The stent dilemma: balancing long-term benefits with risks in the management of walled-off necrosis

We read with interest the study by de Jong et al. [1], which demonstrated that indwelling double-pigtail stents significantly reduced the recurrence of pancreatic fluid collections (PFCs) compared with stent removal or migration (10.8% vs. 25.5%). These findings align with the meta-analysis by Hawa et al. [2], which similarly reported a reduction in PFC recurrence with long-term indwelling plastic stents; however, they stand in contrast to the randomized controlled trial by Chavan et al. [3], which found no significant benefit from maintaining plastic stents after large-caliber metal stent removal in patients with disconnected pancreatic duct syndrome (DPDS).

Although the robust analysis and large cohort in the de Jong study are strengths, the median follow-up of 8.2 months for patients with an indwelling plastic stent may be insufficient to fully assess the long-term complications. Of note, the meta-analysis by Hawa et al. [2] reported an 8% adverse event rate with long-term indwelling plastic stents, including cases that required surgical intervention. The technical approach also warrants attention: placing two or more stents appears more effective, but raises questions about the optimal number to maximize benefits while minimizing risks.

A critical issue is the clinical significance of PFC recurrence. The trial reported by Chavan et al. [3] showed that many recurrences were asymptomatic and did not require further intervention. Similarly, de Jong et al. [1] found that only 7.8% of patients required drainage of their recurrent PFCs. In light of these findings, future research should focus on:

• having longer follow-up to assess late-onset complications such as stent migration, occlusion, or infection

• stratification based on pancreatic parenchymal status and duct disruption pattern

• determination of the optimal technical approach, including the number and configuration of stents

• the establishment of clear criteria for clinically significant recurrence.

Future prospective studies that address these aspects could help in establishing evidence-based guidelines for the management of long-term stenting in patients with walled-off necrosis and DPDS.

Publikationsverlauf

Artikel online veröffentlicht:
22. April 2025

• References

• 1 de Jong DM, Stassen PMC, Schoots IG. et al. Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis. Endoscopy 2024; 56: 676-683
• 2 Hawa F, Chalboub JM, Vilela A. et al. Efficacy and safety of long-term indwelling plastic stents after resolution of pancreatic fluid collections with endoscopic transmural drainage: a systematic review and meta-analysis. Surg Endosc 2024; 38: 2350-2358
• 3 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