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

Abstract

Background Endoscopic transmural drainage (ETD) using double-pigtail stents (DPSs) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPSs left indwelling versus those where stents were removed or migrated.

Methods This retrospective multicenter cohort study included patients with WON who underwent ETD using DPSs 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 covariates.

Results Among 320 patients (median age 58; 36% women), DPSs 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 (n = 39; 25.5%); after migration (n = 4; 14.8%); in patients with indwelling DPSs (n = 14; 10.0%). In 25 patients (7.8%), drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (hazard ratio [HR] 3.45, 95%CI 1.37–8.70) and presence of a disconnected pancreatic duct (HR 5.08, 95%CI 1.84–14.0).

Conclusions Among patients who undergo ETD of WON, leaving DPSs in situ seems to lower the risk of recurrent fluid collections, without any long-term DPS-related complications. These results suggest that DPSs should not be routinely removed and can be safely left indwelling indefinitely.

• References

• 1 Singh VK, Bollen TL, Wu BU. et al. An assessment of the severity of interstitial pancreatitis. Clin Gastroenterol Hepatol 2011; 9: 1098-1103
• 2 Arvanitakis M, Dumonceau JM, Albert J. et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018; 50: 524-546
• 3 Bugiantella W, Rondelli F, Boni M. et al. Necrotizing pancreatitis: A review of the interventions. Int J Surg 2016; 28: S163-S171
• 4 van Santvoort HC, Bakker OJ, Bollen TL. et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 2011; 141: 1254-1263
• 5 Jang JW, Kim MH, Oh D. et al. Factors and outcomes associated with pancreatic duct disruption in patients with acute necrotizing pancreatitis. Pancreatology 2016; 16: 958-965
• 6 Onnekink AM, Boxhoorn L, Timmerhuis HC. et al. Endoscopic versus surgical step-up approach for infected necrotizing pancreatitis (ExTENSION): long-term follow-up of a randomized trial. Gastroenterology 2022; 163: 712-722e714
• 7 van Brunschot S, van Grinsven J, van Santvoort HC. et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58
• 8 Boxhoorn L, Verdonk RC, Besselink MG. et al. Comparison of lumen-apposing metal stents versus double-pigtail plastic stents for infected necrotising pancreatitis. Gut 2023; 72: 66-72
• 9 Chandrasekhara V, Barthet M, Deviere J. et al. Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis. Endosc Int Open 2020; 8: E1639-E1653
• 10 Bang JY, Navaneethan U, Hasan MK. 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: 1200-1209
• 11 Bang JY, Wilcox CM, Navaneethan U. et al. Impact of disconnected pancreatic duct syndrome on the endoscopic management of pancreatic fluid collections. Ann Surg 2018; 267: 561-568
• 12 Shekhar C, Maher B, Forde C. et al. Endoscopic ultrasound-guided pancreatic fluid collections' transmural drainage outcomes in 100 consecutive cases of pseudocysts and walled off necrosis: a single-centre experience from the United Kingdom. Scand J Gastroenterol 2018; 53: 611-615
• 13 Bang JY, Wilcox CM, Arnoletti JP. et al. Importance of disconnected pancreatic duct syndrome in recurrence of pancreatic fluid collections initially drained using lumen-apposing metal stents. Clin Gastroenterol Hepatol 2021; 19: 1275-1281e1272
• 14 Chavan R, Nabi Z, Lakhtakia S. et al. Impact of transmural plastic stent on recurrence of pancreatic fluid collection after metal stent removal in disconnected pancreatic duct: a randomized controlled trial. Endoscopy 2022; 54: 861-868
• 15 Jagielski M, Smoczynski M, Jablonska A. et al. The role of endoscopic ultrasonography in endoscopic debridement of walled-off pancreatic necrosis--A single center experience. Pancreatology 2015; 15: 503-507
• 16 Arvanitakis M, Delhaye M, Bali MA. et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65: 609-619
• 17 Rana SS, Bhasin DK, Rao C. et al. Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis & disconnected pancreatic duct syndrome. Pancreatology 2013; 13: 486-490
• 18 Siddiqui AA, Kowalski TE, Loren DE. 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: 758-765
• 19 Rana SS, Shah J, Sharma RK. et al. Clinical and morphological consequences of permanent indwelling transmural plastic stents in disconnected pancreatic duct syndrome. Endosc Ultrasound 2020; 9: 130-137
• 20 Schmidt PN, Novovic S, Roug S. et al. Endoscopic, transmural drainage and necrosectomy for walled-off pancreatic and peripancreatic necrosis is associated with low mortality--a single-center experience. Scand J Gastroenterol 2015; 50: 611-618
• 21 Jagielski M, Smoczynski M, Adrych K. et al. Endoscopic necrosectomy under fluoroscopic guidance during transmural drainage of walled-off pancreatic necrosis (WOPN). Pol Przegl Chir 2019; 92: 12-17
• 22 Varadarajulu S, Wilcox CM. Endoscopic placement of permanent indwelling transmural stents in disconnected pancreatic duct syndrome: does benefit outweigh the risks?. Gastrointest Endosc 2011; 74: 1408-1412
• 23 Tellez-Avina FI, Casasola-Sanchez LE, Ramirez-Luna MA. et al. Permanent indwelling transmural stents for endoscopic treatment of patients with disconnected pancreatic duct syndrome: long-term results. J Clin Gastroenterol 2018; 52: 85-90
• 24 Watanabe Y, Mikata R, Yasui S. et al. Short- and long-term results of endoscopic ultrasound-guided transmural drainage for pancreatic pseudocysts and walled-off necrosis. World J Gastroenterol 2017; 23: 7110-7118
• 25 Chen YI, Yang J, Friedland S. et al. Lumen apposing metal stents are superior to plastic stents in pancreatic walled-off necrosis: a large international multicenter study. Endosc Int Open 2019; 7: E347-E354
• 26 Basha J, Lakhtakia S, Nabi Z. et al. Impact of disconnected pancreatic duct on recurrence of fluid collections and new-onset diabetes: do we finally have an answer?. Gut 2021; 70: 447
• 27 Pawa R, Dorrell R, Russell G. et al. Long-term transmural drainage of pancreatic fluid collections with double pigtail stents following lumen-apposing metal stent placement improves recurrence-free survival in disconnected pancreatic duct syndrome. Dig Endosc 2022; 34: 1234-1241
• 28 Rana SS, Gupta R. Long-term transmural plastic stenting after metal stent removal in disconnected pancreatic duct: is the debate over?. Endoscopy 2022; 54: 920
• 29 Vanbiervliet G. Prevention of pancreatic fluid collection recurrence after metal stent removal: plastic is not so fantastic!. Endoscopy 2022; 54: 869-870
• 30 Dhar J, Sachan A, Samanta J. To stent or not to stent: do we have an answer yet?. Endoscopy 2022; 54: 728-728
• 31 Rana SS, Bhasin DK, Sharma R. et al. Factors determining recurrence of fluid collections following migration of intended long term transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome. Endosc Ultrasound 2015; 4: 208-212
• 32 Gkolfakis P, Bourguignon A, Arvanitakis M. et al. Indwelling double-pigtail plastic stents for treating disconnected pancreatic duct syndrome-associated peripancreatic fluid collections: long-term safety and efficacy. Endoscopy 2021; 53: 1141-1149
• 33 Anderloni A, Fabbri C, Nieto J. et al. The safety and efficacy of a new 20-mm lumen apposing metal stent (lams) for the endoscopic treatment of pancreatic and peripancreatic fluid collections: a large international, multicenter study. Surg Endosc 2021; 35: 1741-1748
• 34 Khan S, Chandran S, Chin J. et al. Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system. J Gastroenterol Hepatol 2021; 36: 3395-3401
• 35 Mohan BP, 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: 82-90