Endoscopic ultrasound-guided drainage of a post-hepatectomy abscess using a lumen-apposing self-expandable metal stent with electrocautery-enhanced delivery system

Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections and of the gallbladder and bile duct after failure of standard procedures is becoming an attractive minimally invasive alternative to percutaneous drainage [1] [2] [3]. These procedures have been facilitated by the development of a specifically designed lumen-apposing self-expandable metal stent (LA-SEMS) and electrocautery-enhanced delivery system (Hot Axios; Boston Scientific Corp., Marlborough, Massachusetts, USA), which allows the procedure to be performed in one step, mostly under EUS guidance without fluoroscopy [4].

We report on a patient in whom drainage of an abdominal abscess that developed after laparoscopic hepatectomy was performed using the LA-SEMS, thus sparing him from percutaneous drainage and/or repeat surgery.

A 70-year-old man with alcohol-related liver cirrhosis underwent left hepatectomy as treatment for recurrent hepatocellular carcinoma. A month later, he developed persistent abdominal pain with fever. An abdominal computed tomography scan revealed an abscess located between the remnant right liver lobe and the stomach ([Fig. 1]). EUS-guided drainage was offered to the patient and he signed an informed consent form.

Fig. 1 Cross-sectional computed tomography image of the abscess (arrow) located between the remnant liver and the stomach.

Using a therapeutic linear echoendoscope, the 7-cm collection was located and the presence of interposing vessels was excluded using Doppler. Direct transgastric penetration into the collection using the Hot Axios device was accomplished by applying pure cut cautery, and was followed by EUS-guided deployment of a 10 × 10-mm LA-SEMS ([Fig. 2], [Video 1]), with drainage of purulent material ([Fig. 3], [Video 1]). No complications occurred. The patient was discharged completely asymptomatically the following day.

Fig. 2 Endoscopic ultrasound (EUS) view of the distal flange of the lumen-apposing self-expanding metal stent (arrow) that was deployed completely under EUS guidance.

Endoscopic ultrasound-guided drainage using a lumen-apposing fully covered self-expandable metal stent for treatment of an intra-abdominal abscess that developed after laparoscopic hepatectomy.

Fig. 3 Endoscopic view of the stent with drainage of pus.

Removal of the stent was performed 4 weeks later, and complete resolution of the abscess was observed.

Intra-abdominal abscess formation after laparoscopic hepatectomy has been reported to occur in up to 10 % of cases [5]. The case presented shows that this novel LA-SEMS is safe, easy to use, and highly effective, and should be considered when intra-abdominal abscesses accessible to EUS are detected.

Endoscopy_UCTN_Code_TTT_1AS_2AC

• References

• 1 Rinninella E, Kunda R, Dollhopf M et al. EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video). Gastrointest Endosc 2015; 82: 1039-1046
• 2 Walter D, Teoh AY, Itoi T et al. EUS-guided gall bladder drainage with a lumen-apposing metal stent: a prospective long-term evaluation. Gut 2016; 65: 6-8
• 3 Kunda R, Pérez-Miranda M, Will U et al. EUS-guided choledochoduodenostomy for malignant distal biliary obstruction using a lumen-apposing fully covered metal stent after failed ERCP. Surg Endosc 2016; DOI: 10.1007/s00464-016-4845-6.
• 4 Attili F, Rimbaş M, Galasso D et al. Fluoroless endoscopic ultrasound-guided biliary drainage after failed ERCP with a novel lumen-apposing metal stent mounted on a cautery-tipped delivery system. Endoscopy 2015; 47 (Suppl. 01) E619-620
• 5 Matsumata T, Yanaga K, Shimada M et al. Occurrence of intraperitoneal septic complications after hepatic resections between 1985 and 1990. Surg Today 1995; 25: 49-54