A Critical Narrative Review of Coaxial Double-Pigtail Stenting Within the LAMS in the Management of Pancreatic Fluid Collections

Endoscopic ultrasound (EUS)-guided drainage using lumen-apposing metal stents (LAMSs) has become the standard for managing pancreatic fluid collections (PFCs), especially walled-off necrosis (WON). However, LAMS-specific adverse events (AEs), including bleeding, stent occlusion, and infection, remain a concern. To mitigate these complications, some experts advocate placing coaxial double-pigtail plastic stents (DPPSs) within LAMSs. This narrative review critically examines the evidence from retrospective and prospective studies, one RCT, and recent meta-analyses on this combined approach. While the routine use of coaxial double-pigtail plastic stents (DPPSs) within LAMSs is not universally supported, emerging data suggest benefits in select high-risk scenarios, such as large WON, debris-rich cavities, or disconnected pancreatic duct syndrome (DPDS), in which coaxial DPPS within LAMSs can reduce occlusion, infection, and recurrence. In addition, the type of LAMS appears to influence safety outcomes: the SPAXUS stent shows lower bleeding and migration rates than the Hot AXIOS. We propose a pragmatic algorithm for the patient-tailored use of coaxial DPPS and discuss technical innovations to improve outcomes. While evidence is still evolving, personalized strategies and future high-quality studies are needed to define the optimal role of coaxial DPPS within LAMSs in the EUS-guided drainage of PFCs.