Do lumen-apposing metal stents (LAMS) improve treatment outcomes of walled-off pancreatic necrosis over plastic stents using dual-modality drainage?

Abstract

Background and study aims Endoscopic ultrasound-guided drainage of symptomatic walled-off pancreatic necrosis (WON) usually has been performed with double pigtail plastic stents (DPS) and more recently, with lumen-apposing metal stents (LAMS). However, LAMS are significantly more expensive and there are no comparative studies with DPS. Accordingly, we compared our experience with combined endoscopic and percutaneous drainage (dual-modality drainage [DMD]) for symptomatic WON using LAMS versus DPS.

Patients and methods Patients who underwent DMD of WON between July 2011 and June 2016 using LAMS were compared with a matched group treated with DPS. Technical success, clinical success, need for reintervention and adverse events (AE) were recorded.

Results A total of 50 patients (31 males, 25 patients treated with LAMS and 25 patients treated with DPS) were matched for age, sex, computed tomography severity index, and disconnected pancreatic ducts. Technical success was achieved in all patients. Mean days hospitalized post-intervention (14.5 vs. 13.1, P = 0.72), time to resolution of WON (77 days vs. 63 days, P = 0.57) and mean follow-up (207 days vs. 258 days, P = 0.34) were comparable in both groups. AEs were similar in both groups (6 vs. 8, P = 0.53). Patients treated with LAMS had significantly more reinterventions per patient (1.5 vs. 0.72, P = 0.01).

Conclusions In treatment of symptomatic WON using DMD, LAMS did not shorten time to percutaneous drain removal and was not associated with fewer AEs.

• References

• 1 Forsmark CE, Baillie J. et al. Practice AGAIC. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007; 132: 2022-2044
• 2 Baron TH, Morgan DE. Acute necrotizing pancreatitis. N Engl J Med 1999; 340: 1412-1417
• 3 Bradley 3rd EL, Howard TJ, van Sonnenberg E. et al. Intervention in necrotizing pancreatitis: an evidence-based review of surgical and percutaneous alternatives. J Gastrointest Surg 2008; 12: 634-639
• 4 Bakker OJ, van Santvoort HC, van Brunschot S. et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307: 1053-1061
• 5 Freeman ML, Werner J, van Santvoort HC. et al. Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference. Pancreas 2012; 41: 1176-1194
• 6 van Santvoort HC, Besselink MG, Bakker OJ. et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362: 1491-1502
• 7 Singhal S, Rotman SR, Gaidhane M. et al. Pancreatic fluid collection drainage by endoscopic ultrasound: an update. Clin Endosc 2013; 46: 506-514
• 8 Varadarajulu S, Bang JY, Phadnis MA. et al. Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients. J Gastrointest Surg 2011; 15: 2080-2088
• 9 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
• 10 Vazquez-Sequeiros E, Baron TH, Perez-Miranda M. et al. Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry. Gastrointest Endosc 2016; 84: 450-457.e452
• 11 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
• 12 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
• 13 Walter D, Will U, Sanchez-Yague A. et al. A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study. Endoscopy 2015; 47: 63-67
• 14 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 2016; DOI: 10.1136/gutjnl-2016-312812. [Epub ahead of print]
• 15 Adler JM, Gordon SR, Sampath K. et al. Su1312 Cost Effectiveness and Clinical Efficacy of Lumen Apposing Covered Self-Expanding Metal vs Plastic Stents for the Treatment of Walled off Pancreatic Necrosis. Gastrointestinal Endoscopy 2016; 83: AB347-AB348
• 16 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
• 17 Gluck M, Ross A, Irani S. et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg 2012; 16: 248-256 ; discussion 256 – 247
• 18 Gluck M, Ross A, Irani S. et al. Endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resources. Clin Gastroenterol Hepatol. 2010; 8: 1083-1088
• 19 Ross AS, Irani S, Gan SI. et al. Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes. Gastrointest Endosc 2014; 79: 929-935
• 20 Fotoohi M, DʼAgostino HB, Wollman B. et al. Persistent pancreatocutaneous fistula after percutaneous drainage of pancreatic fluid collections: role of cause and severity of pancreatitis. Radiology 1999; 213: 573-578
• 21 Gardner TB, Coelho-Prabhu N, Gordon SR. et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73: 718-726
• 22 Seifert H, Biermer M, Schmitt W. et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009; 58: 1260-1266
• 23 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
• 24 Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 2002; 223: 603-613
• 25 Irani S, Kozarek RA. The buried lumen-apposing metal stent: Is this a stent problem, location problem, or both?. VideoGIE 1: 25-26
• 26 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 27 Bang JY, Hawes R, Bartolucci A. et al. Efficacy of metal and plastic stents for transmural drainage of pancreatic fluid collections: a systematic review. Dig Endosc 2015; 27: 486-498
• 28 Bang JY, Varadarajulu S. Endoscopic ultrasound-guided management of pancreatic pseudocysts and walled-off necrosis. Clin Endosc 2014; 47: 429-431
• 29 Larsen M, Kozarek RA. Management of Disconnected Pancreatic Duct Syndrome. Curr Treat Options Gastroenterol 2016; 14: 348-359
• 30 Lawrence C, Howel 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