Reply to Saito et al.

I thank the authors for their interest in our recent meta-analysis. Anything that can be measured objectively in clinical research is easy to address, define, and improvise. Anything that is subjective can only be perceived, remains undefined, and is difficult to improvise. Randomized trials have a clear end point; hence, the conclusions of our meta-analysis were definitive and unequivocal. Factors such as prolonged treatment duration and repeated instrumentation at endoscopic necrosectomy are difficult to grade, so cannot be compared objectively between endoprostheses. However, despite the lack of objective data, intuitively it makes sense that repeated instrumentation via a lumen-apposing metal stent (LAMS)-gated channel is technically easy to perform. Therefore, when the cost of a dedicated endoprosthesis is not a pain point, one can most certainly opt to use a LAMS in lieu of a plastic stent, knowing full well that the clinical outcome may not be different. To phrase this differently, there is no downside to using plastic stents because clinical outcomes are comparable to LAMSs, but with the caveat that procedural steps such as necrosectomy may be more laborious.

The authors query whether there is a selective patient subset that can benefit from the use of LAMSs. In a study of 303 patients who underwent drainage of pancreatic fluid collections, we observed that the use of plastic stents (odds ratio [OR] 2.7, 95%CI 1.2–6.0; P = 0.01), and patients receiving high acuity care (OR 5.1, 95%CI 2.5–10.4; P < 0.001) or with ≥33% necrosis (OR 4.5, 95%CI 2.0–10.0; P < 0.001) were significantly associated with the presence of a systemic inflammatory response or new organ failure that prolonged overall hospital stay [11]. Consequently, sick patients with a high degree of necrosis, who are also more likely to require multiple reinterventions, form a subset of patients who could benefit from the selective use of LAMSs.

Publication History

Article published online:
28 March 2024

• References

• 1 Bang JY, Wilcox CM, Navaneethan U. et al. Impact of endoprosthesis type on inflammatory response in patients undergoing endoscopic drainage of pancreatic fluid collections. Dig Endosc 2023; DOI: 10.1111/den.14565.