Early removal of biflanged metal stents in the management of pancreatic walled-off necrosis: a prospective study

Abstract

Background and study aims Dedicated stents placed under endoscopic ultrasound (EUS) guidance have shown promise for the management of pancreatic walled-off necrosis (WON). A long duration of stent placement may increase the risk of adverse events. We prospectively evaluated the effects of (i) early removal of biflanged metal stents (BFMSs) and (ii) additional stenting of the pancreatic duct with plastic stents in patients with ductal leaks, on the risk of WON recurrence.

Patients and methods Symptomatic patients with pancreatic WON underwent EUS-guided BFMS placement, followed by necrosectomy, when required, from Day 3. A 5 Fr plastic stent was placed in patients with ductal leak. BFMS was removed when the WON cavity had collapsed completely. Patients were followed up at 3-month intervals.

Results BFMS placement was successful in all 88 patients. A total of 64 patients (72.7 %) underwent necrosectomy (median 3 sessions). All BFMSs were removed at a median of 3.5 weeks (range 3 – 17 weeks). Ductal disconnection and leak occurred in 53/87 (60.9 %) and 61/87 (70.1 %) patients, respectively. A 5 Fr stent was placed in 56/61 patients (91.8 %) with ductal leak. Overall, 22 patients (25.0 %) had adverse events (17 mild, 1 moderate, 3 severe, 1 fatal). Recurrence was noted in 8/88 (9.1 %) at a median follow-up of 22 months. The recurrence rate was higher in patients with ductal disconnection than in those without (13.2 % vs. 2.9 %; P = 0.08), and was similar in patients with vs. without pancreatic duct stenting (7.1 % vs. 12.9 %; P = 0.44). Seven recurrences (87.5 %) partially regressed on follow-up and did not require therapy; in one case, drainage with a plastic stent was performed.

Conclusions Short-term BFMS placement is an effective therapy for pancreatic WON. The majority of recurrences developed in patients with ductal disconnection and did not require therapy. Additional pancreatic duct stents probably do not influence the recurrence rate.

• References

• 1 Tyberg A, Karia K, Gabr M. et al. Management of pancreatic fluid collections: a comprehensive review of the literature. World J Gastroenterol 2016; 22: 2256-2270
• 2 Rinninella E, Kunda R, Dollhopf M. et al. EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video). Gastrointest Endosc 2015; 82: 1039-1046
• 3 Siddiqui AA, Adler DG, Nieto J. et al. EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent: a large retrospective, multicenter U.S. experience (with videos). Gastrointest Endosc 2016; 83: 699-707
• 4 Chandran S, Efthymiou M, Kaffes A. et al. Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: a national experience (with videos). Gastrointest Endosc 2015; 81: 127-135
• 5 Bang JY, Hasan M, Navaneethan U. et al. Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual. Gut 2017; 66: 2054-2056
• 6 Aravanitakis M, Delhaye M, Bali MA. et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65: 609-619
• 7 Dhir V, Teoh AY, Bapat M. et al. EUS-guided pseudocyst drainage: prospective evaluation of early removal of fully covered self expandable metal stents with pancreatic ductal stenting in selected patients. Gastrointest Endosc 2015; 82: 650-657
• 8 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
• 9 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon of endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 10 Sharaiha RZ, Tyberg A, Khashab MA. et al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol 2016; 14: 1797-1803
• 11 Siddiqui AA, Kowalski TE, Loren DE. et al. Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc 2017; 85: 758-765
• 12 Teoh AY, Ng EK, Chan SM. et al. Ex vivo comparison of the lumen-apposing properties of EUS-specific stents (with video). Gastrointest Endosc 2016; 84: 62-68
• 13 Fulcher AS, Turner MA, Capps GW. et al. Half-Fourier RARE MR Cholangiopancreatography. Experience in 300 subjects. Radiology 1998; 207: 21-32
• 14 Nealon WH, Bhutani M, Riall TS. et al. A unifying concept: pancreatic ductal anatomy both predicts and determines the major complications resulting from pancreatitis. J Am Coll Surg 2009; 208: 790-799
• 15 Amin S, Yang DJ, Lucas AL. et al. There is no advantage to transpapillary pancreatic duct stenting for the transmural endoscopic drainage of pancreatic fluid collections: a meta-analysis. Clin Endosc 2017; 50: 388-394
• 16 Trevino JM, Tamhane A, Varadarajulu S. Successful stenting in ductal disruption favorably impacts treatment outcomes in patients undergoing transmural drainage of peripancreatic fluid collections. J Gastroenterol Hepatol 2010; 25: 526-531
• 17 Ng PY, Rasmussen DN, Vilmann P. et al. Endoscopic ultrasound-guided drainage of pancreaic pseudocysts: medium term assessment of outcomes and complications. Endosc Ultrasound 2013; 2: 199-203
• 18 Seewald S, Ang TL, Richter H. et al. Long-term results after endoscopic drainage and necrosectomy of symptomatic pancreatic fluid collections. Dig Endosc 2012; 24: 36-41
• 19 Pelaez-Luna M, Vege SS, Petersen BT. et al. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc 2008; 68: 91-97
• 20 Lawrence C, Howell DA, Stefan AM. et al. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointest Endosc 2008; 67: 673-679
• 21 Bang JY, Wilcox CM, Navaneethan U. et al. Impact of disconnected pancreatic duct syndrome on the endoscopic management of pancreatic fluid collections. Ann Surg 15.11.2016; DOI: 10.1097/SLA.0000000000002082.