Post written by Kulwinder S. Dua, MD, FASGE, FACP, FRCP, from the Department of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, USA.

Lumen-apposing metal stents (LAMSs) have a large internal diameter and hence are routinely used to manage walled-off pancreatic necrosis. Secondary to their simplicity in deployment as a single-step procedure, LAMSs are also increasing being used to drain pancreatic pseudocysts (PPs). The focus of this study was to evaluate the safety and efficacy of using LAMSs for draining PPs.

When we started using LAMSs for draining PPs, we noticed that several of our patients were returning with a cyst cavity infection, and solid unchewed food material was found within the cavity. The objective for doing this study was to determine if a 10 F double-pigtail plastic stent (DPS) simultaneously placed across the LAMS will prevent solid food from entering the cavity and thereby prevent infection.

To test our objective, we studied patients with PPs in whom LAMSs were used either without simultaneously placing DPSs (N=24) or with simultaneously placing DPSs (N=23). Seventeen percent of patients in the group without DPSs returned with fever and chills secondary to PP infection and, in some, onion and tomato skins were noticed lying within the cyst cavity. Half of these patients required additional endoscopic interventions, and the other half required surgical intervention. None of the patients in whom DPSs were simultaneously placed across the LAMSs developed cyst cavity infection, and the cyst resolution rate in this group was 100%. We concluded that the non-collapsible, large-diameter communication between the GI tract and the PP created by LAMSs can allow for bi-directional flow of solid food material resulting in contamination/infection of the PP.  Placing double-pigtail stents across LAMSs minimized this risk. To validate these results, large prospective randomized clinical trials are recommended.

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