Endoscopic ultrasound guided transmural drainage using metal stents versus plastic stent for management of symptomatic walled-off necrosis: A meta-analysis of randomized controlled trials with trial sequential analysis

Aims Endoscopic ultrasound-guided transmural drainage (EUS-D) of symptomatic walled-off necrosis (WON), with or without necrosectomy, is currently the preferred treatment strategy. This can be achieved using either metal or plastic stents. Whether use of metal stent offers any benefit over plastic stent, in terms of clinical efficacy and safety, is still a debatable topic, with ambiguous results across various studies. Hence, a meta-analysis of randomized controlled trials (RCTs) was planned to compare the two stents for various outcome parameters. A trial sequential analysis (TSA) was also performed to assess the credibility of our findings.

Methods A literature search was made using MEDLINE (PubMed), EMBASE and Scopus databases till August 2024, to identify RCTs directly comparing metal (both bi-flanged and/or lumen apposing metal stents) versus plastic stents for management of WON. The key primary and secondary outcome measure was long term clinical success and need for direct endoscopic necrosectomy (DEN), respectively. Other secondary parameters analyzed were technical success, total number of DEN and overall interventions, adverse events (overall and stent related), procedural duration and hospital stay [1] [2] [3].

Results Six RCTs were included in the final analysis (352 patients; metal stent [n=177] vs plastic stent [n=175]). RoB2 criteria yielded low risk of bias in all studies. In the metal stent group, Hot-AXIOS was used in 3 studies, Hot-SPAXUS 1, NAGI stent 1 and both Hot-AXIOS and NAGI stent in 1 study. Except for post-procedural sepsis (6 studies; RR 0.45; 95% CI 0.24-0.84; p=0.01) and procedural duration (6 studies; mean difference -12.20, -19.30 to -5.10; p=0.0008) which was significantly lower in metal stent group, there were no significant differences in terms of long term clinical success (RR 1.02, 0.92-1.13 95% CI; p=0.66), need of DEN (RR 0.94, 0.63-1.37; p=0.72), total number of DEN sessions (mean difference 0.95, -2.14 to 4.04; p=0.55), technical success (RR 1.00, 0.98-1.03; p=0.80), and overall reintervention rates (mean difference 0.01, -0.16 to 0.18; p=0.90). Comparing the safety profile, overall adverse events (RR 0.82, 0.50-1.34; p=0.42) and stent-related adverse events (RR 0.80, 0.42-1.51; p=0.48) were similar (bleeding rates [RR 1.26, 0.51-3.11; p=0.62] and stent migration [RR 0.75, 0.28-2.03; p=0.57]). On follow-up, recurrence rates (p=0.45), need of percutaneous catheter drainage (p=0.58), surgery (p=0.41) and mortality (p=0.86) between the 2 stents was also similar. TSA performed calculated the required information size (RIS) to be 23,609 patients for long-term clinical success and 4412 patients for DEN.

Conclusions The comparison between metal vs plastic stents for EUS-guided drainage of WON was comparable in terms of clinical efficacy and safety, except for lower post-procedural sepsis and procedure duration. This advantage could translate to the preferential use of metal stents in sicker, infected cohort of WON patients (Prospero ID: CRD42024523165)

 

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Conflicts of Interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Kakadiya R, Muktesh G, Samanta J, Mandavdhare HS, Gupta P, Shah J, Sarma P, Gupta V, Yadav TD, Jena A, Sharma V, Kochhar R.. Plastic versus metal stents for transmural drainage of walled-off necrosis with significant solid debris: a randomized controlled trial. Endosc Int Open 2023; 11 (11): E1069-E1077
• 2 Muktesh G, Samanta J, Dhar J, Agarwala R, Bellam BL, James D, Gupta P, Chauhan R, Yadav TD, Gupta V, Sinha SK, Kochhar R.. Endoscopic Ultrasound-guided Drainage of Patients With Infected Walled-off Necrosis: Which Stent to Choose?. Surg Laparosc Endosc Percutan Tech 2022; 32 (03): 335-341
• 3 Samanta J, Dhar J.. Plastic is as good as metal: is the 'debris clearance' debate for walled-off necrosis drainage finally over?. Gut 2023; 72 (06): 1223-1224

Publication History

Article published online:
27 March 2025