We read with great interest the article by Bang JY et al. [11] reporting a meta-analysis that aimed to compare plastic stents and lumen-apposing metal stents (LAMSs) in terms of their clinical outcomes for endoscopic ultrasound (EUS)-guided treatment of walled-off necrosis (WON). In a pooled analysis of three randomized trials, the rates of clinical success, adverse events, and requirement of necrosectomy, as well as the numbers of interventions, were all comparable between the groups.

Based on these findings, which stent should we use? In contrast to plastic stents, a LAMS can serve as a transluminal port and facilitate the treatment of WON that requires a long treatment duration with repeated interventions, including endoscopic necrosectomy [22] [33] [44]. As the next step, we should clarify which patients can benefit from LAMSs to offer personalized management of their WON. Given the small number of studies in the current analysis, a meta-regression analysis, which can examine the heterogeneity in an exposure–outcome relationship by relevant parameters, would not provide robust statistical assessments. In a retrospective investigation, the step-up treatment was more likely required for WON lesions with a proportion of necrosis ≥30%, an extension to the paracolic gutter, and a size ≥10 cm [55]. A promising finding for LAMSs in the current study was that the costs were also similar between the groups. Therefore, LAMSs may be a first-choice option for subgroups that require many interventions.

In summary, the current analysis argues against the routine use of LAMSs for WON. The increasing popularity of LAMSs in interventional EUS overall may prompt us to select this modality without robust supporting evidence. We believe that future research should focus on predictive factors of the need for step-up treatment following EUS-guided WON drainage and identify a subgroup of WON patients for whom the advantages of LAMSs can be maximized.

Article published online:
28 March 2024

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