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

Figure 1 Case 1 (failed fenestration) with indwelling nasal-cyst drainage tube. A: Closely connected walled-off necrosis (WON) and gastric wall (preoperative computed tomography scan); B: Smooth, compressive indentation of stomach by WON; C: Endoscopic ultrasound (EUS) showed closely connected WON and gastric wall (with clear layers, red arrow); D and E: Incising the selected sites layer by layer by an endoscopic submucosal dissection approach; F: Nonadherence of WON and stomach after incising gastric muscularis propria; G: WON mobilization far from fenestration site (orange arrow) under EUS guidance; H: Needle puncture into WON from gastric wall; I: Visible separation of WON and stomach by X-ray fluoroscopy after inserting the guidewire into WON; J: Indwelling nasal-cyst drainage tube passed through the stomach into WON and closing the incised gastric muscularis propria by metal clips; K and L: Nasal-cyst drainage tube was cut off and we reverted to internal drainage 15 d later.

Figure 2 Endoscopic gastric fenestration technique. A: Closely connected walled-off necrosis (WON) and gastric wall lacking clear layers (black arrow, preoperative computed tomography scan); B: Compressive indentation of stomach by WON, with intense inflammation (orange arrow); C: Endoscopic ultrasound assessment and selection of fenestration site, abutment < 1 cm in combined thickness without clear layers (red arrow); D: Marking of prospective fenestration; E: Initial fenestration by endoscopic submucosal dissection; F: Penetration of WON capsule, releasing fluid content; G: Expanded fenestration; H: Self-healing of fenestration as seen by postoperative endoscopy (1 wk after endoscopic gastric fenestration); I: Narrowed area of initial fenestration; J: Enlarged expanded fenestration up to 3 cm; K: Necrotic tissue and exposed blood vessel in WON; L: Debridement of necrotic tissue.