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Abstract

We thank Dr Chen et al1Chen M. Zhu H. Jin Z. et al.Safety of lumen-apposing metal stents for pancreatic fluid drainage: waiting for a clear answer.Gastrointest Endosc. 2018; 87: 319-320Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar for their thoughtful response to our study.2Lang GD, Fritz C, Bhat T, et al. EUS-guided drainage of peripancreatic fluid collections using lumen apposing metal stents and plastic double pigtail stents: comparison of efficacy and complication rates. Gastrointest Endosc. Epub 2017 Jul 14.Google Scholar We noted an increased rate of bleeding in draining peripancreatic fluid collections (PPFCs) with lumen-apposing metal stents (LAMSs), which was not dissimilar from the observations by Bang et al3Bang JY, Hasan M, Navaneethan U, et al. Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual. Gut. Epub 2016 Aug 31.Google Scholar and Siddiqui et al.4Siddiqui A.A. Kowalski T.E. Loren D.E. et al.Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success.Gastrointest Endosc. 2017; 85: 758-765Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar With the ease of use and rapid adoption of LAMSs, we were compelled in reporting our data to insert a note of caution regarding the use of LAMSs for PPFCs. Importantly, none of the patients in this study had pseudoaneurysms identified on preprocedure imaging or EUS. Virtually all patients had cross-sectional imaging performed within 4 weeks after LAMS placement. Although we agree with Chen et al1Chen M. Zhu H. Jin Z. et al.Safety of lumen-apposing metal stents for pancreatic fluid drainage: waiting for a clear answer.Gastrointest Endosc. 2018; 87: 319-320Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar regarding the performance of early cross-sectional imaging to minimize adverse events, the optimal timing of imaging to prevent adverse events remains unknown. In our study, the 5 patients with LAMS obstruction by debris all had walled-off necrosis (WON), did not undergo an initial necrosectomy, and underwent drainage with the use of 15 mm × 10 mm stents. Four of these 5 patients then underwent necrosectomy and placement of 2 or more double-pigtail plastic stents (DPPSs) through the LAMS, with subsequent resolution. The remaining patient required a second necrosectomy and an exchange to DPPS alone for 2 months before resolution. In comparison, none of the 3 patients with up-front placement of 1 or more DPPSs through the LAMS without a preceding necrosectomy had an unplanned procedure. Perhaps the wicking around the DPPS allows for ongoing drainage and prevents occlusion of the LAMS. We also look forward to prospective data to definitively address the issue of which stent is preferred for various clinical situations and to determine whether dilation alone, placement of DPPS, initial necrosectomy, or some combination thereof is the preferred modality in the endoscopic management of WON. All authors disclosed no financial relationships relevant to this publication. Safety of lumen-apposing metal stents for pancreatic fluid drainage: waiting for a clear answerGastrointestinal EndoscopyVol. 87Issue 1PreviewWe read with great interest the article by Lang et al,1 which compared lumen-apposing metal stents (LAMSs) with double-pigtail plastic stents (DPPSs) for the adverse event rates of peripancreatic fluid collection (PPFC) drainage. Adverse events occurred more frequently than we expected in patients undergoing LAMS placement for PPFC, including bleeding episodes (4/19, 21%) and unplanned endoscopic procedures (5/19, 26%). In our previous study, we demonstrated that LAMSs were safe for patients with PPFCs. Full-Text PDF