Reply to Rana and Gupta

We thank Rana et al. for their interest and insightful comments on our recently published article [1]. In our study, metal stents were replaced with plastic stents after resolution of walled-off necrosis (WON). The clinical settings were different from those described in previous studies where index drainage was performed using plastic stents [2] [3]. We believe that this is a highly relevant scenario in the current era where large-caliber metal stents (LCMSs) are being increasingly utilized for the management of WON.

Rana et al. proposed several arguments regarding the potential reasons for recurrent pancreatic fluid collections (PFCs). First, the authors suggested that a pancreatic duct that is disconnected at the genu, with viable upstream pancreatic parenchyma, may predispose the patient to recurrent PFC. Of note, sites of disconnected pancreatic duct were similar in those with and without PFC recurrence (see Supplementary Table 3 s in original article). Therefore, it may be difficult (albeit not impossible) to attribute the recurrences to the site of disconnected pancreatic duct and further studies are required to substantiate this hypothesis.

Second, Rana et al. hypothesized that incomplete resolution of WON may have resulted in a relatively high recurrence rate in the plastic stent group. We would like to emphasize the fact that we included only patients with resolution of WON prior to LCMS removal and therefore it is unlikely that a partially resolved collection may have led to recurrent PFC.

Finally, the authors proposed that shorter pigtail stents may reduce the risk of migration. In our study, the incidence of recurrent PFCs was similar in those with and without migration of plastic stents. Therefore, there may be more to this than meets the eye, and early migration may not be the sole reason for the development of recurrent PFCs. We conclude that replacement of LCMS with a plastic stent may not be a foolproof strategy and future studies are required in order to predict the risk factors for recurrence as well as to investigate effective strategies to prevent them.

Publication History

Article published online:
25 August 2022

• 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 in disconnected pancreatic duct: a randomized controlled trial. Endoscopy 2022; DOI: 10.1055/a-1747-3283.
• 2 Bang JY, Mel Wilcox C, Arnoletti JP. et al. Importance of disconnected pancreatic duct syndrome in recurrence of pancreatic fluid collections initially drained using lumen-apposing metal stents. Clin Gastroenterol Hepatol 2021; 19: 1275-1281
• 3 Pawa R, Dorrell R, Russell G. et al. Long-term transmural drainage of pancreatic fluid collections with double pigtail stents following lumen-apposing metal stent placement improves recurrence-free survival in disconnected pancreatic duct syndrome. Dig Endosc 2022; DOI: 10.1111/den.14266.