Who benefits from long-term plastic stents after walled-off necrosis treatment: prix fixe for all or à la carte?

We read with great interest the article by de Jong and colleagues [1] reporting a retrospective multicenter study on the potential preventive effect of long-term plastic stent(s) on recurrence after endoscopic treatment of walled-off necrosis (WON). In 320 patients receiving endoscopic ultrasound (EUS)-guided treatment, the recurrence rate was 10 % in patients with indwelling plastic stent(s) compared with 25 % in stent-free patients. The results are in line with our previous meta-analysis of nine published studies [2]. We, as endoscopists, will likely incorporate long-term plastic stents into the treatment algorithm and be prompted to conduct a prospective randomized trial.

Here, we would like to commend the investigators’ opinion on the indications for this treatment strategy: either all or just selected patients. The current study attests to the safety and effectiveness of indwelling plastic stent(s) focusing on patients with endoscopically managed WON overall, but this treatment may result in rare but terrible adverse events (e. g. gastrointestinal tract perforation [3]). In the era of lumen-apposing metal stents (LAMSs), this strategy requires an additional cost associated with plastic stent placement at treatment completion and may not always be feasible [4]. Of note, 75 % of stent-free patients did not experience recurrence. In our pooled analysis of pancreatic fluid collections, patients with disconnected pancreatic duct syndrome (DPDS) were at a seven-fold increased risk of recurrence [5]. In the current study, placement of long-term plastic stent(s) was associated with a low recurrence risk, independently of DPDS. We would however be interested to know whether the stent-related risk reduction differs by the pancreatic duct status. This information may help identify patients who will most likely benefit from long-term plastic stent(s) and avoid unnecessary interventions.

In conclusion, this study suggests the potential of transmural plastic stent(s) in preventing WON recurrence. Identifying target populations for long-term plastic stent(s) would maximize patients’ quality of life.

Publikationsverlauf

Artikel online veröffentlicht:
30. Oktober 2024

• References

• 1 de Jong DM, Stassen PMC, Schoots I. et al. Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis. Endoscopy 2024; DOI: 10.1055/a-2307-7123.
• 2 Iwashita T, Sato T, Hamada T. et al. Risk of recurrence with or without plastic stent after EUS-guided treatment of peripancreatic fluid collections: A systematic review and meta-analysis. Endosc Int Open 2024; 12: E188-E198
• 3 Yamauchi H, Iwai T, Kida M. et al. Complications of long-term indwelling transmural double pigtail stent placement for symptomatic peripancreatic fluid collections. Dig Dis Sci 2019; 64: 1976-1984
• 4 Bang JY, Mel Wilcox C, 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: 1275-1281.e1272
• 5 Hamada T, Iwashita T, Saito T. et al. Disconnected pancreatic duct syndrome and outcomes of endoscopic ultrasound-guided treatment of pancreatic fluid collections: Systematic review and meta-analysis. Dig Endosc 2022; 34: 676-686