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.