Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis

Abstract

Background and study aims Lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off pancreatic necrosis (WON). Recent studies suggested greater adverse event (AE) rates with LAMS for WON. We conducted a systematic review and meta-analysis to compare the safety and efficacy of LAMS with double-pigtail plastic stents (DPPS) for endoscopic drainage of WON. The primary aim was to evaluate stent-related AEs. Methods In October 2019, we searched the Ovid (Embase, MEDLINE, Cochrane) and Scopus databases for studies assessing a specific LAMS or DPPS for WON drainage conducted under EUS guidance. Safety outcomes were AE rates of bleeding, stent migration, perforation, and stent occlusion. Efficacy outcomes were WON resolution and number of procedures needed to achieve resolution. A subanalysis including non-EUS-guided cases was performed. Results Thirty studies including one randomized controlled trial (total 1,524 patients) were analyzed. LAMS were associated with similar bleeding (2.5 % vs. 4.6 %, P = 0.39) and perforation risk (0.5 % vs. 1.1 %, P = 0.35) compared to DPPS. WON resolution (87.4 % vs. 87.5 %, P = 0.99), number of procedures to achieve resolution (2.09 vs. 1.88, P = 0.72), stent migration (5.9 % vs. 6.8 %, P = 0.79), and stent occlusion (3.8 % vs. 5.2 %, P = 0.78) were similar for both groups. Inclusion of non-EUS-guided cases led to significantly higher DPPS bleeding and perforation rates. Conclusions LAMS and DPPS were associated with similar rates of AEs and WON resolution when limiting analysis to EUS-guided cases. Higher bleeding rates were seen in historical studies of DPPS without EUS guidance. Additional high-quality studies of WON treatment using consistent outcome definitions are needed.

Predicting the Need for Step-Up Therapy After EUS-Guided Drainage of Pancreatic Fluid Collections With Lumen-Apposing Metal Stents

“…AEs were further stratified according to time from index procedure (ie, early vs delayed) and according to severity of the AE, which are details that have been inconsistently reported in prior studies involving LAMS drainage for PFCs. 17 A recent multicenter retrospective study suggested that LAMS were found to be associated with higher rates of AEs when used for drainage of WON, but the rates of AEs observed in that study were notably higher than we observed in this study. 18 Another strength of the present study was that both radiologists who interpreted the preprocedural cross-sectional imaging studies and the endosonographer who interpreted EUS images captured during the index procedure were blinded to the patient's clinical outcome.…”

Current epidemiological trends and in-hospital mortality of acute pancreatitis in Germany: a systematic analysis of standardized hospital discharge data between 2008 and 2017

“…At the same time, treatment courses of severe pancreatitis can be extremely protracted and often require specific gastroenterological competencies and close interdisciplinary collaboration with interventional radiological and surgical disciplines in the context of complication management [26]. This relates, for example, to the options of endoscopic necrosectomy via lumen-apposing metal stents (LAMS), radiological drainage, and surgical video-assisted necrosectomies [27,28]. Our study observed a total hospital mortality rate for AP of 2.85 %, which is in good agreement with previous studies from Germany [1,4] and other western countries [29,30,31].…”

Direct Endoscopic Necrosectomy: Timing and Technique

“…Fully covered selfexpandable metal stents (FCSEMSs) represented the first alternative to DPPSs. Their larger diameter allows better drainage of solid debris, with lower rates of occlusion [9,[37][38][39].…”

“…The overall LAMS-related AEs rate treating WOPN appears difficult to evaluate because of the lack of data uniformity among published series. The main AEs reported are migration/dislodgement of the stent (2.6-10.6%), occlusion (0.9-8.7%), bleeding (0.7-5.5%) and perforation (0-1.3%) [39].…”

“…A recent systematic review and meta-analysis conducted on 30 studies with 1524 patients with WOPN, tried to solve such doubts [39]. Despite the already mentioned difficulty to perform such analysis because of the lack of uniformity in outcome definitions and reporting across studies, they found a similar AEs rate (bleeding, perforation, stent migration and stent occlusion) and similar efficacy rate between the two devices.…”