Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 7, 2020; 26(41): 6431-6441
Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6431
Endoscopic gastric fenestration of debriding pancreatic walled-off necrosis: A pilot study
Fang Liu, Liang Wu, Xiang-Dong Wang, Jian-Guo Xiao, Wen Li
Fang Liu, Department of Gastroenterology and Hepatology, Medical School of Chinese PLA, Beijing 100853, China
Fang Liu, Xiang-Dong Wang, Wen Li, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
Liang Wu, Department of International Center for Diagnosis and Treatment of Liver Disease, The Fifth Medical Center, Chinese PLA General Hospital, Beijing 100039, China
Jian-Guo Xiao, Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
Author contributions: Liu F and Wu L contributed equally to this manuscript; Li W and Liu F contributed to study conception and design, and the endoscopic operation; Liu F and Wu L wrote and edited the manuscript; Liu F, Wu L, Wang XD, and Xiao JG performed the endoscopic operation, data analysis and interpretation.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of the PLA General Hospital, No. s2019-298-02.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent.
Conflict-of-interest statement: All authors declare no conflicts-of-interest related to this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Wen Li, MD, PhD, Chief Doctor, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing 100853, China. liwen2000@yahoo.com
Received: July 30, 2020
Peer-review started: July 23, 2020
First decision: August 8, 2020
Revised: August 22, 2020
Accepted: September 18, 2020
Article in press: September 18, 2020
Published online: November 7, 2020
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.

Keywords: Endoscopic gastric fenestration, Walled-off necrosis, Lumen-apposing metal stents, Stent-related complications

Core Tip: Endoscopic drainage of walled-off necrosis (WON) is still a challenge due to stent-associated problems. Endoscopic gastric fenestration may be an innovative alternative intervention for WON adherent to the gastric wall, and might outperform lumen-apposing metal stent drainage, with lower cost and no stent-related complications. The challenge is to select appropriate fenestration. We established some characteristics for suitable fenestration sites: Computed tomography: Intimate contact between the stomach and encapsulated WON without clear layers; endoscopy: Intense inflammation (edema, erosion or ulceration) of gastric mucosa; endoscopic ultrasound: Modest abutment (generally < 1 cm) of the stomach and WON without clear layers.