Non-superiority of lumen-apposing metal stents: Is the evidence conclusive?

With great interest we have read the work of Bang et al, comparing the efficacy of lumen-apposing metal stents (LAMS) and double-pigtail plastic stents (DPS) for endoscopic drainage of walled-off necrosis (WON).1 We congratulate the authors on completing the first randomised controlled trial comparing these two drainage strategies. They found no difference in the total number of procedures needed to achieve treatment success at 6-month follow-up. However, we feel that three important limitations have not been mentioned in the discussion.

First, we question whether the potential benefits of LAMS could have been proven in the included study population. The larger calibre lumen of the LAMS allows spontaneous drainage of necrotic tissue, hypothetically reducing the need for endoscopic necrosectomy. Bang et al indeed demonstrated a very low number of endoscopic necrosectomies in patients treated with LAMS (13%), but also an unusual low number of endoscopic necrosectomies in patients drained with...

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