Reply to Zhang and Li

We appreciate the insights of Zhang and Li, and their interest in our article. Regarding their first comment, factors beyond the stent type likely affect the frequency of direct endoscopic necrosectomy (DEN), but our study did not explore these in detail. A regression analysis including factors like persistent symptoms or inadequate drainage was suggested, but persistent symptoms was not part of our initial design, which prevented retrospective assessment. Only eight patients underwent DEN in the intention-to-treat analysis, limiting statistical conclusions because of the small sample size. Additionally, the DEN variable lacked normal distribution, violating linear regression assumptions. Despite this, we performed a regression analysis using stent dysfunction, stent occlusion leading to infection, and stent type. The results are shown in [Table 1]. All of the patients with plastic stents experienced occlusion, which prevented statistical estimation.

Table 1 Regression analysis incorporating variables that may influence the number of direct endoscopic necrosectomies.

Characteristic	Beta (95%CI)	P value
LAMS, lumen-apposing metal stent; NA, not applicable.
Intention-to-treat analysis
LAMS vs. plastic stent	4.8 (0.72 to 8.9)	0.07
Stent dysfunction vs. no dysfunction	−0.5 (−6.5 to 5.5)	0.90
Stent occlusion leading to infection vs. no stent occlusion	NA	NA
Per-protocol analysis
LAMS vs. plastic stent	4.8 (−0.11 to 9.7)	0.11
Stent dysfunction vs. no dysfunction	−1.2 (−7.6 to 5.2)	0.70
Stent occlusion leading to infection vs. no stent occlusion	NA	NA

One finding that contradicts our initial hypothesis concerns plastic stent management. DEN is more challenging with plastic stents owing to repeated dilations, increasing risks such as bleeding and perforation, making clinicians more hesitant to perform DEN [1] [2]. In contrast, lumen-apposing metal stents (LAMSs) allow safer, faster, and simpler DEN owing to their wider lumen and robust structure, so improving drainage and access [3] [4]. Their strong radial force and secure apposition may also enhance safety. The larger diameter improves visualization and instrument maneuverability, potentially increasing the frequency of DEN [5]. This difference in safety and efficiency may explain the higher DEN rate in our LAMS group, highlighting the impact of the stent type on feasibility and decision-making.

The etiology of pancreatitis is often multifactorial, with overlapping contributors that cannot always be excluded. Even when a primary cause is identified, other factors may coexist and, in some cases, no single cause can be definitively determined. Etiologies are not mutually exclusive, for example alcohol-induced pancreatitis often coincides with hypertriglyceridemia. Given these complexities, individual chi-squared tests for each etiology were conducted, instead of a single chi-squared test, to better assess their contributions.

Publikationsverlauf

Artikel online veröffentlicht:
28. Mai 2025

• References

• 1 Bang JY, Navaneethan U, Hasan MK. et al. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial. Gut 2019; 68: 1200-1209
• 2 Nayar M, Leeds JS. UK and Ireland LAMS Collaborative. et al. Lumen-apposing metal stents for drainage of pancreatic fluid collections: does timing of removal matter?. Gut 2022; 71: 850-853
• 3 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
• 4 Anderloni A, Fabbri C, Nieto J. et al. The safety and efficacy of a new 20-mm lumen apposing metal stent (lams) for the endoscopic treatment of pancreatic and peripancreatic fluid collections: a large international, multicenter study. Surg Endosc 2021; 35: 1741-1748
• 5 Mussetto A, Fugazza A, Fuccio L. et al. Current uses and outcomes of lumen-apposing metal stents. Ann Gastroenterol 2018; 31: 535-540