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We read with great interest the recent endoscopy news reported by Bang et al,1 discussing the lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage. Patients with walled-off necrosis (WON) treated by using LAMS in their centre occurred a 50% (6/12) rate of adverse events including delayed bleeding (3/12), buried stent syndrome (2/12) and biliary stricture (1/12), which is higher than we expected on our experiences.
As the authors reported all three patients presented with severe bleeding were confirmed with pseudoaneurysms. But another data from Sharaiha et al2 showed that LAMS method was safe for PFC. In 124 patients with WON underwent endoscopic transmural drainage using LAMS, where only 2 patients developed an acute haemorrhage during direct endoscopic necrosectomy (DEN), not associated with stents, none of them developed buried LAMS syndrome or biliary strictures. LAMS caused some rare complication like small-bowel obstruction due to stent migration.3 Even though, several studies reported that LAMS was safe and effective.4 ,5
Report described the phenomenon of buried stent is also rare. We recently reported a buried stent associated with the LAMS.6 The main reason was that we retained the stent too long for 5 months to overcome the patient's pesudocyst recurrence. Eventually, we ‘stripped’ the stent under the guidance of gastroscopy without surgery.
Siddiqui et al7 compared the clinical outcomes and adverse event of endoscopic ultrasound (EUS)-guided drainage/debridement of WON with double pigtail plastic (DP) stents, fully covered self-expanding metal stent (SEMS) and LAMS, with conclusion using SEMS is superior to DP stents in terms of overall treatment efficacy. The latest review demonstrated that DEN was an important adjunctive technique that could increase the treatment success rate of endoscopic management of WON.8 Given the studies published recently, we were confused with the randomised controlled trial designed by Bang et al,1 considering DP stents are not recommended for WON alone.
However, our team made a comparison between biliary self-expandable metal stent (BSEMS) and LAMS (table 1, unpublished data). We demonstrated that LAMS was safe for patients with PFC, only 2.86% (1/35) with peritonitis, 2.86% (1/35) with stent occlusion leading to infection and totally only 5.7% patients suffered from complications of LAMS. And none of early or delayed haemorrhage happened. Bleeding adverse event occurred in three patients treated with BSEMS; this could be related to stent tip scraping the cavity wall.
In terms of the paper reported, we would be interested to know the amount of solid debris in cyst cavity and the criteria for operators to determine the placement of stent. Further prospective trials are encouraged to compare the role of different stents in the management of PFC and to determine the proper role of LAMS.
Contributors YD and ZJ conceived and designed the study, HZ and HL wrote the draft. All authors final approval of the letter. HZ and HL contributed equally.
Funding This investigation was supported by the grant from National Clinical Research Center for Digestive Diseases of China (2015BAI13B08).
Competing interests None declared.
Patient consent Obtained.
Ethics approval Shanghai Changhai Hospital Ethics Committee.
Provenance and peer review Not commissioned; internally peer reviewed.
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