Plastic stent replacement after metal stent removal – what about patients with residual walled-off necrosis collections?

We read with great interest the article by Chavan et al. [1]. The authors studied the effect of plastic stent placement after removal of a large metal stent in patients with walled-off necrosis (WON) and disconnected pancreatic duct. They conclude that there was no significant difference in the recurrence of pancreatic fluid collections (PFCs) between the patients with or without plastic stent placement.

Although this study was very well conducted, we would like to point out that these results should be interpreted with some caution. The study only included patients with complete resolution of their WON collection at 4 weeks. In our experience, a considerable proportion of patients with a large WON collection do not show complete resolution after 4 weeks. This discrepancy could be due to the fact that the authors claim to include only patients with WON collections as defined by the revised Atlanta criteria [2]; however, the percentage of debris was less than 30 % in almost all cases. Pseudocysts tend to resolve faster owing to their liquid content compared with WON collections. Furthermore, the selection of patients with complete resolution also explains the number of failed plastic stent placements (11.5 %).

We would also advocate the removal of the large metal stent at 4 weeks to prevent complications; however, in cases of a residual WON collection without the need for necrosectomy, we would replace it with plastic double-pigtail stent(s), similarly to Bang et al. [3]. This will promote further resolution and prevent superinfection. However, the debate on whether this prevents PFC recurrence in the future in patients with incomplete WON resolution at 4 weeks remains open.

Publication History

Article published online:
29 March 2023

• References

• 1 Chavan R, Nabi Z, Lakhtakia S. et al. Impact of transmural plastic stent on recurrence of pancreatic fluid collection after metal stent removal is disconnected pancreatic duct: a randomized controlled trial. Endoscopy 2022; 54: 861-868
• 2 Banks PA, Bollen TL, Dervenis C. et al. Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
• 3 Bang JY, Navaneethan U, Hasan MK. et al. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial. Gut 2019; 68: 1200-1209