Increased Incidence of Pseudoaneurysm Bleeding With Lumen-Apposing Metal Stents Compared to Double-Pigtail Plastic Stents in Patients With Peripancreatic Fluid Collections.

There have been few studies that compared the effects of lumen-apposing metal stents (LAMS) and double-pigtail plastic stents (DPS) in patients with peripancreatic fluid collections from pancreatitis. We aimed to compare technical and clinical success and adverse events in patients who received LAMS vs DPS for pancreatic pseudocysts and walled-off necrosis. We performed a retrospective study of endoscopic ultrasound-mediated drainage in 149 patients (65% male; mean age, 47 y) with pancreatic pseudocysts or walled-off necrosis (97 received LAMS and 152 received DPS), from January 2011 through September 2016 at a single center. We collected data on patient characteristics, outcomes, hospitalizations, and imaging findings. Technical success was defined as LAMS insertion or a minimum of 2 DPS. Clinical success was defined as resolution of pancreatic pseudocysts or walled-off necrosis based on imaging results. The primary outcome was resolution of peripancreatic fluid collection with reduced abdominal pain or obstructive signs or symptoms. Secondary outcomes included the identification and management of adverse events, number of additional procedures required to resolve fluid collection, and the recurrence of fluid collection. Patients who received LAMS had larger peripancreatic fluid collections than patients who received DPS prior to intervention (P = .001), and underwent an average 1.7 interventions vs 1.9 interventions for patients who received DPS (P = .93). Technical success was achieved for 90 patients with LAMS (92.8%) vs 137 patients with DPS (90.1%) (odds ratio [OR] for success with DPS, 0.82; 95% CI, 0.33-2.0; P = .67). Despite larger fluid collections in the LAMS group, there was no significant difference in proportions of patients with clinical success following placement of LAMS (82 of 84 patients, 97.6%) vs DPS (118 of 122 patients, 96.7%) (OR for clinical success with DPS, 0.73; 95% CI, 0.13-4.0; P = .71). Adverse events developed in 24 patients who received LAMS (24.7%) vs 27 patients who received DPS (17.8%) (OR for an adverse event in a patient receiving a DPS, 0.82; 95% CI, 0.33-2.0; P = .67). However, patients with LAMS had a higher risk of pseudoaneurysm bleeding than patients with DPS (OR, 10.0; 95% CI, 1.19-84.6; P = .009). In a retrospective study of patients undergoing drainage of pancreatic pseudocysts or walled-off necrosis, we found LAMS and DPS to have comparable rates of technical and clinical success and adverse events. Drainage of walled-off necrosis or pancreatic pseudocysts using DPS was associated with fewer bleeding events overall, including pseudoaneurysm bleeding, but bleeding risk with LAMS should be weighed against the trend of higher actionable perforation and infection rates with DPS.

Brimhall B ，Han S ，Tatman PD ，Clark TJ ，Wani S ，Brauer B ，Edmundowicz S ，Wagh MS ，Attwell A ，Hammad H ，Shah RJ ... -  《-》

Head-to-head comparison between endoscopic ultrasound guided lumen apposing metal stent and plastic stents for the treatment of pancreatic fluid collections: A systematic review and meta-analysis.

Peripancreatic fluid collections (PFCs) result from acute or chronic pancreatic inflammation that suffers a rupture of its ducts. Currently, there exists three options for drainage or debridement of pancreatic pseudocysts and walled-off necrosis (WON). The traditional procedure is drainage by placing double pigtail plastic stents (DPPS); lumen-apposing metal stent (LAMS) has a biflanged design with a wide lumen that avoids occlusion with necrotic tissue, which is more common with DPPS and reduces the possibility of migration. We performed a systematic review and meta-analyses head-to-head, including only studies that compare the two main techniques to drainage of PFCs: LAMS vs DPPS. We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. This meta-analysis considers studies published from 2014 to 2020, including only studies that compare the two main techniques to drainage of PFCs: LAMS vs DPPS. Thirteen studies were included in the meta-analyses. Only one of all studies was a randomized controlled trial. These studies comprise 1584 patients; 68.2% were male, and 31.8% were female. Six hundred sixty-three patients (41.9%) were treated with LAMS, and 921 (58.1%) were treated with DPPS. Six studies included only WON in their analysis, two included only pancreatic pseudocysts, and five studies included both pancreatic pseudocysts and WON. The technical success was similar in patients treated with LAMS and DPPS (97.6% vs 97.5%, respectively, P = .986, RR = 1.00 [95% CI 0.93-1.08]). The clinical success was similar in both groups (LAMS: 90.1% vs DPPS: 84.2%, P = .139, RR = 1.063 [95% CI 0.98-1.15]). Patients treated with LAMS had a lower complication rate than the DPPS groups, with a significant statistical difference (LAMS: 16.0% vs DPPS: 20.2%, P = .009, RR = 0.746 [95% CI 0.60-0.93]). Bleeding was the most common complication in the LAMS group (33 patients, [5.0%]), whereas infection was the most common complication in the DPPS group (56 patients, [6.1%]). The LAMS migration rate was lower than in the DPPS (0.9% vs 2.2%, respectively, P = .05). The mortality rate was similar in both groups, 0.6% in the LAMS group (four patients) and 0.4% in the DPPS group (four patients; P = .640). The PFCs drainage is an indication when persistent symptoms or PFCs-related complications exist. EUS guided drainage with LAMS has similar technical and clinical success to DPPS drainage for the management of PFCs. The technical and clinical success rates are high in both groups. However, LAMS drainage has a lower adverse events rate than DPPS drainage. More randomized controlled trials are needed to confirm the real advantage of LAMS drainage over DPPS drainage.

Guzmán-Calderón E ，Chacaltana A ，Díaz R ，Li B ，Martinez-Moreno B ，Aparicio JR ... -  《-》

Safety of lumen-apposing stent with or without coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a retrospective study.

The aim of this study was to evaluate whether the placement of a coaxial double-pigtail plastic stent (DPS) within a lumen-apposing metal stent (LAMS) may improve the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs). This was a retrospective cohort study including patients with PFCs and an indication for transmural drainage. Two strategies (LAMS alone or LAMS plus DPS) were used at the endoscopist's discretion. A total of 41 patients were treated (21 LAMS alone; 20 LAMS plus DPS). The characteristics of the PFCs, and the technical and clinical success rates did not differ between groups. The LAMS alone group had a significantly higher rate of adverse events than the LAMS plus DPS group (42.9 % vs. 10.0 %; P = 0.04). Bleeding was the most frequent adverse event observed. The addition of a coaxial DPS to LAMS was associated with a lower rate of adverse events in EUS-guided drainage of PFCs.

Puga M ，Consiglieri CF ，Busquets J ，Pallarès N ，Secanella L ，Peláez N ，Fabregat J ，Castellote J ，Gornals JB ... -  《-》

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).

EUS-guided drainage of peripancreatic fluid collection (PFC) (pancreatic pseudocyst [PP] or walled-off necrosis [WON]) by using a novel lumen-apposing, fully covered, self-expandable metal stent (LAMS) has been promising, but few of these data are from the United States. The aim of this study was to evaluate clinical outcomes and safety of EUS-guided drainage of pancreatic pseudocysts and WON by using the LAMS. We conducted a multicenter, retrospective study on 82 patients with symptomatic PFC who underwent EUS-guided drainage by using the LAMS at 4 U.S. tertiary care centers. Outcomes evaluated included successful placement of the LAMS, the number of patients in whom complete resolution of PPs or WON was achieved, the number of procedures performed per patient to achieve PFC resolution, and adverse events. The mean size of the PFC was 11.8 cm. LAMSs were successfully placed in 80 patients (97.5%). Twelve patients had PP and 68 had WON. The median stent in-dwelling time was 2 months (range 1-3 months). Endoscopic debridement with the LAMS in WON was performed in 54 patients. The patency of the stent was maintained in 98.7% of the patients (77/78). There was spontaneous dislodgment of 2 LAMSs. Successful endoscopic therapy by using the LAMS was successful in 12 of 12 patients (100%) with PP compared with 60 of 68 patients (88.2%) with WON. All stents were endoscopically removed from all patients after peripancreatic fluid collection (PFC) resolution. There was 1 PFC recurrence during the 3-month median follow-up period. Procedure-related adverse events occurred in 8 patients (9.8%), and included stent maldeployment (n = 2), and self-limited bleeding (n = 6). In 1 patient with stent maldeployment gastric perforation developed, and the patient underwent surgical repair. EUS-guided drainage of PFCs by using the novel LAMS has high technical and long-term success rates. Due to its ease of use, the LAMSs may simplify and streamline EUS-guided management of PFCs, particularly for the endoscopic debridement of WON, and may help in its widespread adoption as an alternative to surgery.

Siddiqui AA ，Adler DG ，Nieto J ，Shah JN ，Binmoeller KF ，Kane S ，Yan L ，Laique SN ，Kowalski T ，Loren DE ，Taylor LJ ，Munigala S ，Bhat YM ... -  《-》

Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis.

Hammad T ，Khan MA ，Alastal Y ，Lee W ，Nawras A ，Ismail MK ，Kahaleh M ... -  《-》