Comparative safety and effectiveness of stents in drainage of pancreatic fluid collections guided by endoscopic ultrasonography: A systematic review and network meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract; statistical significance inferred from CIs excluding the null

• Effect Size: LAMS vs DPPS (all PFCs): RR 1.07; BFMS vs DPPS (all PFCs): RR 1.08; LAMS+DPPS vs DPPS (infection rate): RR 0.19; BFMS vs DPPS (bleeding in WON): RR 0.32

• Primary Outcome: Clinical success rate across all PFC patients: LAMS and BFMS both superior to DPPS; in WON subgroup, LAMS, LAMS+DPPS, FCSEMS, and BFMS all superior to DPPS

• Nnt Or Sensitivity: NNT not calculable from abstract data alone; absolute risk differences not reported. The modest RR of 1.07–1.08 for clinical success suggests a small absolute benefit that requires baseline event rates to interpret clinically. The wide CI for LAMS+DPPS infection reduction (RR 0.19, 95% CI 0.06–0.62) indicates substantial imprecision.

• Confidence Interval: LAMS success: 95% CI 1.02–1.13; BFMS success: 95% CI 1.01–1.15; LAMS+DPPS infection vs DPPS: 95% CI 0.06–0.62; BFMS bleeding vs DPPS: 95% CI 0.18–0.99

Clinical Application

LAMS and BFMS are technically demanding and require advanced EUS expertise with real-time fluoroscopic or EUS guidance. These devices are significantly more expensive than DPPS. The combination LAMS+DPPS strategy adds procedural complexity but may reduce infectious complications. Feasibility is highest at high-volume tertiary endoscopy centres with dedicated pancreatology teams. LAMS devices (e.g., AXIOS stent system, Boston Scientific) are available in Australia and used at major tertiary centres. However, they are not currently listed on the Prostheses List for public hospital reimbursement in all states, creating access inequity. EUS-guided drainage of PFCs is performed under MBS item numbers for EUS (e.g., 30688), but stent costs are often borne by the hospital or patient. RACGP and GESA guidelines recommend EUS-guided drainage as first-line for symptomatic PFCs at experienced centres. The TGA has approved LAMS devices for use in Australia. Clinicians should note that the modest absolute benefit of metal over plastic stents must be weighed against substantially higher device costs in resource-constrained public hospital settings. Referral to a quaternary centre with a dedicated pancreatic multidisciplinary team is recommended for complex WON cases. Adult patients with symptomatic pancreatic pseudocysts or walled-off necrosis requiring EUS-guided transmural drainage, particularly those at tertiary centres with advanced endoscopic capability. Results are most applicable to patients with mature, well-defined fluid collections ≥6 weeks post-pancreatitis onset.

Abstract

BACKGROUND: Endoscopic ultrasonography-guided drainage is an effective treatment for pancreatic fluid collections (PFCs). However, the optimal stent strategy for endoscopic ultrasonography-guided drainage of PFCs is still unclear. This study aims to compare the clinical outcomes of different stent types to identify the best option. METHODS: Databases including PubMed, EMBASE, and Cochrane were searched up to August 2024. The analysis focused on comparisons between bi-flanged metal stents (BFMS), double-pigtail plastic stents (DPPS), fully covered self-expanding metal stents (FCSEMS), lumen-apposing metal stents (LAMS), and the combination of LAMS and DPPS (LAMS + DPPS). RESULTS: A total of 38 studies, involving 4265 patients with PFCs, were analyzed. In all of these patients, LAMS (risk ratio [RR]: 1.07, 95% confidence interval [CI]: 1.02-1.13) and BFMS (RR: 1.08, 95% CI: 1.01-1.15) showed higher clinical success rates compared with DPPS. LAMS + DPPS reduced infection rates compared with BFMS (RR: 0.32, 95% CI: 0.10-0.99), DPPS (RR: 0.19, 95% CI: 0.06-0.62), and FCSEMS (RR: 0.23, 95% CI: 0.07-0.76). Within the pancreatic pseudocysts subgroup, LAMS (RR: 1.08, 95% CI: 1.01-1.16) and LAMS + DPPS (RR: 1.24, 95% CI: 1.03-1.48) demonstrated higher clinical success rates compared with DPPS. Similarly, in the walled-off necrosis subgroup, LAMS (RR: 1.10, 95% CI: 1.02-1.17), LAMS + DPPS (RR: 1.19, 95% CI: 1.01-1.41), FCSEMS (RR: 1.14, 95% CI: 1.03-1.26), and BFMS (RR: 1.11, 95% CI: 1.03-1.20) all showed higher success rates compared with DPPS, with BFMS exhibiting a lower bleeding rate than DPPS (RR: 0.32, 95% CI: 0.18-0.99). CONCLUSION: Newer metal stents, including BFMS, LAMS, and LAMS + DPPS, offer advantages over plastic stents like DPPS alone. BFMS is preferable when bleeding risk is a concern, while LAMS + DPPS is more effective in reducing infection rates in PFCs.

References

1. 1.Chen, S., Zhang, Y., Wu, Y., Chen, B., & Huang, H. (2026). Comparative safety and effectiveness of stents in drainage of pancreatic fluid collections guided by endoscopic ultrasonography: A systematic review and network meta-analysis. Medicine. https://doi.org/10.1097/MD.0000000000049877