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Hépato-Gastro & Oncologie Digestive

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Contribution of lumen apposing metal stent in management of walled-off necrosis Volume 27, issue 5, Mai 2020

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Authors
1 CHRU de Strasbourg, Nouvel Hôpital Civil, Pôle Hépato-digestif, Service d’hépato-gastroentérologie, 1, quai Louis Pasteur, 67000 Strasbourg
2 Centre Hospitalier Dron, Service d’hépato-gastroentérologie, Tourcoing
3 Centre Hospitalier Saint Philibert, GHICL, Service de pathologie digestive, Lomme
* Correspondance

Walled off necrosis (WON) is a major complication of acute necrotizing pancreatitis (ANP) and strikes patients’ prognosis. Many studies have been studying ANP management which has progressively evolved from exclusive surgery towards to a step-up approach including radiological and endoscopic drainages.

As far as endoscopy is concerned, initial management consisted on stenting pancreatic collection with double pigtail plastic stent. Then full covered self-expandable metallic stent was developed to allow a direct access to WON passing through a standard gastroscope. It was the emergence of Direct Endoscopic Necrosectomy.

More recently, a lumen apposing metal stent (LAMS) was designed to anastomose digestive tract to adjacent structure. It represents an important technical and clinical success since WON resolution was observed nine times out of ten with lower recurrence. Finally, new LAMS integrating electrocautery enhanced delivery system emerged reducing procedure steps.

However, severe complications have been described, including acute hemorrhage by erosion of an adjacent vessel. These adverse events advocate close monitoring by compute tomodensitometry and early stent's removal. Unfortunately, there are no recommendations for the withdrawal of the stent. This new device has an additional cost compared to DPPS. However, it is important to keep in mind the global cost of management of WON not only endoscopic procedure to compare it with other devices.

In conclusion, LAMS redefine the management of symptomatic WON and appear to provide a benefit in terms of technical and clinical success. But now, this technique should be reserved only for expert centers in order to propose a step-up approach in coordination with the radiology and surgery teams. Moreover, serious complications can occur and should be manage by expert teams. New studies should be carried out to determine the management of this stent and their complications and include them in new recommendation in management of WON.