WONDER-02 Trial: Plastic Stent vs. Lumen-apposing Metal Stent for Pancreatic Pseudocysts
- Conditions
- Pancreatic PseudocystPancreatic Fluid CollectionPancreatitis
- Interventions
- Procedure: LAMSProcedure: Plastic stent
- Registration Number
- NCT06133023
- Lead Sponsor
- Tokyo University
- Brief Summary
Endoscopic ultrasound (EUS)-guided transluminal drainage has become a first-line treatment modality for symptomatic pancreatic pseudocysts. Despite the increasing popularity of lumen-apposing metal stents (LAMSs), the use of a LAMS is limited by its high costs and specific adverse events compared to plastic stent placement. To date, there has been a paucity of data on the appropriate stent type in this setting. This trial aims to assess the non-inferiority of plastic stents to a LAMS for the initial EUS-guided drainage of pseudocysts.
- Detailed Description
Pancreatic fluid collections (PFCs) develop as local complications of acute pancreatitis after four weeks of the disease onset. Pancreatic pseudocysts are a type of PFC, which is characterised by encapsulated non-necrotic contents. Pseudocysts occasionally become symptomatic (e.g., infection, GI symptoms), and given the high morbidity and mortality, it is mandatory to manage symptomatic pseudocysts appropriately to improve clinical outcomes of patients with acute pancreatitis overall. EUS-guided transluminal drainage has become a first-choice treatment option for symptomatic PFCs. In the setting of EUS-guided treatment of walled-off necrosis (WON, the other type of PFC), the potential benefits of LAMSs have been reported. Compared to plastic stents, LAMSs can serve as a transluminal port and thereby, facilitate the treatment of WON that often requires a long treatment duration with repeated interventions including direct endoscopic necrosectomy. With the increasing popularity and availability of LAMSs in interventional EUS overall, several retrospective studies have reported the feasibility of LAMS use for EUS-guided drainage of pancreatic pseudocysts.
While a LAMS may enhance the drainage efficiency of pseudocysts due to its large calibre, the benefits of this stent may be mitigated in pseudocysts that, by definition, contain non-necrotic liquid contents and can be managed without necrosectomy. Indeed, several retrospective comparative studies failed to demonstrate the superiority of plastic stents to a LAMS. In addition, the use of a LAMS has been limited by higher costs compared to plastic stents and potential specific adverse events (e.g., bleeding, buried stent). Studies suggest that a prolonged duration of LAMS placement (approximately ≥ 4 weeks) may predispose the patients to an elevated risk of adverse events associated with LAMSs. Therefore, patients requiring long-term drainage (e.g., cases with disconnected pancreatic duct syndrome) should be subjected to a reintervention in which a LAMS is replaced by a plastic stent. However, the technical success rate of the replacement has not been high. Given these lines of evidence, the investigators hypothesised that plastic stents might be non-inferior to a LAMS in terms of the potential of resolving a pseudocyst and associated symptoms.
To test the hypothesis, the investigators have planned a multicentre randomised controlled trial (RCT) to examine the non-inferiority of plastic stents to a LAMS as the initial stent for EUS-guided drainage of pancreatic pseudocysts in terms of the achievement of clinical treatment success (the resolution of a pseudocyst). Given the lower costs of plastic stents compared to a LAMS, the results would help not only establish a new treatment paradigm for pancreatic pseudocysts but also improve the cost-effectiveness of the resource-intensive treatment.
Recruitment & Eligibility
- Status
- NOT_YET_RECRUITING
- Sex
- All
- Target Recruitment
- 80
- Patients with pancreatic pseudocyst(s) defined by the revised Atlanta classification
- The longest diameter of a targeted pseudocyst ≥ 5 cm
- Patients requiring drainage for symptoms associated with a pseudocyst (e.g., infection, gastrointestinal symptoms including abdominal pain, or jaundice)
- Patients aged 18 years or older
- Written informed consent obtained from patients or their representatives
- A pseudocyst that is inaccessible via the EUS-guided approach
- A plastic or lumen-apposing metal stent in situ
- Coagulopathy (e.g., platelet count < 50,000/mm3 or prothrombin time international normalised ratio [PT-INR] >1.5)
- Users of antithrombotic agents that cannot be discontinued according to the Japan Gastroenterological Endoscopy Society [JGES] guidelines
- Patients who do not tolerate endoscopic procedures
- Pregnant women
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description LAMS group LAMS In the LAMS group, a LAMS with electrocautery enhanced delivery will be placed (Hot AXIOS; Boston Scientific Japan, Tokyo, Japan). A guidewire or dilator will be used if needed. Plastic stent group Plastic stent In the plastic stent group, two (at least one) 7-Fr double pigtail stents will be placed. Following EUS-guided puncture of a pseudocyst, a guidewire will be coiled within the lesion, and another guidewire will be inserted alongside the prepositioned guidewire. The puncture tract will be dilated if needed.
- Primary Outcome Measures
Name Time Method Clinical success within 180 days of randomisation Six months Clinical success is defined as 1) a decrease in the size of a targeted pancreatic pseudocyst to 2 cm or less and 2) an improvement of at least two out of the following inflammatory indicators: body temperature, white blood cell count, and C-reactive protein.
- Secondary Outcome Measures
Name Time Method Costs of the index hospitalisation Six months Total costs of the index hospitalisation
Incidence of biliary stricture Five years Biliary stricture due to a pseudocyst
Time requiring endoscopic drainage Six months Time requiring endoscopic drainage for a pseudocyst
Time requiring percutaneous drainage Six months Time requiring percutaneous drainage for a pseudocyst
Length of ICU stay during the index hospitalisation Six months Total ICU stay of the index hospitalisation
Costs of interventions Six months Total costs of treatment interventions
Time to clinical success Six months Time from randomization to clinical success
Incidence of pseudocyst recurrence Five years Incidence of pseudocyst recurrence after clinical success
Mortality Five years Mortality from any cause
Technical success of the initial EUS-guided drainage One day Technical success is defined as the successful placement of any stent in the targeted pseudocyst during the initial EUS-guided drainage.
Number of interventions Six months Total number of interventions needed for the treatment of a pseudocyst
Time of interventions Six months Total procedure time needed for the treatment of a pseudocyst
Duration of antibiotics administration Six months Total administration days of antibiotics
Number of participants with treatment-related adverse events Five years The adverse events are defined and graded by the ASGE lexicon guideline.
Incidence of gastrointestinal stricture Five years Gastrointestinal obstruction due to a pseudocyst
Length of the index hospitalisation Six months Total days of the index hospitalisation
Time to recurrence of pancreatic pseudocyst Five years Time from clinical success to recurrence of pancreatic pseudocyst
Treatment duration of new onset pancreatic pseudocyst Five years Total treatment days for new-onset pancreatic pseudocyst
The presence of sarcopenia Five years The presence of sarcopenia and the date of diagnosis
Incidence of new onset clinical symptoms of pancreatic exocrine insufficiency Five years New-onset clinical symptoms associated with pancreatic exocrine insufficiency, such as steatorrhea , constipation, diarrhea, maldigestion, flatulence, and tenesmus
Treatment duration of recurrent pancreatic pseudocyst Five years Total treatment days for recurrent pancreatic pseudocyst
New onset of pancreatic pseudocyst Five years Incidence of new-onset pancreatic pseudocyst
Incidence of new onset diabetes Five years Incidence of new-onset diabetes mellitus
Success rate of surgical procedures Six months Success rate of surgeries associated with pancreatic pseudocyst
Incidence of new pancreatic cancer Five years New-onset pancreatic cancer
The presence of medications for pancreatic exocrine insufficiency Five years The start of medications for pancreatic exocrine insufficiency and the date
Change in volume of pancreas Five years Change in volume of pancreas. Volume is evaluated by contrast-enhanced Computed Tomography (CT) using SYNAPSE VINCENT (FUJIFILM).
Operation time of surgical procedures Six months Total operation times
Trial Locations
- Locations (26)
Department of Gastroenterology, Aichi Medical University
🇯🇵Aichi, Japan
Department of Gastroenterology, St. Marianna University School of Medicine
🇯🇵Kanagawa, Japan
Department of Gastroenterology, Graduate School of Medicine, Juntendo University
🇯🇵Bunkyō-Ku, Tokyo, Japan
Department of Gastroenterology, Graduate School of Medicine, Chiba University
🇯🇵Chiba, Japan
Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University
🇯🇵Fukuoka, Japan
Department of Gastroenterology, Gifu Municipal Hospital
🇯🇵Gifu, Japan
Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences
🇯🇵Kagoshima, Japan
Department of Gastroenterology, The University of Tokyo Hospital
🇯🇵Bunkyō-Ku, Tokyo, Japan
Division of Hepatobiliary and Pancreatic Diseases, Department of Gastroenterology, Hyogo Medical University
🇯🇵Hyōgo, Japan
Department of Gastroenterology, Kameda Medical Center
🇯🇵Kamogawa, Japan
Department of Gastroenterological Endoscopy, Kanazawa Medical University
🇯🇵Kanazawa, Japan
Department of Gastroenterology, Teikyo University Mizonokuchi Hospital
🇯🇵Kawasaki, Japan
Department of Gastroenterology and Hepatology, Okayama University Hospital
🇯🇵Okayama, Japan
2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University
🇯🇵Osaka, Japan
Department of Gastroenterology, Gifu Prefectural General Medical Center
🇯🇵Gifu, Japan
Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University
🇯🇵Kagawa, Japan
Department of Gastroenterology and Hepatology, Mie University Hospital
🇯🇵Mie, Japan
First Department of Internal Medicine, Gifu University Hospital
🇯🇵Gifu, Japan
Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University
🇯🇵Kawagoe, Japan
Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine
🇯🇵Kobe, Japan
Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine
🇯🇵Tokyo, Japan
Department of Gastroenterology, Yamanashi Prefectural Central Hospital
🇯🇵Yamanashi, Japan
Department of Gastroenterology and Hepatology, Hokkaido University Hospital
🇯🇵Sapporo, Japan
Third Department of Internal Medicine, University of Toyama
🇯🇵Toyama, Japan
Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine
🇯🇵Ōsaka, Japan
Department of Gastroenterology, Wakayama Medical University School of Medicine
🇯🇵Wakayama, Japan