Reply to Dhar et al.

We thank Dr. Dhar and colleagues for their interest in our recent article entitled “Impact of transmural plastic stent on recurrence of pancreatic fluid collection after metal stent removal in disconnected pancreatic duct: a randomized controlled trial” [1]. The study quoted by author on the time interval to recurrence of pancreatic fluid collections (PFCs) is about the use of plastic stents placed during the index drainage [2]; however, our study is about the exchange of a large-caliber metal stent (LCMS) with a plastic stent. A randomized controlled trial (RCT) by Arvanitakis et al. on permanent indwelling stenting versus stent removal showed that recurrences had occurred within a median (interquartile range) of 4 months (1–5 months) of stent retrieval [3]. The authors mentioned the value of recurrent PFC interval from the time of drainage, and gave data from previous studies in their table 1 s. In our own previous study, PFC recurrence were seen at a median (range) of 5 months (1–19 months) [4]. Therefore, as there was no previous RCT and based on our past experience, a 3-month period was considered to be meaningful to see the incidence of recurrent PFCs after LCMS removal.

We agree that a 20 % dropout rate is significant at 1 year; however, our primary outcome was to see the recurrence of PFCs at 3 months; there were 46 and 45 patients in the stent and no stent groups at 6 months, respectively. Even with a 19 % migration rate of plastic stents in the stent arm, PFC recurrence was seen in only two patients (20 %).

While Bang et al. have shown a recurrence rate of 2 % in their stent exchange group, their study was not randomized and had a heterogeneous study population [5], so the results of this study cannot be generalized and compared with our study, where we have randomized patients and included a homogeneous population of patients with walled-off necrosis.

We agree that patients with a distal collection drained during the index drainage procedure had more recurrences. While our study was not powered to evaluate the effect of other predictors for recurrence, larger studies are warranted to assess this issue.

Publication History

Article published online:
28 June 2022

• References

• 1 Chavan R, Nabi Z, Lakhtakia S. et al. Impact of transmural plastic stent on recurrence of pancreatic fluid collection after metal stent removal in disconnected pancreatic duct: a randomized controlled trial. Endoscopy 2022; DOI: 10.1055/a-1747-3283.
• 2 Gkolfakis P, Bourguignon A, Arvanitakis M. et al. Indwelling double-pigtail plastic stents for treating disconnected pancreatic duct syndrome-associated peripancreatic fluid collections: long-term safety and efficacy. Endoscopy 2021; 53: 1141-1149
• 3 Arvanitakis M, Delhaye M, Bali MA. et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65: 609-619
• 4 Basha J, Lakhtakia S, Nabi Z. et al. Impact of disconnected pancreatic duct on recurrence of fluid collections and new-onset diabetes: do we finally have an answer?. Gut 2021; 70: 447-449
• 5 Bang JY, Wilcox CM, Arnoletti JP. et al. Importance of disconnected pancreatic duct syndrome in recurrence of pancreatic fluid collections initially drained using lumen-apposing metal stents. Clin Gastroenterol Hepatol 2021; 19: 1275-1281 e2