**5. Endoscopic management: metal vs. plastic stent**

There are two types of stents that are usually used in the management of PPC: metal stent and double pigtail plastic stent. There have been some concerns about using the plastic stents, which are possible for re-intervention due to ineffective drainage, longer procedure time regarding the need of two plastic stents placement, or even the risk of leakage. However, some studies have shown that plastic stent success rate for PPC drainage ranges from 84 to 94%, but the success rate was found to be lower in few studies when managing WON cases [27–29]. One of the studies by Bang et al. showed that there was no difference for the treatment success between 7 and 10 Fr plastic stents, and even only one plastic stent placement when compared to more than one plastic stents. Another consideration need to be put in clinical practice is the cost, where it would be cheaper to use the plastic stent [30]. Recent meta-analysis study showed that there was a higher clinical success rate (OR 3.39, 95% CI 1.35–21.19) and lower adverse events (OR 0.37, 95% CI 0.21–0.66) in the metal stent studies. The concern is regarding adverse events, such as bleeding, perforation, and stent migration. Fully covered metallic stent (FCMS) might be considered better in bleeding prevention due to the tamponade direct effect from the stent. In the subgroup analysis, even though the success rate in the metal stent group was 98.3%, however, the success rate in the plastic stent group also more than 90%. The success rate in the plastic group was below than 90% only in the WON group, where the metal stent group has still more than 90% success rate [31]. Another development in the stent evolution, lumen apposing metal stent (LAMS) development where this stent is used not only for endoscopic drainage procedure, but also for endoscopic necrosectomy procedure. This stent has also advantage in migration prevention when compared to FCMS [32–35].

Until now, there are still debates and conflicting data with regard to the use of type of the stents. However, even though technically there is no significant difference between placing metal stent versus plastic stent, every type of case need to

be decided individually as the cost issue, stent availability, PFC type, and possible complications are still important things for clinical consideration.
