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      Endoscopic ultrasound-guided drainage of pelvic abscesses with lumen-apposing metal stents

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      Endoscopic Ultrasound
      Medknow Publications & Media Pvt Ltd

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          Abstract

          The development of pelvic abscesses is a well-described complication of abdominal and pelvic surgery and is associated with numerous medical conditions including diverticulitis, inflammatory bowel disease, ischemic colitis, and pelvic inflammatory disease.[1] Numerous therapeutic modalities have been described in the literature, including percutaneous, surgical, transrectal, transvaginal, and transgluteal drainage.[2 3 4] Complex pelvic anatomy and presence of loculations are often barriers to successful percutaneous drainage and historically required surgical management. Recently, endoscopic ultrasound (EUS)-guided drainage has been described as a minimally invasive alternative to management of pelvic abscesses. Previously reported case series employed numerous techniques, including abscess aspiration, dilation with aspiration, and the use of drainage catheters with or without placement of plastic stents.[5 6 7 8 9] Novel therapeutic applications of lumen-apposing self-expanding metal stents (LAMS) remain an active area of investigation. We recently reported a single case of successful perirectal abscess drainage with a LAMS.[10] Based on our initial experience, the use of LAMS for EUS-guided drainage of pelvic abscesses is a safe and highly efficacious alternative to percutaneous, surgical, and non-LAMS EUS-guided drainage. We are currently preparing a manuscript of a multicenter case series describing our initial experience using LAMS for pelvic abscess drainage in fifteen patients. Our technical and clinical success rates were 100%, and we encountered a single adverse event in our study cohort. A pediatric patient who developed a pelvic abscess secondary to perforated appendicitis developed clinically insignificant rectal bleeding after LAMS placement. The stent was subsequently removed 3 days after placement with clinical and radiographic resolution of the abscess. No abscess recurrence was noted in our study population, and none of the patients required repeat procedures for definitive abscess drainage. To date, there are no published case series of EUS-guided LAMS drainage of pelvic abscesses. With regard to the procedure, cross-sectional imaging is initially reviewed to approximate the abscess size and confirm perisigmoid or perirectal abscess location. Flexible sigmoidoscopy is used to approximate the location of the abscess, typically associated with extrinsic compression noted in the rectum or sigmoid colon. Examination with a linear-array echoendoscope is then performed to identify the abscess. Attempts at LAMS placement are reserved for abscesses with a minimum diameter of 4 cm. A 19-gauge fine-needle aspiration needle is used to puncture the abscess under EUS guidance. Aspiration of purulent fluid is performed to confirm the presence of an abscess. The 19-gauge needle is then withdrawn and the abscess cavity is then punctured with an electrocautery-enhanced, lumen-apposing metal stent (AXIOS, Boston Scientific). The LAMS is then deployed under EUS and endoscopic guidance, with or without fluoroscopic guidance. Successful stent deployment is confirmed by the drainage of purulent material through the distal phalange into the rectosigmoid colon. Antibiotics are continued and surveillance computed tomography scans are obtained. After clinical and radiographic resolution, repeat flexible sigmoidoscopy is performed and the stent is subsequently removed. Our unpublished data suggest that EUS-guided LAMS drainage of pelvic abscesses is more efficacious and has a more favorable safety profile when compared to EUS-guided drainage with catheters and plastic stents. In the largest published series of 26 patients describing EUS-guided drainage without LAMS, abscesses larger than 4 cm were managed with tract dilation and pigtail stent placement for enhanced drainage. The need for repeat endoscopic or surgical drainage was 16% in this cohort.[6] Two patients required stent replacement due to stent migration.[6] While endoscopic drainage with pigtail stent placement was highly effective overall in the study cohort, there was a relatively high incidence of repeat therapeutic procedures required to achieve clinical resolution. In other published case series, infrequent complications of pigtail stent placement included stent dislodgement, occlusion, as well as migration that ranged from 6% to 15%.[5 6 8] A wide range of duration to abscess resolution was noted; between 1 and 6 weeks following endoscopic drainage. In contrast, we observed no instances of stent migration or occlusion with LAMS, and no patients required repeat therapeutic procedures for definitive abscess drainage. With the exception of clinically insignificant rectal bleeding in a pediatric patient, which we speculate was related to the size of the LAMS, no additional adverse events were noted. In addition, the median time to abscess resolution in our patient cohort was 9 days, which is substantially shorter than the average reported time to abscess resolution in published case series employing EUS-guided drainage without LAMS. Our initial experience supports the use of LAMS for EUS-guided pelvic abscess drainage as a viable alternative to conventional EUS-guided and percutaneous drainage techniques. Larger, prospective studies are needed to evaluate the comparative effectiveness of LAMS and more conventional drainage modalities, optimal stent indwelling time, incidence of adverse events, and the cost-effectiveness of LAMS placement, both with respect to procedure-related costs and effects on length of stay.

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          Drainage of deep pelvic abscesses using therapeutic echo endoscopy.

          The purpose of this study was to evaluate the clinical efficacy of endosonographically guided transrectal aspiration and drainage by plastic stent of deep pelvic abscesses, using a therapeutic echo endoscope device. Between September 2000 and June 2001, 12 patients (nine men, three women, mean age 67 years) were treated for a perirectal or a pelvic abscess using an endoscopic ultrasound (EUS) technique. The drainage of these fluid collections was performed under EUS guidance, using therapeutic EUS scopes with a large working channel. No major complication occurred during this study. Transrectal stent insertion succeeded in nine patients. In three patients, only aspiration was possible. Among the nine patients in whom a stent was successfully introduced into the fluid collection, complete drainage without relapse was achieved in eight patients (mean follow-up 10.6 months, range 6-14 months). The stent was removed endoscopically after 3 to 6 months. Drainage was incomplete in one patient (with a large abscess, diameter > 8 cm), who subsequently underwent surgical drainage. However, two out of the three patients in whom aspiration alone was performed developed a recurrence of the abscess and required surgical treatment. EUS-guided drainage of deep pelvic abscesses could offer an alternative treatment to surgery in the management of these postoperative complications.
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            Transgluteal approach for percutaneous drainage of deep pelvic abscesses: 154 cases.

            To assess the effectiveness of a computed tomographic (CT) image-guided transgluteal approach for percutaneous drainage of deep pelvic abscesses as an alternative to surgical drainage. The medical records of 140 patients who underwent percutaneous CT-guided transgluteal drainage of 154 deep pelvic abscesses were reviewed to determine the origins, location, and size of the abscesses; volume of initial aspirate; organisms identified in fluid culture; duration of catheter drainage; incidence of catheter-related pain and procedure-related complications; and short- and long-term outcomes. The resultant data were analyzed with a Fisher exact test for difference in the incidence of postprocedural catheter-site pain between transpiriformis and infrapiriformis approaches. The origins of the pelvic abscesses included postoperative fluid collection (n = 115), perforating appendicitis (n = 6), diverticulitis (n = 16), tubo-ovarian inflammation (n = 5), Crohn disease (n = 10), and internal bowel fistula due to irradiation (n = 2). The abscesses were 4-12 cm in diameter. The volume of the aspirate was 5-310 mL. Laboratory cultures of the aspirate grew mixed flora, but the organism most frequently isolated was Escherichia coli. Catheters were removed after a mean of 8 days. In 134 (96%) of 140 patients, there was complete resolution of the abscess following transgluteal drainage, without subsequent surgery. In six of 140 (4%) patients, incomplete resolution necessitated subsequent surgery for postoperative fluid collection (n = 3), diverticulitis (n = 2), or perforating appendicitis (n = 1). Complications of transgluteal drainage were rare and included hemorrhage in three (2%) of the 140 patients. There was no procedure-related mortality. A transpiriformis approach was significantly more likely to be associated with postprocedural pain (P <.001) than was an infrapiriformis approach. Percutaneous CT-guided transgluteal drainage is a safe and effective alternative to surgery for deep pelvic abscesses. Major complications are rare.
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              Effectiveness of EUS in drainage of pelvic abscesses in 25 consecutive patients (with video).

              Preliminary evidence suggests that EUS is a minimally invasive alternative to surgery and percutaneous techniques for drainage of pelvic abscesses. The EUS 2008 Working Group identified the technique as a priority for research and recommended its validation in a larger cohort of patients.
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                Author and article information

                Journal
                Endosc Ultrasound
                Endosc Ultrasound
                EUS
                Endoscopic Ultrasound
                Medknow Publications & Media Pvt Ltd (India )
                2303-9027
                2226-7190
                Jul-Aug 2017
                : 6
                : 4
                : 217-218
                Affiliations
                [1]Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
                Author notes
                Address for correspondence Dr. Amar Manvar, Montefiore Medical Center, Bronx, New York, United States. E-mail: amanvar4@ 123456gmail.com
                Article
                EUS-6-217
                10.4103/eus.eus_46_17
                5579905
                28820143
                39d29464-2737-4884-9c05-182e8ce42e5c
                Copyright: © 2017 Spring Media Publishing Co. Ltd

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                History
                : 20 June 2017
                : 03 July 2017
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