Treatment of walled-off necrosis using lumen-apposing metal stents versus plastic stents: a systematic review and meta-analysis of data from randomized trials

Abstract

Background Walled-off necrosis (WON) is highly morbid disease most effectively managed by endoscopic drainage with lumen-apposing metal stents (LAMSs) or plastic stents, with or without necrosectomy. This meta-analysis compared the clinical outcomes of patients included in randomized trials treated using LAMSs or plastic stents.

Methods The MEDLINE and EMBASE databases were searched to identify all data collected from randomized trials comparing LAMSs and plastic stents for the treatment of WON. The primary outcome measure was need for endoscopic necrosectomy.

Results Three studies comprising 206 patients met inclusion criteria. Except for procedure duration, which was significantly shorter for LAMSs (standardized mean difference [SMD] −1.22, 95%CI −1.64 to −0.79), there was no significant difference in need for necrosectomy (38.5% vs. 41.2%; risk ratio [RR] 1.07, 95%CI 0.79–1.45), number of interventions (SMD −0.09, 95%CI −0.40 to 0.22), treatment success (90.7% vs. 94.5%; RR 0.96, 95%CI 0.87–1.06), recurrence (4.6% vs. 0.6%; RR 3.73, 95%CI 0.42–33.0), readmission (42.6% vs. 50.2%; RR 0.84, 95%CI 0.62–1.14), length of hospitalization (SMD −0.06, 95%CI −0.55 to 0.43), mortality (8.5% vs. 9.8%; RR 0.70, 95%CI 0.30–1.66), new-onset organ failure (10.6% vs. 14.6%; RR 0.72, 95%CI 0.16–3.32), bleeding (11.0% vs. 10.7%; RR 1.09, 95%CI 0.34–3.44), procedural adverse events (23.6% vs. 19.2%; RR 1.38, 95%CI 0.82–2.33), or overall costs (SMD −0.04, 95%CI −0.31 to 0.24) between LAMSs and plastic stents, respectively.

Conclusions Except for procedure duration, there is no significant difference in clinical outcomes for patients with WON treated using LAMSs or plastic stents.

• References

• 1 Peery AF, Dellon ES, Lund J. et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012; 143: 1179-1187
• 2 Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 92: 2379-2400
• 3 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
• 4 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13: e1-e15
• 5 Bang JY, Wilcox CM, Arnoletti JP. et al. Superiority of endoscopic interventions over minimally invasive surgery for infected necrotizing pancreatitis: meta-analysis of randomized trials. Dig Endosc 2020; 32: 298-308
• 6 Bang JY, Hasan MK, Navaneethan U. et al. Lumen-apposing metal stents for drainage of pancreatic fluid collections: When and for whom?. Dig Endosc 2017; 29: 83-90
• 7 Baron TH, DiMaio CJ, Wang AY. et al. American Gastroenterological Association Clinical Practice Update: Management of pancreatic necrosis. Gastroenterology 2020; 158: 67-75
• 8 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
• 9 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
• 10 Karstensen JG, Novovic S, Hansen EF. et al. EUS-guided drainage of large walled-off pancreatic necroses using plastic versus lumen-apposing metal stents: a single-centre randomised controlled trial. Gut 2023; 72: 1167-1173
• 11 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-188
• 12 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
• 13 Higgins JP, Altman DG, Gotzsche PC. et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928
• 14 Jadad AR, Moore A, Carroll D. et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials 1996; 17: 1-12
• 15 Ryan R, Hill S. How to GRADE the quality of the evidence. Cochrane Consumers and Communication Group. Version 3.0 December 2016. Zugriff am 09. September 2023 unter: https://opal.latrobe.edu.au/articles/journal_contribution/How_to_GRADE/6818894
• 16 Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variable from the median, range, and the size of a sample. BMC Med Res Methodology 2005; 5: 13
• 17 Wan X, Wang W, Liu J. et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodology 2014; 14: 135
• 18 Rana SS, Sharma R, Dhalaria L. et al. Efficacy and safety of plastic versus lumen-apposing metal stents for transmural drainage of walled-off necrosis: a retrospective single-center study. Ann Gastroenterol 2020; 33: 426-432
• 19 Arvanitakis 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: 524-546
• 20 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