EUS-guided drainage of a diverticular abscess as an adjunct to surgical therapy

Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review

The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.

Comparison of outcomes between endoscopic ultrasound-guided transcolonic and transrectal drainage of abdominopelvic abscesses

BACKGROUND

Transrectal endoscopic ultrasound (EUS)-guided pelvic abscess drainage has been reported, but data on transcolonic drainage are scant.

AIM

To compare outcomes in patients undergoing transcolonic and transrectal drainage of abdominopelvic abscesses.

METHODS

Retrospective study of all patients who underwent EUS-guided drainage of abdominopelvic abscesses over a 7-year period. Abscesses were drained by a standard single-step EUS-guided technique with deployment of double-pigtail stents ± catheters. Technical success was defined as successful placement of stents or drainage catheters within the abscess cavity. Treatment success was defined as resolution of abscess on follow-up computed tomography at 2 weeks with symptom improvement.

RESULTS

Of 38 patients, 11 underwent transcolonic and 27 transrectal drainages. There was no difference in patient demographics, laboratory values, and median abscess size (65 vs 70 mm, P = 0.85) between the two cohorts. Etiology of abscess was postsurgical in 65.7%, diverticulitis in 13.1%, perforated viscus in 10.5%, and other causes in 10.5%. There was no difference in rates of technical success (100% in each cohort), treatment success (70% vs 96.3%, P = 0.052), or complications (none). Three patients in the transcolonic and one in the transrectal cohort underwent surgery for failed endoscopic drainage (27.3% vs 3.7%, P = 0.06). When evaluated by etiology, treatment success for diverticular abscess was significantly lower compared with others (25% vs 97%, P = 0.002). At a median follow-up of 1228.5 days (interquartile range = 131-1660), all patients with treatment success were doing well with no recurrence.

CONCLUSION

Except for patients with diverticular etiology, treatment of abdominopelvic abscess under EUS guidance is highly effective and safe for both routes.

Role of endosonography in drainage of fluid collections and other NOTES procedures

Endosonography (EUS) has become the accepted procedure for drainage of pancreatic fluid collections in the past decade. EUS was shown to be safe and effective and it has been the first-line therapy for uncomplicated pseudocysts. Where walled-off pancreatic necrosis was originally thought to be a contraindication for endoscopic treatment, multiple case series have now shown that these fluid collections also can be treated endoscopically with low morbidity and mortality. Analogous to the treatment of pancreatic fluid collections, others, such as abscesses in the lower and upper abdomen, have also been treated successfully, although there is limited literature in this regard, EUS appears to be a useful technique in natural orifice transluminal endoscopic surgery (NOTES) procedures as well.

Endoscopic ultrasound in the diagnosis, staging and management of colorectal tumors

Endoscopic ultrasound (EUS) has evolved as a useful technique for imaging and intervention in the colon and rectum. This article reviews the clinical applications of EUS for imaging and intervention in colorectal cancer, with an emphasis on the most recent clinical studies.

EUS-guided drainage of pelvic abscess (with video)

BACKGROUND

Although pelvic abscesses have traditionally been drained by surgery or under radiologic guidance, a small subset of patients who are not candidates for these interventions require an alternate mode of drainage.

OBJECTIVE

Evaluate the efficacy of EUS for drainage of pelvic abscesses that could not be drained under US or CT guidance.

DESIGN

Prospective case series.

SETTING

Tertiary referral center.

PATIENTS

Four patients underwent EUS-guided drainage of pelvic abscesses that were not amenable for drainage by US and/or CT guidance.

INTERVENTIONS

A 10F drainage catheter was deployed in the abscess cavity under EUS guidance in all patients. The catheters were flushed periodically until resolution of the abscess was confirmed by CT imaging.

MAIN OUTCOME MEASUREMENTS

Resolution of a pelvic abscess on follow-up CT and improvement in clinical symptoms.

RESULTS

A drainage catheter was successfully placed in all 4 patients. The mean size of the abscess was 68 x 72 mm. There were no procedure-related complications. One patient died of worsening congestive heart failure 48 hours after the procedure. The abscesses resolved in the remaining 3 patients within a mean duration of 6 days, with complete symptom relief.

LIMITATIONS

A small number of patients and short duration of follow-up.

CONCLUSIONS

EUS-guided placement of drainage catheter is a minimally invasive technique for draining pelvic abscesses that are within the reach of the echoendoscope.

Recent developments in the role of endoscopic ultrasonography in diseases of the colon and rectum

PURPOSE OF REVIEW

Endoscopic ultrasound has evolved as a useful technique for imaging and intervention in a variety of gastrointestinal and extraintestinal diseases including diseases of the colon and rectum. This paper will review recent developments in endoscopic ultrasound for colorectal diseases.

RECENT FINDINGS

Recent studies have shown significant clinical impact of endoscopic ultrasound in rectal cancer staging. Iliac lymph node evaluation by endoscopic ultrasound-guided fine needle aspiration may further expand the role of endoscopic ultrasound in rectal cancer. Three-dimensional endoscopic ultrasound may help decrease some of the errors of staging with two-dimensional endoscopic ultrasound and may further improve staging accuracy. Recent studies have confirmed continued problems with re-staging rectal cancer after chemoradiation. Endoscopic ultrasound-fine needle aspiration can be helpful in detecting local recurrence of rectal cancer and has been shown to be useful in evaluation of subepithelial masses of the colon and rectum and evaluation of rectosigmoid endometriosis.

SUMMARY

Endoscopic ultrasound continues to be useful for a variety of conditions of the colon and rectum with recent studies confirming its clinical impact as well as expanding its role into newer indications. Assessment for residual cancer after chemoradiation is still problematic and hopefully technological developments in ultrasound in the future may help in improving the accuracy of endoscopic ultrasound in this situation.