Endoscopic ultrasound-guided abscess drainage

Lumen-Apposing Metal Stents in the Management of Complex Pelvic Abscesses

BACKGROUND

Lumen-apposing metal stents (LAMS) are utilized in a wide range of therapeutic gastrointestinal applications. We present our experience with LAMS-assisted drainage of complex pelvic abscesses at a large safety-net hospital.

METHODS

EUS-guided LAMS placements for pelvic abscesses from July 2020 to June 2024 were analyzed. Data were collected on patient demographics, procedure indications, fluid collection size, stent characteristics, stent dwell time, and complications. All cases underwent multidisciplinary review with Surgery and Interventional Radiology (IR) prior to LAMS-assisted drainage; all were deemed not amenable to drainage by IR.

RESULTS

Eleven patients underwent EUS-guided drainage of complex pelvic abscesses with cautery-enhanced LAMS. Diverticulitis was the most common cause of abscesses (n = 6; 55%). The average time from presentation to drainage was 7 days (1-18). The average abscess size was 7.2 cm (3.9-12.0 cm). The most common LAMS size was 15 mm × 10 mm; each was placed through the left colon and rectum with both technical and clinical success. All abscesses completely resolved with a mean stent dwell time of 28 days (17-42 days). After stent removal, the fistula was not routinely closed. No complications such as stent migration, bleeding, or perforation occurred. There were no recurrences and no patients required additional surgical or IR procedures with a mean follow-up of 25 weeks (SD 35.6).

CONCLUSIONS

Adequate drainage is the cornerstone of pelvic abscess management, but IR or surgical access can be challenging, with inadequate drainage and prolonged hospitalization leading to significant morbidity. In our experience, EUS-guided, LAMS-assisted drainage provides a safe and effective alternative for managing pelvic abscesses.

An Unusual Abscess Associated with Gallbladder Perforation Successfully Treated with Percutaneous Transhepatic Gallbladder Drainage and Endoscopic Ultrasound-guided Abscess Drainage

Abscesses associated with gallbladder perforation are often confined to the peri-gallbladder region. We herein report a rare case of gallbladder perforation in which the abscess cavity extended into the left upper quadrant. A 79-year-old woman developed gallbladder perforation secondary to acalculous cholecystitis. Computed tomography revealed fluid collection extending from the peri-gallbladder to the dorsal left hepatic lobe in contact with the stomach. We successfully treated percutaneous transhepatic gallbladder drainage and simultaneous endoscopic ultrasound-guided transgastric internal and external abscess drainage. This minimally invasive approach is considered safe and feasible for managing such a rare case.

Surgical Emergencies in the ICU

Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.

Endoscopic Ultrasound-Guided Transgastric Puncture and Drainage of an Adrenal Abscess in an Immunosuppressed Patient: A Case Report

Adrenal gland infection is a clinical entity of great importance, but it is a largely unrecognized pathology. Immunosuppressed individuals are at a higher risk of presentation. Herein, we describe a young female patient, recently diagnosed with HIV, who presented with severe sepsis due to methicillin-resistant Staphylococcus aureus, associated with a left adrenal abscess. She was initially treated with antibiotics; however, due to the persistence of the systemic inflammatory response and bacteremia, endoscopic ultrasound-guided drainage was performed. This procedure was successful in resolving the clinical situation. Endoscopic ultrasound-guided adrenal gland drainage can be a safe, efficacious, and minimally invasive option for managing antibiotic-refractory adrenal abscesses in immunosuppressed patients.

EUS-guided pelvic drainage: A systematic review and meta-analysis

Background and Objectives:

EUS-guided pelvic abscess drainage (EUS-PAD) is a procedure that utilizes an echoendoscope to visualize an area of interest for needle insertion and placement of a stent, catheter, or both for drainage of the target abscess. The aim of this study was to perform a systematic review and meta-analysis for the safety and efficacy of EUS-PAD.

Materials and Methods:

We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to February 2020). The primary outcomes for this study were the technical and clinical success of EUS-PAD. The secondary outcomes assessed for this study were adverse events of the procedure and subgroup analysis of individual adverse events.

Results:

Eight studies with a total of 135 patients combined were included in our analysis. The rate of technical success was 100% and the calculated pooled rate of clinical success was 92% (95% confidence interval [CI]: 87%, 98%; P = 0.31; I² = 15%). The calculated pooled rate of adverse events was 9.4% (±17.9%), with stent migration (5.5 ± 18.06%) being the most common adverse event.

Conclusion:

EUS-PAD offers a viable alternative that can minimize the need for surgical intervention in the drainage of pelvic abscesses. EUS-PAD has also demonstrated long-term clinical success with an acceptable rate of complications.

Endoscopic ultrasound guided versus surgical transrectal drainage of pelvic abscesses

BACKGROUND

Pelvic abscesses are common but only small case series reporting outcome of either endoscopic ultrasound (EUS) guided or surgical transrectal drainage have been reported.

METHODS

We performed a retrospective consecutive cohort study, assessing effectivity and safety of EUS guided or surgical transrectal drainage of previously untreated pelvic abscesses from all causes, diagnosed using CT scan between 09/2010 and 06/2014 in a Dutch teaching hospital.

RESULTS

Forty-six patients with comparable demographics, apart from stoma presence (p = .016), were included. The success rate after a single intervention was 83% in the EUS guided compared to 48% in the surgical transrectal drainage group (p = .013). However, the mean duration of drainage was threefold in the EUS group [42 versus 13 days (p = .001)]. The length of stay in hospital was similar for both EUS and surgical group [24 versus 20 days (p = .56)] as was abscess resolution during follow-up [78% versus 74%]. We recorded a total of 12 anastomotic leaks [3 versus 9]. In the occurrence of leakage, only one stoma was finally closed in each group.

CONCLUSION

EUS guided and surgical transrectal drainage of pelvic abscesses from any cause are safe, nonetheless EUS guided drainage(if feasible) seems more effective after a single treatment, with high overall cure rates.

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 Direct Intervention for Solid Pancreatic Tumors

Development and use of linear-array echoendoscope and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) have made endoscopic ultrasound (EUS) more of an interventional procedure than a purely diagnostic procedure. This is a literature review of previously published clinical studies on EUS-guided direct intervention for solid pancreatic tumors, including EUS-guided fine needle injection (EUS-FNI) of antitumor agents, EUS-guided fiducial marker placement, EUS-guided brachytherapy and EUS-guided tumor ablation.

Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management

Walled-off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.

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.

EUS-FNA can be an effective procedure for the transesophageal drainage of a patient with intra-peritoneal abscess

Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is considered to be a highly beneficial and safe diagnostic tool. EUS-FNA now has a greater clinical impact because the technique is currently being applied for therapeutic as well as diagnostic purposes. The treatment of intra-peritoneal abscess after peptic ulcer perforation has traditionally been by surgery, especially when percutaneous abscess drainage is unfeasible. We report that less invasive drainage using EUS-FNA was useful in treating a patient with an abscess who had no other option but to select surgical treatment.

Endoscopic ultrasound guided interventional procedures

Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.

Endoscopic ultrasound-guided pelvic and prostatic abscess drainage: experience in 30 patients

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage is an effective treatment for many abscesses in the abdomen. We review our experience with EUS-guided drainage of pelvic abscesses.

METHODS

Thirty consecutive patients who underwent EUS-guided pelvic abscess drainage were evaluated after excluding three patients with distance to transducer >2 cm or organized abscess.

RESULTS

Thirty patients (25 male) aged 60 ± 4.5 years (mean ± SD) had 4 prostatic abscesses, 7 perisigmoid abscesses, and 19 perirectal abscesses with mean ± SD sizes of 2.5 ± 0.3, 4.7 ± 0.6, and 5.4 ± 0.4 cm, respectively. Surgery was the most common predisposing factor (n = 14, 46.6 %) followed by diverticulitis (n = 5, 16.6 %). Interventions included aspiration only (2 prostatic and 3 perisigmoid), aspiration and dilatation (2 patients in each group), and dilatation and stenting (2 perisigmoid and 17 perirectal). Five (16.6 %) patients needed re-intervention, and two (6.6 %) needed surgery. There were no recurrences. Technical success of EUS-guided pelvic abscess drainage overall was 90.9 % (30/33) and was 93.3 % (27/30) in patients in whom EUS-guided drainage was attempted, with 16.5 % (n = 5) re-intervention rate.

CONCLUSION

EUS-guided drainage has an excellent success rate in drainage of pelvic abscesses.

Endoscopic ultrasound-guided endoluminal drainage of the gallbladder

For patients with acute cholecystitis who are not suitable for surgery, endoscopic ultrasound-guided endoluminal drainage of the gallbladder (EUS-GBD) has been developed to overcome the limitations of percutaneous transhepatic gallbladder drainage when endoscopic transpapillary gallbladder drainage is not feasible. In the present review we have summarized the studies describing EUS-GBD. Indications, techniques, accessories, endoprostheses, limitations and complications reported in the different studies are discussed. There were 90 documented cases in the literature. The overall reported technical success rate was 87/90 (96.7%). All patients with technical success were clinically successful. A total of 11/90 (12.2%) patients had complications including pneumoperitoneum, bile peritonitis and stent migration. The advantage of EUS-GBD is its ability to provide gallbladder drainage especially in situations where percutaneous or transpapillary drainage is not feasible or is technically challenging. It also provides the option of internal drainage and the ability to carry out therapeutic maneuvers via cholecystoscopy.

Endoscopic ultrasound in gastroenterology: From diagnosis to therapeutic implications

Since its advent in 1980, the scope of endoscopic ultrasound (EUS) has grown to include a wide range of indications, and it is now being incorporated as an integral part of everyday practice in the field of gastroenterology. Its use is extending from an adjuvant imaging aid to utilization as a therapeutic tool for various gastrointestinal disorders. EUS was first used to visualize remote organs, such as the pancreas and abdominal lymph nodes. When fine needle aspiration was introduced, the indications for EUS expanded to include tissue sampling for diagnostic purposes. At the same time, the needle can be used to convey a potential therapy to the internal organs, allowing access to remote sites. In this review, we aim to highlight the expanding spectrum of EUS indications and uses in the field of gastroenterology.