Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study

Abstract

BACKGROUND Endoscopic drainage of walled-off necrosis (WON) is still a challenge due to stent-associated problems. We explored endoscopic gastric fenestration (EGF) as an innovative alternative intervention. AIM To assess the feasibility, efficacy and safety of EGF for WON. METHODS Between March 2019 and March 2020, five patients with symptomatic WON in close contact with the stomach wall were treated by EGF. Endoscopic ultrasound (EUS) was used to select appropriate sites for gastric fenestration, which then proceeded layer by layer as in endoscopic submucosal dissection. Both the stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy. RESULTS EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the other four cases by further refinement of fenestration site selection according to computed tomography, endoscopy and EUS features. The average procedure time for EGF was 124 min (EUS assessment, 32.3 min; initial fenestration, 28.8 min; expanded fenestration, 33 min), and tended to decrease as experience gradually increased. The diameter of the fenestration site was 1.5-3 cm, beyond the caliber of a lumen-apposing metal stent (LAMS), to ensure effective drainage or subsequent necrosectomy. Fenestration sites showed surprising capacity for postoperative self-healing within 1-3 wk. No EGF-related complications were seen. WON disappeared within 3 wk after EGF. In Case 3, another separate WON, treated by endoscopic LAMS drainage, recurred within 4 d after LAMS removal due to stent-related hemorrhage, and resolved slowly over almost 3 mo. No recurrences were observed in the five patients. CONCLUSION EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall. The challenge resides in the gauging of actual adherence and in selecting appropriate fenestration sites.

Endoscopic transgastric fenestration versus percutaneous drainage for management of (peri)pancreatic fluid collections adjacent to gastric wall (with video)

“…In the present study, seven patients had nasocystic tube implanted due to pus and necrosis in the cavity, of which 3 lesions were more than 150 mm and another 3 lesions were > 100 mm. A study on ETGF found that there were 3 of 5 patients received a nasocystic tube and the mean catheterization time was 10 d, which was longer than that in our study (8.6 d)[ 23 ]. We also recommended an indwelling nasocystic tube for large lesion or lesions combined with infection.…”

Invasive intervention timing for infected necrotizing pancreatitis: Late invasive intervention is not late for collection

“…To avoid stent-related complications, we explored endoscopic gastric fenestration (EGF) as an innovative alternative intervention for infected WON[ 19 ]. First, endoscopic submucosal dissection achieved initial fenestration between the stomach and the WON lesion.…”

Direct Endoscopic Necrosectomy: Timing and Technique

“…With the purpose to overcome disadvantages of DPPs and LAMS for the therapy of WOPN (small caliber and poor drainage, occlusion of the stent, bleeding, migration, jaundice, and high cost) Liu et al have recently explored a different modality to gain access to the necrotic collection, the endoscopic gastric fenestration (EGF) [56]. For the feasibility of the procedure, a complete evaluation of the characteristics of the collection with CECT and EUS is performed, as a close adherence between the gastric and the collection wall is mandatory to proceed.…”