Endoscopic fenestration in the diagnosis and treatment of delayed anastomotic submucosal abscess:A case report and review of literature

BACKGROUND Abscess formation is one of the complications after radical resection of rectal cancer;cases with delayed postoperative anastomotic abscess are rare.Here,we report a rare case of postoperative anastomotic abscess with a submucosal neoplasm appearing after rectal surgery.Ultimately,the patient was diagnosed and treated by endoscopic fenestration.In addition,we review the literature on the appearance of an abscess as a complication after rectal cancer surgery.CASE SUMMARY A 57-year-old man with a history of rectal malignancy resection complained of a smooth protuberance near the anastomotic stoma.Endoscopic ultrasonography revealed a hypoechoic structure originating from the muscularis propria,and a submucosal tumor was suspected.The patient was subsequently referred to our hospital and underwent pelvic contrast-enhanced computed tomography,which revealed no thickening or strengthening of the anastomotic wall.In order to clarify the origin of the lesion and obtain the pathology,endoscopic fenestration was performed.After endoscopic procedure,a definitive diagnosis of delayed anastomotic submucosal abscess was established.The patient achieved good recovery and prognosis after the complete clearance of abscess.CONCLUSION Endoscopic fenestration may be safe and effective for the diagnosis/treatment of delayed intestinal smooth protuberance after rectal cancer surgery.

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

BACKGROUND Percutaneous drainage(PCD)and endoscopic approaches have largely replaced surgical drainage as the initial approach for(peri)pancreatic fluid collections(PFC)s,while complications associated with endoscopic stent implantation are common.AIM To introduce a novel endoscopic therapy named endoscopic transgastric fenestration(ETGF),which involves resection of tissue by endoscopic accessory between gastric and PFCs without stent implantation,and to evaluate its efficacy and safety compared with PCD for the management of PFCs adjacent to the gastric wall.METHODS Patients diagnosed with PFCs adjacent to the gastric wall and who subsequently received ETGF or PCD were restrospectively enrolled.Indications for intervention were consistent with related guidelines.We analyzed patients baseline characteristics,technical and clinical success rate,recurrence and reintervention rate,procedure-related complications and adverse events.RESULTS Seventy-two eligible patients were retrospectively identified(ETGF=34,PCD=38)from October 2017 to May 2021.Patients in the ETGF group had a significantly higher clinical success rate than those in the PCD group(97.1 vs 76.3%,P=0.01).There were no statistically significant differences regarding recurrence,reintervention and incidence of complication between the two groups.While long-term catheter drainage was very common in the PCD group.CONCLUSION Compared with PCD,ETGF has a higher clinical success rate in the management of PFCs adjacent to the gastric wall.ETGF is an alternative effective strategy for the treatment of PFCs adjacent to the gastric wall.

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

BACKGROUND Endoscopic drainage of walled-off necrosis(WON) is still a challenge due to stentassociated 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.

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

With the advance of invasive interventions,the treatment model for infected necrotizing pancreatitis(INP)has shifted from open surgery to the step-up minimally invasive treatment.Late intervention,originating from the open surgery era,has been questioned in the minimally invasive period.With the emergence of new high-quality evidence about the timing for intervention,it seems to be increasingly apparent that,even in the age of minimal invasiveness,“late intervention”waiting for the necrotic collections to be encapsulated is still necessary.This opinion review mainly discusses the intervention timing for INP.