Lumen-apposing metal stents for pancreatic fluid collections: what makes a difference?

We read with great interest the article by Mangiavillano and colleagues [1] reporting a retrospective multicenter study on lumen-apposing metal stents (LAMSs) for endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs). Using propensity score matching, the authors demonstrated that the Spaxus stent, with its smoothly shaped edges, may mitigate bleeding risk compared with the widely used Axios stent. Based on these promising results, we endoscopists will likely be prompted to conduct a prospective randomized trial.

We should pay attention to the following factors to prevent severe bleeding [2] [3]: (i) EUS-guided puncture of a PFC and self-expansion of the LAMS (with supplementary balloon dilation); (ii) mechanical contact with the LAMS edge; and (iii) subsequent endoscopic necrosectomy for walled-off necrosis. Severe bleeding occurred in two patients with the Spaxus stent (one around the stent and one within a PFC cavity), whereas five and four patients in the Axios group experienced stent-related and intracavity bleeding, respectively. LAMSs were deployed using an electrocautery-enhanced delivery system or a cystotome with the same cutting current for all cases. Most of the bleeding events occurred more than 48 hours after the procedure. Therefore, the difference in bleeding risk appeared not to be attributable to the between-group heterogeneity in the puncture procedures. Herein, we commend the authors for providing information on whether intracavity bleeding was related to necrosectomy or other factors (e.g. pseudoaneurysm [4]) and whether the preventive effect of the Spaxus stent on bleeding differed with the placement of a coaxial plastic stent [5]. This information may serve as valuable data when considering preventive measures for LAMS-related bleeding events.

In conclusion, this study suggests differential risk profiles for LAMSs, presumably owing to the stent designs. A better understanding of the mechanism through which the different designs affect bleeding risk would help us design new LAMSs and improve patient outcomes.

Publication History

Article published online:
29 August 2024

• References

• 1 Mangiavillano B, Lakhtakia S, Samanta J. et al. Lumen-apposing metal stents for the treatment of pancreatic and peripancreatic fluid collections and bleeding risk: a propensity matched study. Endoscopy 2024; DOI: 10.1055/a-2219-3179.
• 2 Saito T, Omoto S, Takenaka M. et al. Risk factors for adverse outcomes at various phases of endoscopic ultrasound-guided treatment of pancreatic fluid collections: data from a multi-institutional consortium. Dig Endosc 2023; DOI: 10.1111/den.14683.
• 3 Fugazza A, Sethi A, Trindade AJ. et al. International multicenter comprehensive analysis of adverse events associated with lumen-apposing metal stent placement for pancreatic fluid collection drainage. Gastrointest Endosc 2020; 91: 574-583
• 4 Abdallah M, Vantanasiri K, Young S. et al. Visceral artery pseudoaneurysms in necrotizing pancreatitis: risk of early bleeding with lumen-apposing metal stents. Gastrointest Endosc 2022; 95: 1150-1157
• 5 Vanek P, Falt P, Vitek P. et al. EUS-guided transluminal drainage using lumen-apposing metal stents with or without coaxial plastic stents for treatment of walled-off necrotizing pancreatitis: a prospective bicentric randomized controlled trial. Gastrointest Endosc 2023; 97: 1070-1080 DOI: 10.1016/j.gie.2022.12.026. (PMID: 36646148)