Metal Versus Plastic for Pancreatic Pseudocyst Drainage: Clinical Outcomes and Success

Abstract

Introduction: Endoscopic transmural drainage of pancreatic pseudocyst (PP) using double pigtail plastic (DP) stents requires placement of multiple stents. Recently, the use of fully covered selfexpanding metal stents (FCSEMS) has been reported to be an alternative. Aim: To compare the clinical outcomes, success rate, and adverse events (AE) of EUS-guided drainage of PP with DP stents and FCSEMS. Methods: Consecutive patients with PP managed by EUS-guided drainage were divided into 2 groups: 1) those that underwent drainage using DP stents, and 2) drainage using FCSEMS. Technical success (ability to access and drain a pseudocyst by placement of transmural stents), early adverse events, stent occlusion requiring reintervention, and long−term success (complete resolution of the PP without need for further re-intervention at 12 months following treatment) were evaluated. Results: From October 2010 to May 2014, 230 patients (37.4% female; mean age 52.6 years) underwent PP drainage, including 118 who were drained using DP stents and 112 using FCSEMS. The 2 groups were matched with age, sex, etiology of the pancreatitis, PP size, and location. The etiology of the patients’ pancreatitis was gallstones (49.7%), alcohol (31.2%), idiopathic (9.6%), and other causes (8.7%). The mean cyst size was 98 mm (39-250 mm). The mean number of endoscopy sessions was 1.5 (range: 1-5). A transgastric approach was used in 210 patients (91%) and in 20 (9%) transduodenal drainage was performed. There was no statistically significant difference in the technical success rate between the DP stent and FCSEMS (92% vs 98%; p=0.06). Procedural AE were noted in 15% in the DP and 8% in the FCSEMS group (p=0.062). In multivariable analysis patients with DP were 2.5 times more likely to report AE. (OR 2.5; 95% CI 1.00-6.35) after adjusting for age, sex, and cyst size. On 12-month follow-up after the initial procedure, complete resolution of pseudocysts using DP stents was lower compared to those who underwent drainage with FCSEMS (89% vs 98%; p=0.01). Additionally, those who had FCSEMS were 5 times more likely to have their PP resolved even after adjusting for cyst size, age, sex, and number of endoscopic sessions (OR 4.7; 95% CI 1.02-22.3; p=0.04).Two patients (1 in each group) required surgery due to a persistent PP. Conclusion: EUS-guided drainage of PP using FCSEMS is superior to DP stents in terms of overall treatment efficacy.Table 1: Multivariable Analysis for Factors Associated With Successful Outcome