Reply to Saito et al

We would like to thank Saito T and colleagues for their comments about and interest in our study about the timing of lumen-apposing metal stent (LAMS) removal during endoscopic ultrasound-guided treatment of pancreatic fluid collections (PFCs) [1]. We agree with the authors that a better understanding of which PFCs will require longer LAMS placement is needed to optimize patient care. Here are some details about our results.

The major reasons for clinical failure in the early stent removal group were either exacerbating infection despite endoscopic management or recurrent sepsis after stent removal. We also experienced adverse events (AEs) such as stent dislodgement during early necrosectomies, which resulted in clinical failure. Walled-off necrosis (WON) was associated with a lower clinical success rate in both the early stent removal group (61.5%) and the delayed stent removal group (94.6%) as compared with the pseudocyst group (85.7% and 100% respectively).

As therapeutic endoscopists who treat PFCs on a regular basis, many of us have experienced the difference between a simple collection that can be drained in one session and more complex, larger, debris-filled collections which will likely require multiple interventions [2]. In our experience, patience is key in management of this second group of patients. The inflammatory process following the initial insult in acute pancreatitis can take several weeks to resolve [3]. We believe a more conservative approach, with longer stent placement for passive drainage, can reduce the need for necrosectomies or stent replacement, both of which can cause AEs and result in clinical failure [4] [5].

Finally, we agree with our colleagues: A large prospective clinical trial is now needed to better understand which patients will benefit from longer LAMS placement. Before we move forward, the endoscopic ultrasound community needs to standardize the definition of treatment success and refine the classification of WON to better characterize large and complex collections that will likely require multiple interventions.

Publication note

Letters to the editor do not necessarily represent the opinion of the editor or publisher. The editor and publisher reserve the right to not publish letters to the editor, or to publish them abbreviated or in extracts.

Conflict of Interest

Anand Sahai is a consultant for Boston Scientific. Philippe Willems has been paid honoraries for presentations by Boston Scientific and Advanz Pharma. SP has no conflicts to declare.

• References

• 1 Willems P, Esmail E, Paquin SC. et al. Safety and efficacy of early versus late removal of LAMS for pancreatic fluid collections. Endosc Int Open 2024; 12: E317-E323
• 2 Gardner TB. Plastic stents: silenced by the LAMS?. Endoscopy 2024; 56: 196-197
• 3 Hoque R, Malik AF, Gorelick F. et al. Sterile inflammatory response in acute pancreatitis. Pancreas 2012; 41: 353-357
• 4 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
• 5 Bang JY, Lakhtakia S, Thakkar S. et al. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial. Lancet Gastroenterol Hepatol 2024; 9: 22-33

Publication History

Received: 25 March 2024

Accepted: 09 April 2024

Article published online:
21 May 2024