Reply to Saito et al.

We would like to thank Saito et al. for their interest in our manuscript [11]. Our findings align with the meta-analysis reported by Iwashita et al. [22], supporting long-term indwelling double-pigtail stents (DPSs) to reduce pancreatic fluid collection (PFC) recurrence. Whether leaving DPSs indwelling should be a prix fixe for all or à la carte requires balanced consideration.

For patients with disconnected pancreatic duct syndrome (DPDS), indwelling a DPS is beneficial. As the studies of both Sato et al. and ourselves confirm, DPDS is a risk factor for recurrent PFCs; however, our study’s retrospective nature and lack of standardized DPDS diagnosis mean that the total number of DPDS patients is unknown. Actively assessing pancreatic duct integrity using secretin-magnetic resonance cholangiopancreatography could be an interesting approach, although its sensitivity and accuracy for DPDS remain uncertain. The results of the currently running POLAR trial (Netherlands Trial Register: NL8123) are eagerly awaited.

We found leaving DPSs indwelling was relatively safe, with only one patient experiencing gastrointestinal perforation following DPS migration, which contrasts with the report of Yamauchi et al. who reported an 8% incidence of colonic perforation with long-term indwelling DPSs [33]. Despite the 26.1% pooled complication rate reported in the aforementioned meta-analysis, none of the 37 complications were gastrointestinal perforations [22]. Additionally, Gkolfiakis et al. reported no severe complications that could not be managed by simple removal of the DPS [44].

We suggest using DPSs over lumen-apposing metal stents (LAMSs) for initial drainage. The use of DPSs reduces procedural costs and eliminates the need for a gastroscopy to remove the LAMS and replace it with a DPS, although LAMS placement may reduce the procedural time without affecting outcomes [55].

The proposed randomized trial by Sato et al. is eagerly anticipated to provide definite answers. Until then, owing to the DPDS status often being unknown and the low risk of long-term DPS complications, we advocate for the use of indwelling DPSs in all patients with walled-off necrosis to reduce the risk of PFC recurrence.

Publication History

Article published online:
30 October 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; 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 Gkolfakis P, Bourguignon A, Arvanitakis M. et al. Indwelling double-pigtail plastic stents for treating disconnected pancreatic duct syndrome-associated peripancreatic fluid collections: long-term safety and efficacy. Endoscopy 2021; 53: 1141-1149
• 5 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