TY - JOUR

T1 - Tailoring treatment to the circumstance

T2 - reasoning behind metal versus plastic drainage of pancreatic collections - authors' reply

AU - Karstensen, John Gásdal

AU - Novovic, Srdan

AU - Schmidt, Palle Nordblad

N1 - Publisher Copyright: © Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.

PY - 2024

Y1 - 2024

N2 - We thank Vanella et al for their interest in our paper and for pointing out additional details and perspectives.1 2 In our study, we randomised patients with large pancreatic walled-off necrosis (WON) and a need for transgastric drainage to either a 20 mm lumen apposing metal stent (LAMS) or double pigtail stent (DPT) and found no superiority of the LAMS in terms of number of necrosectomies, clinical resolution or length of stay.2 Vanella et al point out that a weekly dilatation of the transgastric stoma in the DPT study group might have favoured the DPT technique. We agree that this may be the case and it should be included when assessing the results of our study. However, two other interventional studies, which did not include a weekly dilatation in the DPT group also failed to demonstrate superiority of the LAMS.3 4 We used nasocystic catheters in both study groups, which in addition to irrigation facilitates continuous transgastric access to remote parts of the WON, for instance, to the paracolic gutters. This adjunct is, as correctly pointed out, not evidence based, but rather based on long-standing experience in treatment of large WON.5 Of note, the irrigation catheter was placed in both study groups and thus, was unlikely to hamper the comparison of LAMS to DPT. We agree with Vanella et al that endoscopic necrosectomy is somewhat easier via LAMS, but there are also drawbacks. As pointed out in our paper, the drainage in those parts of WON that are in close proximity of the LAMS is very efficient and may in some cases cause isolation of distal parts of the WON, which will complicate the treatment and require additional access routes. Second, although we routinely use coaxial pigtail stents placed through the LAMS, removal of the LAMS before resolution of the WON is often needed when the distal flange becomes obstructed by or buried in vital tissue of the cavity near the drainage tract (figure 1).

AB - We thank Vanella et al for their interest in our paper and for pointing out additional details and perspectives.1 2 In our study, we randomised patients with large pancreatic walled-off necrosis (WON) and a need for transgastric drainage to either a 20 mm lumen apposing metal stent (LAMS) or double pigtail stent (DPT) and found no superiority of the LAMS in terms of number of necrosectomies, clinical resolution or length of stay.2 Vanella et al point out that a weekly dilatation of the transgastric stoma in the DPT study group might have favoured the DPT technique. We agree that this may be the case and it should be included when assessing the results of our study. However, two other interventional studies, which did not include a weekly dilatation in the DPT group also failed to demonstrate superiority of the LAMS.3 4 We used nasocystic catheters in both study groups, which in addition to irrigation facilitates continuous transgastric access to remote parts of the WON, for instance, to the paracolic gutters. This adjunct is, as correctly pointed out, not evidence based, but rather based on long-standing experience in treatment of large WON.5 Of note, the irrigation catheter was placed in both study groups and thus, was unlikely to hamper the comparison of LAMS to DPT. We agree with Vanella et al that endoscopic necrosectomy is somewhat easier via LAMS, but there are also drawbacks. As pointed out in our paper, the drainage in those parts of WON that are in close proximity of the LAMS is very efficient and may in some cases cause isolation of distal parts of the WON, which will complicate the treatment and require additional access routes. Second, although we routinely use coaxial pigtail stents placed through the LAMS, removal of the LAMS before resolution of the WON is often needed when the distal flange becomes obstructed by or buried in vital tissue of the cavity near the drainage tract (figure 1).

KW - ACUTE PANCREATITIS

KW - ENDOSCOPIC ULTRASONOGRAPHY

U2 - 10.1136/gutjnl-2023-330948

DO - 10.1136/gutjnl-2023-330948

M3 - Comment/debate

C2 - 37699695

AN - SCOPUS:85172311102

JO - Gut

JF - Gut

SN - 0017-5749

ER -