Reply to Zhai et al.

We would like to thank Zhai et al. for their interest and comments regarding our recent publication “Safety and efficacy of the use of lumen-apposing metal stents in the management of postoperative fluid collections: a large, international, multicenter study” [1].

The definition of clinical success in our study was based on our aim to evaluate the clinical outcomes of endoscopic ultrasound (EUS)-guided transmural drainage of postoperative fluid collections specifically using lumen-apposing metal stents (LAMS); thus, additional treatment modalities after LAMS placement, such as percutaneous drainage, were considered as treatment failures. This definition has been used in prior studies. Mudireddy et al. reported that one of the two treatment failures was a patient requiring dual-modality treatment using a percutaneous drain in addition to LAMS [2]. Téllez-Ávilla et al. and Kwon et al. also used similar definitions for clinical success; thus, our clinical definition is congruent with some of the existing literature [3] [4]. Nonetheless, we agree that the definition of clinical success varies between studies.

Although we did not specifically evaluate for types of postoperative pancreatic fistula, in our experience, most pancreatic duct leaks eventually resolve without the need for further interventions. Endoscopic retrograde cholangiopancreatography is not consistently performed in such patients, and our experience is that it is frequently not needed. This is also similar to cases of peripancreatic fluid collections that result from duct leakage. Transmural drainage seems to suffice in the majority of cases.

As pointed out by the authors, the relative small number of cases per institution in the current study suggests that the majority of cases are still managed by alternative techniques (percutaneously and/or surgically). We agree that a multidisciplinary approach to such cases is crucial and ensures that other disciplines are aware of recent developments in the field, including availability of LAMS.

• References

• 1 Yang J, Kaplan JH, Sethi A. et al. Safety and efficacy of the use of lumen-apposing metal stents in the management of postoperative fluid collections: a large, international, multicenter study. Endoscopy 2019; 51: 715-721
• 2 Mudireddy PR, Sethi A, Siddiqui AA. et al. EUS-guided drainage of postsurgical fluid collections using lumen-apposing metal stents: a multicenter study. Gastrointest Endosc 2018; 87: 1256-1262
• 3 Téllez-Ávila F, Carmona-Aguilera GJ, Valdovinos-Andraca F. et al. Postoperative abdominal collections drainage: percutaneous versus guided by endoscopic ultrasound. Dig Endosc 2015; 27: 762-766
• 4 Kwon YM, Gerdes H, Schattner MA. et al. Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage. Surg Endosc 2013; 27: 2422-2427