To the Editor:
We read with interest the elegant multicenter study by Yang et al
1
in which they compared endoscopic transmural drainage (TMD) alone with combined transmural and transpapillary drainage (CD) in patients with pseudocysts. Pancreatic pseudocysts (PP) are invariably associated with pancreatic duct (PD) disruption, and TMD does not directly treat the PD disruption. Theoretically, bridging of the PD disruption by stenting would act synergistically and improve the treatment outcomes of transmural drainage. However, previous studies on this topic have yielded divergent results.2
, 3
In this study in Gastrointestinal Endoscopy, the authors reported no difference in long-term symptom or radiologic resolution in patients who underwent TMD alone compared with those undergoing CD. Contrary to expectations, they found a negative association between attempting transpapillary drainage and radiologic resolution rates. However, this study included a heterogeneous group of patients, including patients with both acute and chronic pancreatitis; in addition, the PD disruption was not characterized as partial versus complete. This distinction is important because early removal of transmural stents in PD disruption can lead to recurrence of fluid collections, with recurrence rates being higher in chronic pancreatitis because of persistence of ductal abnormalities.
4
Therefore, leaving transmural stents in place indefinitely has been suggested as one strategy for preventing recurrence in patients with complete PD disruption.5
Moreover, transpapillary drainage is more effective when the disruption is bridged by endoprosthesis,6
and in this study bridging stents were placed in only 36.2% of patients.This study adds to the evidence supporting no difference in outcomes between CD and TMD in patients with PP. However, we believe that this perplexing problem would ideally be answered by a prospective, randomized study comparing CD with TMD alone in patients with PP and partial PD disruption in which the disruption has been bridged during transpapillary drainage.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
References
- Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.Gastrointest Endosc. 2016; 83: 720-729
- Successful stenting in ductal disruption favorably impacts treatment outcomes in patients undergoing transmural drainage of peripancreatic fluid collections.J Gastroenterol Hepatol. 2010; 25: 526-531
- Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes.Gastrointest Endosc. 2006; 63: 635-643
- Combining transpapillary pancreatic duct stenting with endoscopic transmural drainage for pancreatic fluid collections: two heads are better than one!.J Gastroenterol Hepatol. 2010; 25: 433-434
- Endoscopic therapy for pancreatic duct leaks and disruptions.Gastrointest Endosc Clin N Am. 2013; 23: 863-892
- Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement.Gastrointest Endosc. 2005; 61: 568-575
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- Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter studyGastrointestinal EndoscopyVol. 83Issue 4
- PreviewThe need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution.
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