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Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis

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Abstract

Background and Aims

Endoscopic ultrasound (EUS)-guided transmural drainage has been increasingly utilized as a first-line therapeutic modality for drainage of pancreatic fluid collections (PFC). Recently, lumen-apposing metal stents (LAMS) have been utilized for management of PFCs. We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy and safety of LAMS in the management of PFC (primary outcome). We also compared the efficacy and safety of LAMS with multiple plastic stents (MPS) in the management of PFC (secondary outcome).

Methods

We searched Medline, Embase and Cochrane databases from inception to November 5, 2016, to identify studies (with ≥ 10 patients) reporting technical success, clinical success, and adverse events (AE) of EUS-guided transmural drainage of PFC using LAMS. Weighted pooled rates (WPR) were calculated for technical success, clinical success and AE. Risk ratios (RR) were calculated and pooled to compare LAMS with MPS in terms of technical success, clinical success, and AE. Pooled mean difference (MD) was calculated to compare the number of endoscopic sessions required by each type of stent to achieve clinical success. All analyses were done using random effects model.

Results

Eleven studies with 688 patients were included in this meta-analysis. WPR for technical success of LAMS in PFC management was 98% (96, 99%), (I 2 = 15%). WPR for clinical success was 93% (89, 96%) with moderate heterogeneity (I 2 = 50%). There was no difference in clinical success for pseudocysts (PP) versus walled-off pancreatic necrosis (WON) (P = 0.51). WPR for AE was 13% (9, 20%), (I 2 = 64%). AE were 10% more in WON as compared to PP (P = 0.009). Most common AE requiring intervention was stent migration (4.2%), followed by infection (3.8%), bleeding (2.4%), and stent occlusion (1.9%). Six studies with 504 patients compared the performance of LAMS with MPS. Pooled RR for technical success was 1.71 (0.38, 7.37). Pooled RR for clinical success was 0.37 (0.20, 0.67) in favor of LAMS. Pooled RR for AE was 0.39 (0.18, 0.84), (I 2 = 50%). Pooled MD for number of endoscopic sessions was − 0.84 (− 1.69, 0.01).

Conclusions

LAMS seem to have excellent efficacy and safety in the management of PFCs. They may be preferred over plastic stents as they are associated with better clinical success and lesser adverse events.

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Acknowledgments

Dr. Michel Kahaleh has received Grant support from Boston Scientific, Olympus and Gore. He is a consultant for Boston Scientific and Olympus.

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Author notes

  1. Tariq Hammad and Muhammad Ali Khan contributed equally to the manuscript.

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA

    Tariq Hammad, Yaseen Alastal & Ali Nawras

  2. Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA

    Tariq Hammad

  3. Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, TN, USA

    Muhammad Ali Khan & Mohammad Kashif Ismail

  4. Carlson and Mulford Libraries, University of Toledo, Toledo, OH, USA

    Wade Lee

  5. Department of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA

    Michel Kahaleh

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Appendix

Appendix

Pancreatic-fluid-collection* OR walled-off-pancreatic-necros* OR WOPN OR pancreatic-abscess* OR peripancreatic-fluid-collection*

OR

((Pancreas OR pancreatic OR intrapancreatic OR peripancreatic) AND (pseudocyst* OR walled-off-necros* OR WON OR necrotic-collection* OR cystic-collection*))

AND

Lumen-apposing-metal-stent* OR lumen-apposing-metallic-stent* OR lumen-apposing-stent* OR LAMS OR lumen-apposing-self-expandable-metallic-stent* OR lumen-apposing-self-expandable-metal-stent* OR LASEMS OR self-expandable-metal-stent* OR self-expandable-metallic-stent* OR self-expanding-metal-stent* OR self-expanding-metallic-stent* OR Supremo OR WallFlex OR WallStent OR AXIOS

Pubmed

Pancreatic-fluid-collection* OR walled-off-pancreatic-necros* OR WOPN OR pancreatic-abscess* OR peripancreatic-fluid-collection*

OR

((Pancreas OR pancreatic OR intrapancreatic OR peripancreatic) AND (pseudocyst* OR walled-off-necros* OR WON OR necrotic-collection* OR cystic-collection*))

OR “pancreatic pseudocyst”[Mesh]

AND

Lumen-apposing-metal-stent* OR lumen-apposing-metallic-stent* OR lumen-apposing-stent* OR LAMS OR lumen-apposing-self-expandable-metallic-stent* OR lumen-apposing-self-expandable-metal-stent* OR LASEMS OR self-expandable-metal-stent* OR self-expandable-metallic-stent* OR self-expanding-metal-stent* OR self-expanding-metallic-stent* OR Supremo OR WallFlex OR WallStent OR AXIOS

Embase

‘pancreas pseudocyst’/exp OR ‘pancreas abscess’/exp OR Pancreatic-fluid-collection* OR walled-off-pancreatic-necros* OR WOPN OR pancreatic-abscess* OR peripancreatic-fluid-collection*

OR

((Pancreas OR pancreatic OR intrapancreatic OR peripancreatic) AND (pseudocyst* OR walled-off-necros* OR WON OR necrotic-collection* OR cystic-collection*))

AND

‘self expandable metallic stent’/exp OR Lumen-apposing-metal-stent* OR lumen-apposing-metallic-stent* OR lumen-apposing-stent* OR LAMS OR lumen-apposing-self-expandable-metallic-stent* OR lumen-apposing-self-expandable-metal-stent* OR LASEMS OR self-expandable-metal-stent* OR self-expandable-metallic-stent* OR self-expanding-metal-stent* OR self-expanding-metallic-stent* OR Supremo OR WallFlex OR WallStent OR AXIOS

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Hammad, T., Khan, M.A., Alastal, Y. et al. Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis. Dig Dis Sci 63, 289–301 (2018). https://doi.org/10.1007/s10620-017-4851-0

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