The learning curve for EUS-guided drainage of symptomatic intraabdominal collections: experience of a single endoscopist in a general hospital

Introduction and aim: EUS-guided drainage is now an established treatment modality for symptomatic intraabdominal fluid collections. There is a lack of data on the learning curve required to master this technique. This study evaluated the efficacy and safety of EUS-guided drainage of intraabdominal fluid collections in relation to the experience of a single endoscopist. Methods: The clinical data of consecutive patients with symptomatic intraabdominal fluid collections referred for endoscopic drainage during the period from December 2006 to August 2010 were maintained in a prospective database and reviewed. All procedures were performed by a single endoscopist (ATL) trained in ERCP and EUS/EUSFNA who observed but did not have any hands-on training in EUS-guided drainage during his fellowship.

Results: A total of 18 patients (mean age: 54 years, range: 23 - 81; 50% male) were referred for endoscopic drainage (mean of 1 case every 3 months). The indications were: symptomatic pseudocysts (5); pancreatic abscess (7); infected walled off pancreatic necrosis (4); walled off peripancreatic abscess following liver abscess rupture (1); rectal abscess (1). The mean size of the collection was 10cm (range: 4.2 - 17.2). EUS-guided transenteric drainage with double pigtail stents was performed in 16 patients, while a patient with 4.2cm pseudocyst and another with 5.4cm peri-rectal abscess were treated with EUS-guided aspiration using a 19 gauge needle alone. Immediate procedural success was achieved in all patients. Adjunctive endoscopic necrosectomy was required and performed in 6 patients (4 with walled off necrosis and 2 with pancreatic abscesses) successfully. The first patient in the series developed asymptomatic pneumoperitoneum after transenteric stenting that was treated conservatively while the third developed bleeding after balloon dilatation of the puncture tract that required blood transfusion. No other complications occurred. Pancreatic duct stenting to treat pancreatic duct disruption was required in 11 patients and performed successfully. Apart from 2 patients yet to return for review, among patients who completed treatment, over a mean follow period of 420 days, no recurrence occurred.

Conclusion: EUS-guided drainage of symptomatic intraabdominal fluid collections may be safely performed by an endoscopist trained in both ERCP and EUSFNA following a period of observation without hands-on training.