Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6431
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
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 for WON.
In this retrospective study, we report our preliminary experience in assessing the feasibility, efficacy and safety of EGF for WON.
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 stomach muscularis propria and pseudocyst capsule were penetrated. Fenestrations were expanded up to 1.5-3 cm for drainage or subsequent necrosectomy. The detail procedure-related outcome data (including the time of EUS assessment and fenestration procedures), procedure-related complications, postoperative management, procedural cost, overall cost of hospitalization and follow-up, hospital stay, follow-up time and recurrence were recorded.
EGF failed in Case 1 due to nonadherence of WON to the gastric wall. EGF was successfully implemented in the subsequent four cases. The average procedural time of EGF was 124 min (EUS assessment, 32.3 min; initial fenestration, 28.8 min; expanded fenestration, 33 min), and tended to decrease as experience of the technique was gained. No EGF-related complications were observed. WON disappeared within 3 wk after EGF. In Case 3, WON, treated by endoscopic lumen-apposing metal stent (LAMS) drainage, recurred within a few days after LAMS removal due to stent-related hemorrhage and showed slow resolution for almost 3 mo. No recurrences were observed in all five patients.
EGF is an innovative and promising alternative intervention for WON adherent to the gastric wall, and might outperform endoscopic LAMS drainage, involving less cost and no stent-related complications.
The challenge of this technique resides in the gauging of actual adherence and in selecting appropriate sites for fenestration. We intend to conduct a prospective study to compare EGF with endoscopic LAMS/plastic stent drainage in the future.