Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis

EUS-guided transrectal drainage of pelvic abscesses: a retrospective analysis of 17 patients

Background

Pelvic abscess is a common complication of abdominal surgery or intestinal or gynecological diseases. Over the last decades, endoscopic ultrasound (EUS)-guided drainage has emerged as a minimally invasive alternative to percutaneous or surgical treatment of pelvic abscesses.

Aim

To evaluate safety and efficacy of EUS-guided transrectal pelvic abscess drainage in a single center.

Methods

From February 2017 to April 2023, all data on patients who were treated for pelvic abscesses by EUS-guided drainage in a single center, were retrospectively analyzed.

Results

A total of 17 patients were treated for pelvic abscesses by EUS-guided drainage. The procedure was technically successful and uneventful in all 17 patients (100%). Etiology of the abscess was postsurgical (n=5, 29%), secondary to medical illness (n=10, 59%) or gastrointestinal perforation (n=2, 12%). The abscess was multilocular in 5 patients (29%), the mean largest diameter was 76 mm (range 40-146 mm). Drainage was performed using 2 double pigtail stents, and in 1 patient an additional 10 Fr drainage catheter was deployed. Two patients (12%) required a second endoscopic intervention. Treatment success, defined by complete abscess resolution on follow-up CT scan along with symptom relief, was 100%. There was no need for surgical intervention. The median post-procedural hospital stay was 5 days. No recurrence was reported within a median time of follow-up of 39 months.

Conclusion

EUS-guided transrectal drainage of pelvic abscesses using double pigtail stents is safe and highly effective. This case series contributes to the cumulative evidence that, in expert hands, EUS-guided drainage should be considered as first-line approach for treatment of pelvic abscesses.

A Rare Case of Delayed Perigastric Abscess after Curative Resection of Early Gastric Cancer by Uncomplicated Endoscopic Submucosal Dissection: Successful Treatment with Endoscopic Ultrasound-guided Drainage

A 72-year-old man had undergone uncomplicated endoscopic submucosal dissection (ESD) with en bloc resection of a localized 20-mm IIc lesion in the anterior wall of the gastric angle. Twenty-eight days later, he was re-admitted with epigastric pain of one-week duration. Contrast-enhanced computed tomography (CT) revealed a 60-mm mass bordered by viscera; repeat endoscopy confirmed a smooth elevated submucosal tumor at the greater curvature on the oral side of the post-ESD ulcer. We diagnosed him with a perigastric abscess as a complication of ESD and performed endoscopic ultrasound-guided drainage. Subsequently, the symptoms and blood inflammatory parameters improved, and follow-up CT showed the disappearance of the abscess.

Endoscopic Management of Peri-Pancreatic Fluid Collections

In the past decade, there has been a progressive paradigm shift in the management of peri-pancreatic fluid collections after acute pancreatitis. Refinements in the definitions of fluid collections from the updated Atlanta classification have enabled better communication amongst physicians in an effort to formulate optimal treatments. Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has emerged as the procedure of choice over surgical cystogastrostomy. The approach provides similar success rates with low complications and better quality of life compared with surgery. However, an endoscopic "step up" approach in the management of pancreatic walled-off necrosis has also been advocated. Both endoscopic and percutaneous drainage routes may be used depending on the anatomical location of the collections. New-generation large diameter EUS-specific stent systems have also recently been described. The device allows precise and effective drainage of the collections and permits endoscopic necrosectomy through the stents.

Endoscopic ultrasound-guided transduodenal drainage of idiopathic retroperitoneal abscess in an immunocompromised patient: A case report

RATIONALE

Idiopathic retroperitoneal abscesses are insidious, occult illnesses with high mortality if inadequately drained. Endoscopic ultrasound-guided drainage is an alternative to percutaneous or surgical drainage, it is not widely performed for retroperitoneal abscesses other than peripancreatic fluid collection.

PATIENT CONCERNS

We present a 76-year-old Japanese woman with abdominal pain, high fever, and a history of rheumatism on treatment with immunosuppressants.

DIAGNOSES

The patient was diagnosed with idiopathic retroperitoneal abscess based on results obtained from her clinical course and findings on computed tomography.

INTERVENTIONS

We performed Endoscopic ultrasound-guided drainage. After we performed needle puncture via the descending portion of the duodenum, the fistula was expanded using a dilator, and a double-pigtail stent and endoscopic nasobiliary drainage tube were inserted.

OUTCOMES

The patient was kept nil by mouth, together with intravenous antibiotic therapy, and repeated washing of the abscess cavity with saline was performed. After that, we confirmed disappearance of the cavity, and, after removing the tubes, commenced oral feeding. We were able to avoid surgery in this immunosuppressed patient.

LESSONS

Endoscopic ultrasound (EUS)-guided abscess drainage can be overall considered a safe and useful procedure. We also propose the double-stent method, with both internal and external stents, for the treatment of idiopathic retroperitoneal abscesses.

Endoscopic Ultrasound-Guided Drainage without Fluoroscopic Guidance for Extraluminal Complicated Cysts

Background. Endoscopic ultrasound- (EUS-) guided drainage is generally performed under fluoroscopic guidance. However, improvements in endoscopic and EUS techniques and experience have led to questions regarding the usefulness of fluoroscopy. This study aimed to retrospectively evaluate the safety and efficacy of EUS-guided drainage of extraluminal complicated cysts without fluoroscopic guidance. Methods. Patients who had undergone nonfluoroscopic EUS-guided drainage of extraluminal complicated cysts were enrolled. Drainage was performed via a transgastric, transduodenal, or transrectal approach. Single or double 7 Fr double pigtail stents were inserted. Results. Seventeen procedures were performed in 15 patients in peripancreatic fluid collections (n = 13) and pelvic abscesses (n = 4). The median lesion size was 7.1 cm (range: 2.8-13.0 cm), and the mean time spent per procedure was 26.2 ± 9.8 minutes (range: 16-50 minutes). Endoscopic drainage was successful in 16 of 17 (94.1%) procedures. There were no complications. All patients experienced symptomatic improvement and revealed partial to complete resolution according to follow-up computed tomography findings. Two patients developed recurrent cysts that were drained during repeat procedures, with eventual complete resolution. Conclusion. EUS-guided drainage without fluoroscopic guidance is a technically feasible, safe, and effective procedure for the treatment of extraluminal complicated cysts.

Biliary and pancreatic stenting: Devices and insertion techniques in therapeutic endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography

Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bilio-pancreatic leakages, for preventing post- endoscopic retrograde cholangiopancreatography pancreatitis and to drain the gallbladder and pancreatic fluid collections. Recent progresses in techniques of stent insertion and metal stent design are represented by new, fully-covered lumen apposing metal stents. These stents are specifically designed for transmural drainage, with a saddle-shape design and bilateral flanges, to provide lumen-to-lumen anchoring, reducing the risk of migration and leakage. This review is an update of the technique of stent insertion and metal stent deployment, of the most recent data available on stent types and characteristics and the new applications for biliopancreatic stents.

Developments in flexible endoscopic surgery: a review

Flexible endoscopy is increasingly developing into a therapeutic instead of a purely diagnostic discipline. Improved visualization makes early lesions easily detectable and allows us to decide ad hoc on the required treatment. Deep enteroscopy allows the exploration of even the small bowel - for long a "white spot" for gastrointestinal endoscopy - and to perform direct treatment. Endoscopic submucosal dissection is a considerable step forward in oncologically correct endoscopic treatment of (early) malignant lesions. Though still technically challenging, it is increasingly facilitated by new manipulation techniques and tools that are being steadily optimized. Closure of wall defects and hemostasis could be improved significantly. Even the anatomy beyond the gastrointestinal wall is being explored by the therapeutic use of endoluminal ultrasound. Endosonographic-guided surgery is not only a suitable fallback solution if conventional endoscopic retrograde cholangiopancreatography fails, but even makes necrosectomy procedures, abscess drainage, and neurolysis feasible for the endoscopist. Newly developed endoscopic approaches aim at formerly distinctive surgical domains like gastroesophageal reflux disease, appendicitis, and cholecystitis. Combined endoscopic/laparoscopic interventional techniques could become the harbingers of natural orifice transluminal endoscopic surgery, whereas pure natural orifice transluminal endoscopic surgery is currently still in its beginnings.

Endoscopic Ultrasound-Guided Treatment beyond Drainage: Hemostasis, Anastomosis, and Others

Since the introduction of endoscopic ultrasound (EUS) in the 1990s, it has evolved from a primarily diagnostic modality into an instrument that can be used in various therapeutic interventions. EUS-guided fine-needle injection was initially described for celiac plexus neurolysis. By using the fundamentals of this method, drainage techniques emerged for the biliary and pancreatic ducts, fluid collections, and abscesses. More recently, EUS has been used for ablative techniques and injection therapies for patients with for gastrointestinal malignancies. As the search for minimally invasive techniques continued, EUS-guided hemostasis methods have also been described. The technical advances in EUS-guided therapies may appear to be limitless; however, in many instances, these procedures have been described only in small case series. More data are required to determine the efficacy and safety of these techniques, and new accessories will be needed to facilitate their implementation into practice.

Interventional endoscopic ultrasonography. ACTA ACUST UNITED AC. 2014;12:183-210. [PMID: 24609891 DOI: 10.1007/s11938-014-0015-x]

OPINION STATEMENT

Endoscopic ultrasound (EUS) is not only a diagnostic tool but also an interventional and therapeutic procedure. Indeed, in addition to tissue acquisition, it can also drain fluid collections adjacent to the gastrointestinal tract, provide access to biliary and pancreatic ducts, biliary, pancreatic, and gallbladder drainage, pancreatic cyst ablation, and, finally, provide anti-tumoral treatments and interventional vascular procedures. Although several improvements have been made in the last decade, the full potential of interventional EUS is yet to be completely explored. Future areas of research are the development of dedicated tools and accessories, the standardization of the interventional procedures, and the widening of the use of EUS, while increasing the expertise worldwide. In addition, more data, based on well-performed, possibly randomized clinical trials, are needed to accurately determine the risks and long-term outcomes of these interventions. We firmly believe that interventional EUS can play a pivotal role in anti-tumor treatments, by the fine-needle injection of anti-tumoral agents, tumor ablation, and assisting radiation treatment with gold fiducial placement and the implantation of intralesional seeds. The goal of the near future will be to offer targeted therapy and monitoring of tumor treatment response in a more biologically driven manner than has been available in the past. Interventional EUS will be an essential part of the multidisciplinary approach to cancer treatment.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) develop secondary to either fluid leakage or liquefaction of pancreatic necrosis following acute pancreatitis, chronic pancreatitis, surgery or abdominal trauma. Pancreatic fluid collections include acute fluid collections, acute and chronic pancreatic pseudocysts, pancreatic abscesses and pancreatic necrosis. Before the introduction of linear endoscopic ultrasound (EUS) in the 1990s and the subsequent development of endoscopic ultrasound-guided drainage (EUS-GD) procedures, the available options for drainage in symptomatic PFCs included surgical drainage, percutaneous drainage using radiological guidance and conventional endoscopic transmural drainage. In recent years, it has gradually been recognized that, due to its lower morbidity rate compared to the surgical and percutaneous approaches, endoscopic treatment may be the preferred first-line approach for managing symptomatic PFCs. Endoscopic ultrasound-guided drainage has the following advantages, when compared to other alternatives such as surgical, percutaneous and non-EUS-guided endoscopic drainage. EUS-GD is less invasive than surgery and therefore does not require general anesthesia. The morbidity rate is lower, recovery is faster and the costs are lower. EUS-GD can avoid local complications related to percutaneous drainage. Because the endoscope is placed adjacent to the fluid collection, it can have direct access to the fluid cavity, unlike percutaneous drainage which traverses the abdominal wall. Complications such as bleeding, inadvertent puncture of adjacent viscera, secondary infection and prolonged periods of drainage with resultant pancreatico-cutaneous fistulae may be avoided. The only difference between EUS and non-EUS drainage is the initial step, namely, gaining access to the pancreatic fluid collection. All the subsequent steps are similar, i.e., insertion of guide-wires with fluoroscopic guidance, balloon dilatation of the cystogastrostomy and insertion of transmural stents or nasocystic catheters. With the introduction of the EUS-scope equipped with a large operative channel which permits drainage of the PFCs in “one step”, EUS-GD has been increasingly carried out in many tertiary care centers and has expanded the safety and efficacy of this modality, allowing access to and drainage of overly challenging fluid collections. However, the nature of the PFCs determines the outcome of this procedure. The technique and review of current literature regarding EUS-GD of PFCs will be discussed.

A novel approach for the treatment of pelvic abscess: transrectal endoscopic drainage facilitated by transanal endoscopic microsurgery access

BACKGROUND

Postoperative pelvic abscesses in patients submitted to colorectal surgery are challenging. The surgical approach may be too risky, and image-guided drainage often is difficult due to the complex anatomy of the pelvis. This article describes novel access for drainage of a pelvic collection using a minimally invasive natural orifice approach.

METHODS

A 37 year-old man presented with sepsis due to a pelvic abscess during the second postoperative week after a Hartmann procedure due to perforated rectal cancer. Percutaneous drainage was determined by computed tomography to be unsuccessful, and another operation was considered to be hazardous. Because the pelvic fluid was very close to the rectal stump, transrectal drainage was planned. The rectal stump was opened using transanal endoscopic microsurgery (TEM) instruments. The endoscope was advanced through the TEM working channel and the rectal stump opening, accessing the abdominal cavity and pelvic collection.

RESULTS

The pelvic collection was endoscopically drained and the local cavity washed with saline through the scope channel. A Foley catheter was placed in the rectal stump. The patient's recovery after the procedure was successful, without the need for further intervention.

CONCLUSIONS

Transrectal endoscopic drainage may be an option for selected cases of pelvic fluid collection in patients submitted to Hartmann's procedure. The technique allows not only fluid drainage but also visualization of the local cavity, cleavage of multiloculated abscesses, and saline irrigation if necessary. The use of TEM instrumentation allows safe access to the peritoneal cavity.

EUS-guided drainage and stent placement for postoperative intra-abdominal and pelvic fluid collections in oncological surgery

OBJECTIVES

The objective of this study was to evaluate the role and benefits of endoscopic ultrasonography (EUS) in the management of postoperative intra-abdominal fluid collections after attempted curative surgery for abdominal cancer.

METHODS

The authors retrospectively analysed the Endobase from 1 July 2007 to 30 January 2011 for patients with a postoperative intra-abdominal fluid collection who had undergone EUS-guided drainage and the placement of a stent. The data analysed included the demographics, type of surgery and clinical indications of each patient as well as their clinical and radiological findings.

RESULTS

Six patients (three men and three women; mean age, 61.8 years [range, 38-78 years]) with intra-abdominal and pelvic fluid collections after abdominal surgery for cancer had undergone EUS-guided internal drainage. All procedures had been performed using linear EUS guidance and 8-Fr stent drainage catheters ('one step device', Giovannini, NWOA system Needle-Wire, Cook). The collection types included perigastric abscess (n = 3), perigastric hematoma and rectal hematoma (n = 1), perirectal biloma (n = 1), and perirectal abscess (n = 1). Patients had undergone the following types of surgery: lower-anterior rectal resection (n = 2), Whipple's duodenopancreatectomy type (n = 1), total gastrectomy (n = 1), splenectomy (n = 1), and distal pancreatectomy (n = 1). The number of stents inserted for each collection was one (five patients) and two (one patient).

CONCLUSIONS

EUS-guided drainage and stenting provide another option for the management of postoperative collections. It allows access to areas that are difficult to reach with the CT-guided approach and it can be performed accurately, efficiently and safely. In addition to this, the internal nature of the drainage offers patients more comfort.

Gallbladder drainage guided by endoscopic ultrasound

The gold-standard management of acute cholecystitis is cholecystectomy. Surgical intervention may be contraindicated due to permanent causes. To date, the classical approach is percutaneous cholecystostomy in patients unresponsive to medical therapy. However, with this treatment some patients may experience discomfort, complications and a decrease in their quality of life. In these cases, endoscopic ultrasound (EUS)-guided gallbladder drainage may represent an effective minimally invasive alternative. Our objective is to describe in detail this new and not well-known technique: EUS-guided cholecystenterostomy. We will describe how the patient should be prepared, what accessories are needed and how the technique is performed. We will also discuss the possible indications for this technique and will provide a brief review based on published reports and our own experience.

EUS-guided drainage of hepatic abscesses not accessible to percutaneous drainage (with videos)

BACKGROUND

Currently, percutaneous drainage is the first treatment of choice for hepatic abscesses because of its high success and low mortality rates compared with other surgical procedures. However, percutaneous drainage of hepatic abscesses in the caudate lobe or gastrohepatic space may be difficult.

OBJECTIVE

The aim of this study was to determine the technical feasibility and clinical implication of EUS-guided drainage for hepatic abscesses not accessible to percutaneous biliary drainage.

DESIGN

Single-center prospective case series.

SETTING

Academic tertiary referral center.

PATIENTS

This study involved 3 consecutive patients with hepatic abscesses not accessible to percutaneous biliary drainage: 2 in the caudate lobe and 1 in the gastrohepatic extension from the posteromedial aspect of the lateral segment.

INTERVENTIONS

EUS-guided drainage with a plastic stent and/or nasocystic tube was conducted using a therapeutic linear-array echoendoscope under endoscopic and fluoroscopic guidance.

RESULTS

The EUS-guided transgastric approach was performed in 2 patients (1 in the caudate lobe, and 1 in the gastrohepatic space). In the other patient (caudate lobe), EUS-guided transduodenal drainage was conducted. EUS-guided drainage with the placement of a plastic stent and/or nasocystic tube was successful in all of the patients. Complete resolution of the hepatic abscesses and symptom relief were achieved in all of the patients (3 out of 3, 100%). No procedural complications were observed. Follow-up results were also favorable.

LIMITATIONS

Small series of cases.

CONCLUSIONS

For this case series, EUS-guided drainage of hepatic abscesses not accessible to percutaneous drainage, such as those in the caudate lobe or gastrohepatic space, is technically feasible, safe, and provides complete drainage, symptom relief, and favorable follow-up results.

EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis

Endoscopic ultrasound (EUS)-guided drainage has emerged as the leading treatment modality for symptomatic pancreatic fluid collections. Endoscopic ultrasound-guided endoscopic drainage is less invasive than surgery and avoids local complications related to percutaneous drainage. In addition, unlike non-EUS guided endoscopic drainage, EUS-guided drainage is able to drain non-bulging fluid collections and may reduce the risk of procedure-related bleeding. Excellent treatment success rates exceeding 90% have been reported for pancreatic pseudocysts and abscesses. In the context of infected pancreatic necrosis, adjunctive endoscopic necrosectomy is required for effective treatment. With such an aggressive approach, the treatment success rate may reach 81%-92%. The potential complications of concern for EUS-guided drainage are severe bleeding and perforation. To minimize risk, only fluid collections with a mature wall and within 1 cm of the gastrointestinal lumen should undergo endoscopic drainage. Any coagulopathy, if present, should be corrected. Patients with pseudocysts undergoing drainage should also receive prophylactic antibiotics in order to prevent secondary infection of a sterile collection.