Re-evaluation of the role of lumen-apposing metal stents (LAMS) for pancreatic fluid collection drainage

Timing of lumen-apposing metal stents removal in pancreatic fluid collections: Could we go beyond?

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMS) are the mainstay treatment for pancreatic fluid collections (PFC). A 4-weeks interval for LAMS removal has been suggested to avoid adverse events (AEs). Primary aim is to evaluate the AEs rate in patients with LAMS removal <4 and >4 weeks from placement and possible associated factors.

METHODS

Retrospective study on patients underwent EUS-guided drainage of PFC with LAMS at two Italian centers between January 2017 and November 2023. PFC and LAMS features were collected. AEs were defined as bleeding, obstruction and buried LAMS.

RESULTS

108 patients were enrolled (62.9 % males; mean age 61 ± 14 years old). In 38 % PFC was in pancreatic head. In 64.8 % of patients LAMS ≥15 mm was used. Mean time of LAMS indwelling was 71 ± 87 days and in 73.1 % of patients the LAMS was removed after 4 weeks. AE occurred in 8.3 % of patients and the most common (77.8 %) was bleeding. There was no association between LAMS indwelling >4 weeks (8/9 vs 65/93 p = 0.44) and the rate of AE. A comparable mean time of LAMS persistence (108 ± 96 vs 67 ± 86 p = 0.18) between patients with and without AE was observed. PFC in the head (7/9 vs 33/93 p = 0.02) and LAMS ≥15 mm (9/9 vs 58/93 p = 0.03) were associated with a higher rate of AE.

CONCLUSION

When needed, LAMS removal >4 weeks appears to be as safe as LAMS removal within 4 weeks. LAMS ≥15 mm and Head location were associated with higher rate of AE and thus should arouse more caution.

The role of solid debris in endoscopic ultrasound-guided drainage of walled-off necrosis: A large cohort study

BACKGROUND AND AIM

The effect of solid debris on walled-off necrosis (WON) drainage remains unknown. Our study evaluated the role of solid debris in endoscopic ultrasound (EUS)-guided drainage of WON compared lumen-apposing metal stent (LAMS) with double-pigtail plastic stent (DPPS).

METHODS

We retrospectively evaluated consecutive patients with WON who underwent EUS-guided drainage in our endoscopic center over a 9-year period. The amount of solid debris in WON was assessed with computed tomography or magnetic resonance imaging and EUS images.

RESULTS

From 2011 to 2019, 84 WON patients were included. In WON with < 20% solid debris, the short-term clinical success of LAMSs (96.8%) was significantly higher than DPPSs (66.7%) (P = 0.03), and LAMSs were safer than DPPSs with less early adverse events (P = 0.02) and late adverse events (P = 0.03). On multivariable analysis, DPPS (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.04-0.65; P = 0.01) and solid debris > 40% (OR, 0.11; 95% CI, 0.02-0.62; P = 0.01) were the predictors for failure of resolution of WON after adjusting for age and cyst size. The number of DPPSs used was significantly higher than LAMSs in managing WONs (P < 0.001).

CONCLUSION

For WON with < 20% solid debris, LAMSs might superior to DPPSs in terms of efficacy and safety.

Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis

Background and study aims  Lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off pancreatic necrosis (WON). Recent studies suggested greater adverse event (AE) rates with LAMS for WON. We conducted a systematic review and meta-analysis to compare the safety and efficacy of LAMS with double-pigtail plastic stents (DPPS) for endoscopic drainage of WON. The primary aim was to evaluate stent-related AEs. Methods  In October 2019, we searched the Ovid (Embase, MEDLINE, Cochrane) and Scopus databases for studies assessing a specific LAMS or DPPS for WON drainage conducted under EUS guidance. Safety outcomes were AE rates of bleeding, stent migration, perforation, and stent occlusion. Efficacy outcomes were WON resolution and number of procedures needed to achieve resolution. A subanalysis including non-EUS-guided cases was performed. Results  Thirty studies including one randomized controlled trial (total 1,524 patients) were analyzed. LAMS were associated with similar bleeding (2.5 % vs. 4.6 %, P =  0.39) and perforation risk (0.5 % vs. 1.1 %, P =  0.35) compared to DPPS. WON resolution (87.4 % vs. 87.5 %, P =  0.99), number of procedures to achieve resolution (2.09 vs. 1.88, P =  0.72), stent migration (5.9 % vs. 6.8 %, P =  0.79), and stent occlusion (3.8 % vs. 5.2 %, P =  0.78) were similar for both groups. Inclusion of non-EUS-guided cases led to significantly higher DPPS bleeding and perforation rates. Conclusions  LAMS and DPPS were associated with similar rates of AEs and WON resolution when limiting analysis to EUS-guided cases. Higher bleeding rates were seen in historical studies of DPPS without EUS guidance. Additional high-quality studies of WON treatment using consistent outcome definitions are needed.

Protocol of early lumen apposing metal stent removal for pseudocysts and walled off necrosis avoids bleeding complications

Background: EUS-guided drainage of pancreatic fluid collections (PFCs; pancreatic pseudocyst (PPC) or walled-off necrosis (WON)) using lumen apposing metal stents (LAMSs) is now standard of care. We adopted a protocol of early LAMS removal and prospectively followed patients to determine if this protocol avoids bleeding complications.Methods: Prospective, consecutive case series of all patients with PPC and WON who underwent drainage with LAMS at a tertiary care referral center from July 2016 to November 2018. LAMS was removed within 4 weeks for PPC and within 6 weeks for WON. Patients with residual necrosis after 6 weeks underwent removal of initial LAMS and replacement with new LAMS every 6 weeks until resolution. Patients were followed within protocol while monitoring for bleeding complications and clinical success. We also performed a literature review to determine rates of LAMS related bleeding at various timepoints.Results: Forty patients (PPC n = 19, WON n = 21) underwent drainage with LAMS. Median time for LAMS removal was 21.0 days for PPC and 33.5 days for WON. Technical success and clinical success were achieved in 40/40 patients with zero cases of delayed bleeding. A literature review of 21 studies and 1378 patients showed 52/1378 (3.8%) bleeding events with 24/52 (46.2%) events occurring within 1 week of LAMS placement.Conclusions: An early removal LAMS protocol for PFC is highly efficacious and prevents delayed bleeding. Based on analysis of published cases, half of LAMS related bleeding occurs within the first week suggesting procedural factors rather than stent dwell time impact risk of bleeding.

Lumen-apposing metal stents (LAMS) versus plastic stents for EUS-guided drainage of walled-off necrosis (WON) (LVPWON): study protocol for a multicenter randomized controlled trial

BACKGROUND

Endoscopic ultrasonography (EUS)-guided drainage has become the first-line therapy for late peri-pancreatic fluid collection (PFC). Double pigtail plastic stents (DPPS) and lumen-apposing metal stents (LAMS) are commonly used for PFC drainage. Recently, a multi-institutional consensus on PFC drainage has recommended that LAMS should be the standard care for patients with walled-off necrosis (WON). However, given the poor quality of evidence, we aim to perform a large-scale randomized controlled trial to determine whether LAMS is superior to DPPS for WON drainage.

METHODS/DESIGN

The study is an open-label, prospective, parallel-group, superiority, multicenter randomized controlled trial. Two hundred and fifty-six patients with WON who will attend 18 tertiary hospitals in China will be randomly allocated to the LAMS or DPPS group before the procedure. The primary endpoint is the clinical success at one month after drainage (reduction in the size of WON to < 2 cm). Secondary endpoints include technical success, operation time, recurrence, adverse events, and secondary interventions.

DISCUSSION

The LVPWON trial is designed to determine whether LAMS is effective, safe, and superior to DPPS for WON drainage.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03027895 . Registered on 14 January 2017.