WONDER-02 Trial: Plastic Stent vs. Lumen-apposing Metal Stent for Pancreatic Pseudocysts

Официальное название

WONDER-02: Plastic Stent vs. Lumen-apposing Metal Stent for Endoscopic Ultrasound-guided Drainage of Pancreatic Pseudocysts-a Multicentre Randomised Non-inferiority Trial

Обзор

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.

Подробное описание

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.

Вмешательства

• Процедура Plastic stent
  EUS-guided drainage will be conducted under endosonographic and fluoroscopic guidance within 72 hours of the randomisation. A linear echoendoscope will be advanced to the stomach or duodenum with moderate sedation, and the targeted pseudocyst will be visualised and punctured under endosonographic guidance. In cases with an insufficient improvement in inflammatory indicators (i.e., body temperature, white blood cell count, and C-reactive protein), the investigators will perform additional interve
• Процедура LAMS
  EUS-guided drainage will be conducted under endosonographic and fluoroscopic guidance within 72 hours of the randomisation. A linear echoendoscope will be advanced to the stomach or duodenum with moderate sedation, and the targeted pseudocyst will be visualised and punctured under endosonographic guidance. In cases with an insufficient improvement in inflammatory indicators (i.e., body temperature, white blood cell count, and C-reactive protein), the investigators will perform additional interve

Первичные конечные точки

• Clinical success within 180 days of randomisation [Срок оценки: Six months]

Вторичные конечные точки (12)

• Number of participants with treatment-related adverse events [Срок оценки: Five years]
• Mortality [Срок оценки: Five years]
• Technical success of the initial EUS-guided drainage [Срок оценки: One day]
• Time to clinical success [Срок оценки: Six months]
• Incidence of biliary stricture [Срок оценки: Five years]
• Incidence of gastrointestinal stricture [Срок оценки: Five years]
• Time requiring endoscopic drainage [Срок оценки: Six months]
• Time requiring percutaneous drainage [Срок оценки: Six months]
• Number of interventions [Срок оценки: Six months]
• Time of interventions [Срок оценки: Six months]
• Length of the index hospitalisation [Срок оценки: Six months]
• Length of ICU stay during the index hospitalisation [Срок оценки: Six months]

Критерии участия

Критерии включения

• 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

Критерии исключения

• 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

Критерии приведены из реестра в оригинале (на английском). Окончательную оценку соответствия проводит исследовательский центр.

Здоровые добровольцы: Нет

Дизайн исследования

Распределение

Рандомизированное

Модель

Параллельные группы

Маскирование

Открытое

Основная цель

Лечение

Центры проведения

Япония · 26 центров

• Department of Gastroenterology, Aichi Medical University — Aichi
• Department of Gastroenterology, The University of Tokyo Hospital — Bunkyō-Ku, Tokyo
• Department of Gastroenterology, Graduate School of Medicine, Juntendo University — Bunkyō-Ku, Tokyo
• Department of Gastroenterology, Graduate School of Medicine, Chiba University — Chiba
• Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyu — Fukuoka
• Department of Gastroenterology, Gifu Municipal Hospital — Gifu
• Department of Gastroenterology, Gifu Prefectural General Medical Center — Gifu
• First Department of Internal Medicine, Gifu University Hospital — Gifu
• … и ещё 18 центров

Публикации

• Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PMID 23100216
• Saito T, Takenaka M, Kuwatani M, Doi S, Ohyama H, Fujisawa T, Masuda A, Iwashita T, Shiomi H, Hayashi N, Iwata K, Maruta A, Mukai T, Matsubara S, Hamada T, Inoue T, Matsumoto K, Hirose S, Fujimori N, Kashiwabara K, Kamada H, Hashimoto S, Shiratori T, Yamada R, Kogure H, Nakahara K, Ogura T, Kitano M, Yasuda I, Isayama H, Nakai Y; WONDERFUL study group in Japan and collaborators. WONDER-02: plastic PMID 39182137

Идентификаторы

NCT: NCT06133023 · 2023002P

Первоисточники (государственные реестры)

• ClinicalTrials.gov (NIH, США)

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