Safety and efficacy of lumen-apposing metal stents with and without simultaneous double-pigtail plastic stents for draining pancreatic pseudocyst

Published:December 09, 2017DOI:

      Background and Aims

      Lumen-apposing metal stents (LAMSs) are used to perform necrosectomy in walled-off necrosis (WON). Although necrosectomy is not required for pancreatic pseudocyst (PP), an increasing number of PPs are also being drained with LAMSs in view of their ease of deployment. The aim of the present study was to evaluate the safety and efficacy of using LAMSs to drain PPs.


      At 1 tertiary center from January 2014 to May 2016, all consecutive patients with PPs were drained by LAMSs, and the data were retrospectively reviewed. After observing cyst-cavity infection in patients enrolled initially (group I), 10F double-pigtail stents (DPSs) were placed across LAMSs in the subsequent patients (group II). Data on technical success, PP resolution, adverse events, and reintervention rates were collected.


      Forty-seven patients with PPs (mean size, 9.5 ± 4.0 cm) were enrolled (group I, 24; group II, 23). There was 1 perforation at deployment (technical success, 98%). In the remaining 46 patients, resolution of the PP was observed in 44 patients (96%). Four patients (17%) in group I presented with PP infection requiring reinterventions. Food material was observed in the cyst cavity. None of the patients in group II had PP infection (relative risk, .84; 95% confidence interval, .71-1.0; P = .054).


      Similar to WON, LAMSs are also effective in endoscopic drainage of PPs. However, there was a trend toward higher PP infection with LAMSs, and placing a DPS across the LAMS minimized this risk.


      DPS (double-pigtail stent (plastic 10F)), LAMS (lumen-apposing metal stents), PFC (postpancreatitis fluid collection), PP (pancreatic pseudocyst), WON (walled-off necrosis)
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        • Peery A.F.
        • Crockett S.D.
        • Barritt A.S.
        • et al.
        Burden of gastrointestinal, liver, and pancreatic diseases in the United States.
        Gastroenterology. 2015; 149: 1731-1741
        • Johnson C.D.
        • Abu-Hilal M.
        Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis.
        Gut. 2004; 53: 1340-1344
        • Banks P.A.
        • Bollen T.L.
        • Dervenis C.
        • et al.
        Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus.
        Gut. 2013; 62: 102-111
        • Varadarajulu S.
        • Christein J.D.
        • Tamhane A.
        • et al.
        Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos).
        Gastrointest Endosc. 2008; 68: 1102-1111
        • Singhal S.
        • Rotman S.R.
        • Gaidhane M.
        • et al.
        Pancreatic fluid collection drainage by endoscopic ultrasound: an update.
        Clin Endos. 2013; 46: 506-514
        • Sharaiha R.Z.
        • Tyberg A.
        • Khashab M.A.
        • et al.
        Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis.
        Clin Gastroenterol Hepatol. 2016; 2: 1797-1803
        • Siddiqui A.A.
        • Adler D.G.
        • 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
        • Siddiqui A.A.
        • Kowalski T.E.
        • Loren D.E.
        • 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
        • Rinninella E.
        • Kunda R.
        • Dollhopf M.
        • et al.
        EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video).
        Gastrointest Endosc. 2015; 82: 1039-1046
        • Shah R.J.
        • Shah J.N.
        • Waxman I.
        • et al.
        Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered self-expanding metal stents.
        Clin Gastroenterol Hepatol. 2015; 13: 747-752
        • Bang J.Y.
        • Hasan M.K.
        • Navaneethan U.
        • et al.
        Lumen-apposing metal stents for drainage of pancreatic fluid collections: When and for whom?.
        Dig Endosc. 2017; 29: 83-90
        • Vazquez-Sequeiros E.
        • Baron T.H.
        • Pérez-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
        • 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
        • Amin S.
        • Yang D.J.
        • Lucas A.L.
        • et al.
        There is no advantage to transpapillary pancreatic duct stenting for the transmural endoscopic drainage of pancreatic fluid collections: a meta-analysis.
        Clin Endosc. 2017; 50: 388-394
        • Varadarajulu S.
        • Bang J.Y.
        • Sutton B.S.
        • et al.
        Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial.
        Gastroenterology. 2013; 145: 583-590
        • Zhao X.
        • Feng T.
        • Ji W.
        Endoscopic versus surgical treatment for pancreatic pseudocyst.
        Dig Endosc. 2016; 28: 83-91
        • Saul A.
        • Ramirez Luna M.A.
        • Chan C.
        • et al.
        EUS-guided drainage of pancreatic pseudocysts offers similar success and complications compared to surgical treatment but with a lower cost.
        Surg Endosc. 2016; 30: 1459-1465
        • Varadarajulu S.
        • Lopes T.L.
        • Wilcox C.M.
        • et al.
        EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts.
        Gastrointest Endosc. 2008; 68: 649-655
        • Sharaiha R.Z.
        • DeFilippis E.M.
        • Kedia P.
        • et al.
        Metal versus plastic for pancreatic pseudocyst drainage: clinical outcomes and success.
        Gastrointest Endosc. 2015; 82: 822-827
        • Bang J.Y.
        • Haws 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
        • Lakhtakia S.
        • Basha J.
        • Talukdar R.
        • et al.
        Endoscopic “step-up approach” using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos).
        Gastrointest Endosc. 2017; 83: 1243-1252
        • Varadarajulu S.
        • Bang J.Y.
        • Phadnis M.A.
        • 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

      Linked Article

      • The role of co-axially placed double-pigtail stents within lumen-apposing metal stents in draining pancreatic fluid collections
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          Aburajab et al1 reported their recent experience with lumen-apposing metal stents (LAMSs) in the treatment of pancreatic pseudocysts (PPs). They described a decreasing tendency in cyst cavity infection after placing double-pigtail stents (DPSs) across LAMSs compared with those without DPSs. Moreover, several centers reported their experience in DPS placement through LAMSs while draining walled-off necrosis (WON), and DPS was supposed to prevent occlusion by impacting necrotic tissue.2-4 Because PPs have no necrotic component, the authors postulate that DPSs might play a role in holding back the large pieces of solid food material from entering the cavity, which may subsequently lead to infection.
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      • The silence of the LAMS
        Gastrointestinal EndoscopyVol. 87Issue 6
        • Preview
          We read with interest the single-center, retrospective study by Aburajab et al1 on EUS-guided lumen-apposing metal stents (LAMSs) for symptomatic pancreatic pseudocyst (PP) drainage. Technical success was achieved in 98% (46/47) of patients. An interim analysis of their initial 23 cases revealed high rates of cyst infection (4/23; 17.4%), which prompted them to routinely place a 10F double-pigtail (DP) stent across the LAMS in the remaining 23 cases. Overall, there was a trend toward a lower rate of infection in patients with DP through the LAMS versus LAMS alone (relative risk 0.8; 95% confidence interval, 0.7-1.0; P = .054).
        • Full-Text
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