Endoscopy 2022; 54(09): 920
DOI: 10.1055/a-1857-5600
Letter to the editor

Long-term transmural plastic stenting after metal stent removal in disconnected pancreatic duct: is the debate over?

Surinder S. Rana
1   Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
,
Rajesh Gupta
2   Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
› Author Affiliations

We read with interest the randomized controlled trial by Chavan et al. demonstrating that in patients with walled-off necrosis (WON) and disconnected pancreatic duct (DPD), deployment of plastic stents after removal of a large-caliber metal stent (LCMS) did not reduce the recurrence of pancreatic fluid collections (PFCs) [1]. In patients with resolved WON and DPD, the current practice is to leave plastic stents indefinitely to maintain the patency of the cystenterostomy tract, as published retrospective studies have shown that this strategy reduces the risk of recurrent PFCs [2] [3] [4] [5]. What is the explanation for the discordant results of the Chavan et al. trial?

The recurrence in DPD depends on the amount of functional pancreatic parenchyma left upstream of the disconnection, and we have previously shown that patients with pancreatic atrophy and diabetes have markedly reduced incidence of recurrent PFC [2]. Conversely, patients with minimal necrosis involving the neck resulting in PD disconnection at the genu, with viable pancreatic parenchyma of the body and tail, are at high risk for recurrent PFC. Hence, it would be interesting to know the extent of parenchymal necrosis in both groups as it could be one of the confounding factors.

The authors removed the LCMS at a scheduled time of 4 weeks after drainage and it is possible that the collection may not have completely resolved at this time. Placing a plastic stent in an incompletely resolved PFC can lead to subsequent blockage by necrotic material, resulting in increased risk for recurrence. In addition, a plastic stent hanging in the gastric lumen anchored only by the pigtail may not be able to provide adequate drainage and it would be interesting to study the efficacy of shorter pigtail stents, which have lower risk of migration.

Importantly, some patients with DPD do develop recurrent PFCs and the challenge is to identify these patients who can be offered long-term plastic stents.



Publication History

Article published online:
25 August 2022

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