Response to: ‘Lumen-apposing metal stents for pancreatic fluid collections: has advancing technology encouraged overreach?’ by Besim Fazil et al

We sincerely thank Besim Fazil and colleagues1 for their interest in our recent study on the nationwide impact of lumen-apposing metal stent (LAMS) implementation on the clinical outcomes of endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs).2 They thoughtfully highlighted the clinical and research implications of our study. We agree that LAMS use should be reserved for selected subgroups of patients with PFCs. Recent randomised controlled trials,3–5 including our WONDER-01 trial, have demonstrated the superiority of immediate endoscopic necrosectomy following the initial EUS-guided drainage of walled-off necrosis over the step-up approach. In this setting, a LAMS may be particularly advantageous, functioning as a stable transluminal port for necrosectomy. Its lumen-apposing design facilitates prolonged, technically demanding necrosectomy procedures while minimising fluid leakage. In contrast, pancreatic pseudocysts—which, by definition, contain only non-necrotic fluid—may be effectively managed with a smaller calibre plastic stent, without clear benefit from LAMS use. Accordingly, our WONDERFUL study group has initiated a randomised controlled trial (WONDER-02) to evaluate the non-inferiority of plastic stents compared with LAMS in terms of clinical success.6 We believe that the findings of our current study reinforce these prior observations.