Response

We thank Rizzatti et al for their comments on our work entitled “International multicenter comprehensive analysis of adverse events associated with lumen-apposing metal stent placement for pancreatic fluid collection drainage,” recently published in Gastrointestinal Endoscopy. Indeed, in their letter, some important questions about the current knowledge of pancreatic fluid collection (PFC) endoscopic management are raised, and most of them do not yet have a definitive answer. We fully agree with the authors that several uncertainties persist in this field, in particular about the use of lumen-apposing metal stents (LAMSs) for PFC drainage. Indeed, this was the main reason that led us to develop this work. Nevertheless, we believe that our data helped advance the understanding of some mechanisms underlying the occurrence of adverse events (AEs) in these patients and remarked the need of countermeasures to prevent and treat such events. In particular, pneumatic dilation of the LAMSs was associated with a lower risk of AEs (infection and stent occlusion) without increasing the risk of stent migration or dislodgement. Moreover, patients with walled-off necrosis emerge as a high-risk subgroup, therefore deserving targeted studies aimed at defining the specific mechanisms of AEs. In this regard, bleeding has been already attributed to friction of the distal flange of the LAMS against retroperitoneal vessels after cavity collapse, and this was considered a delayed event. Interestingly, we found that most bleeding episodes (13/22, 59%) occurred in the first 14 days from the positioning of the LAMS, thus suggesting that a further reduction in the timing of LAMS removal should be considered. Many other points have not yet been completely addressed, including the pressing issue of the cost effectiveness of such procedures.^{,  ,}  For this reason, as already underlined in the conclusions of our article, we agree with the conclusion of Rizzatti et al about the urgent need for well-designed controlled trials that give a more solid basis to our clinical practice.