: a large retrospective study.J Gastroenterol Hepatol. 2019; 34: 791-798Crossref PubMed Scopus (23) Google Scholar,5Mohan B.P. Jayaraj M. Asokkumar R. et al.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.Endosc Ultrasound. 2019; 8: 82-90Crossref PubMed Google Scholar Moreover, LAMSs were recommended to be replaced by indwelling PSs in patients with suspected disconnected pancreatic duct syndrome (DPDS) to prevent PFC recurrence.6Arvanitakis M. Dumonceau J.M. Albert J. et al.Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines.Endoscopy. 2018; 50: 524-546Crossref PubMed Scopus (185) Google Scholar Of note, DPDS is reported to occur in approximately 20% to 40% of patients with NP.7Boxhoorn L. Voermans R.P. Bouwense S.A. et al.Acute pancreatitis.Lancet. 2020; 396: 726-734Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Thus, the initial use of PSs instead of LAMSs may benefit most in selected patients with suspected DPDS, high risk of bleeding, financial difficulty, or other potential situations, and early removal or subsequent replacement of LAMSs could be avoided. All authors disclosed no financial relationships. Visceral artery pseudoaneurysms in necrotizing pancreatitis: risk of early bleeding with lumen-apposing metal stentsGastrointestinal EndoscopyVol. 95Issue 6PreviewVisceral artery pseudoaneurysm (PSA) in necrotizing pancreatitis (NP) is associated with significant morbidity and mortality. This study aimed to evaluate the incidence, clinical presentation, management, and outcomes of PSA in NP. Full-Text PDF ResponseGastrointestinal EndoscopyVol. 95Issue 6PreviewWe thank Wang et al1 for their interest in our recent publication.2 The authors have proposed revisiting the indications for lumen-apposing metal stents (LAMSs) in necrotizing pancreatitis, given its risk for bleeding, the need for revision to plastic stents in the setting of disconnected pancreatic duct syndrome (DPDS), and financial concerns. Although we agree with these observations, we wish to highlight some of our study findings that should be taken into context. Whereas an earlier incidence of pseudoaneurysm (PSA) was identified in patients treated with LAMSs (44 days vs 85 days, P = .02), PSA can occur in patients treated with plastic stents. Full-Text PDF