Chen-Guo Ker, Department of General Surgery, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan

Author contributions: Ker CG performed literature search and evaluation, and manuscript preparation.

Conflict-of-interest statement: The author declares no conflict of interest for 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: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Chen-Guo Ker, FACS, MD, PhD, Professor of Surgery, Department of General Surgery, E-Da Hospital, I-Shou University, No. 1 Yi-Da Rd, Yanchao District, Kaohsiung 824, Taiwan. ed112739@edah.org.tw

Received: October 31, 2023
Peer-review started: October 31, 2023
First decision: December 4, 2023
Revised: December 8, 2023
Accepted: January 16, 2024
Article in press: January 16, 2024
Published online: February 14, 2024

Percutaneous or endoscopic drainage is the initial choice for the treatment of peripancreatic fluid collection in symptomatic patients. Endoscopic transgastric fenestration (ETGF) was first reported for the management of pancreatic pseudocysts of 20 patients in 2008. From a surgeon’s viewpoint, ETGF is a similar procedure to cystogastrostomy in that they both produce a wide outlet orifice for the drainage of fluid and necrotic debris. ETGF can be performed at least 4 wk after the initial onset of acute pancreatitis and it has a high priority over the surgical approach. However, the surgical approach usually has a better success rate because surgical cystogastrostomy has a wider outlet (> 6 cm vs 2 cm) than ETGF. However, percutaneous or endoscopic drainage, ETGF, and surgical approach offer various treatment options for peripancreatic fluid collection patients based on their conditions.

A comment was raised after reading the article titled “Endoscopic transgastric fenestration vs percutaneous drainage for management of (peri) pancreatic fluid collections adjacent to gastric wall (with video)” by Zhang et al[1]. The clinical consequences of local complications in the natural course of acute pancreatitis are acute peripancreatic fluid collection (PPFC), pancreatic pseudocyst (PPC), acute necrotic collection (ANC), and walled-off necrosis (WON)[2,3]. Acute PPFC tends to be poorly walled-off and can leak into the retroperitoneum, peritoneal cavity, or a third space. Therefore, early interventions for these local complications are not recommended according to Japanese or American guidelines[4,5]. If percutaneous or endoscopic interventions for these local complications are necessary, it is necessary to wait until well-encapsulated formation, such as PPC or WON, is achieved. This condition usually occurs more than 4 wk after the onset of interstitial edematous pancreatitis to mature[3].

Percutaneous drainage (PD) or the endoscopic approach is the initial choice for the treatment of symptomatic patients[6]. However, most cystic spaces contain solid debris, which can occlude the tube, leading to impaired drainage. Hence, percutaneous or transmural drainage alone is often inadequate, and additional endoscopic or surgical necrosectomy is frequently required[7-10]. Surgical drainage is reserved only when PD is not successful[11]. Bleeding during management with endoscopic necrosectomy for ANC or WON may occur and result in catastrophic complications. Therefore, it is better to perform this procedure at referral centers with surgical backup[5].

Zhang et al[1] compared endoscopic transgastric fenestration (ETGF) with PD for the management of PPFC, and Liu et al[12] conducted the first ETGF in 2015. Actually, Varadarajulu et al[7] reported endoscopic ultrasound (EUS)-guided cystogastrostomy (same procedure as ETGF) for the management of PPS of 20 patients in 2008. From a surgeon’s viewpoint, ETGF performed by an endoscopist is a similar procedure to cystogastrostomy performed by a surgeon, and both are used for producing a wide outlet orifice for the drainage of fluid and necrotic debris between the cyst and stomach. Therefore, ETGF can be performed only under the condition of stringent adhesion between the posterior gastric and cystic walls. Additionally, ETGF has the same indications as surgical cystogastrostomy. Technically, the operator should first use EUS guidance to demonstrate presumably a resection line on the gastric wall at the site of maximal prominence of the PPC into the stomach to select the thinnest wall, thus minimizing adverse events.

As a novel development, therapeutic endoscopy can extend the dissection skills to perform ETGF to drain and clean the PPFC with well encapsulation where possible. What is already known about ETGF for PPC or WON is accepted as a minimally invasive alternative to the surgical approach. EUS guidance reduces the risk of perforation and hemorrhage. The probability of post-procedure complications and outcomes differs among the various techniques (Table 1). Varadarajulu et al[7] conducted a retrospective study to compare patients with uncomplicated PPC managed by surgical or EUS-guided cystogastrostomy. The results showed no significant differences in treatment success rates, complications, or re-interventions. Furthermore, costs were lower, and the post-procedure length of hospital stay was shorter for EUS-guided cystogastrostomy[7].

Procedure	Percutaneous cystic drainage	EUS-guided drainage with/without necrosectomy	ETGF1 with/without necrosectomy	Surgical cystogastrostomy2
Variable
Technique difficulty	Less	Less	High	High
Risk	Less	Less	Moderate	High
Re-insertion	Yes	Yes	-	-
Complications	Less	Less	Moderate	Less
Healing course	Long	Long	Short	Short
Cost	Less	Moderate	Moderate	High
Ref.	Johnson et al[11]; Akshintala et al[6]	Seicean et al[8]; McGuire et al[10]	Varadarajulu et al, 2008[7]; Suggs et al[14]; Liu et al[12]	Varadarajulu et al[7]; Suggs et al[14]

¹ETGF: Similar to the surgical procedure (cystogastrostomy).

²Cystogastrostomy performed using a traditional or laparoscopic approach.

ETGF: Endoscopic transgastric fenestration; EUS: Endoscopic ultrasound.

Generally, EUS-guided drainage and necrosectomy or ETGF has a high priority over the surgical approach. However, the surgical approach usually has a better success rate because surgical cystogastrostomy has a wider outlet (> 6 cm vs 2 cm) than ETGF[13,14]. Either ETGF or operative cystogastrostomy is indicated in cases where: (1) The cystic wall is well matured; and (2) the cyst is large enough to have a severe adhesion area with the gastric posterior wall instead of the early phase of PPFC without being walled-off. However, PD, endoscopic drainage, ETGF, and surgical approach offer various treatment options that can be tailored to the needs of individual patients with PPFC and the facilities of institutions.