Endoscopic ultrasound-guided drainage of a liver abscess with a self-expandable metal stent as rescue therapy after plastic stent misdeployment

Endoscopic ultrasound (EUS) is an alternative to percutaneous drainage of abdominal abscesses [1]. Percutaneous abscess drainage may be challenging in poorly accessible locations [2].

A 53-year-old woman underwent palliative biliary drainage for a Bismuth IIIb hilar cholangiocarcinoma. A transpapillary plastic biliary stent was placed by endoscopic retrograde cholangiopancreatography (ERCP) into the right hepatic duct and EUS-guided hepaticogastrostomy performed with a metal stent into the left hepatic duct. Four weeks later, a 5-cm subphrenic abscess was noted in liver segment II ([Fig. 1]).

Fig. 1 Computed tomography scan showing a 5-cm abscess in liver segment II.

The abscess location was deemed unfavorable for percutaneous drainage. An EUS-guided approach was suggested instead. The abscess was imaged under linear EUS and punctured with a 19-G needle from the distal esophagus. Serial dilation with a 6F cystotome and 4-mm balloon dilation was performed ([Fig. 2]). A 7-Fr 5-cm double-pigtail stent (DPS) was then inadvertently deployed fully within the abscess ([Fig. 3]). A covered biliary self-expandable metal stent (SEMS) was placed across the tract from the gastroesophageal junction just below the Z line into the abscess, balloon-dilated to 10 mm, and anchored to the esophageal wall with a hemostatic clip ([Fig. 4], [Fig. 5]). A 0.035-inch guidewire was coiled within the abscess. The echoendoscope was removed over the wire. An ultra-slim gastroscope was carefully advanced over the wire through the SEMS into the abscess. The DPS was grasped with a 5-F tripod forceps under endoscopic view and repositioned into the stomach under gentle traction ([Video 1]).

Fig. 2 Radiological view of a plastic biliary stent into the right duct and an endoscopic ultrasound (EUS)-guided hepaticogastrostomy into the left duct. Also, the liver abscess is outlined after contrast injection.

Fig. 3 Radiological view of the self-expandable metal stent being deployed from the liver abscess containing the double-pigtail stent. The previously placed EUS-guided hepaticogastrostomy can be observed in the lower right quadrant.

Fig. 4 Endoscopic ultrasound view of the misdeployed double-pigtail stent inside the liver abscess. Note the colse proximity to the left ventricule.

Fig. 5 Endoscopic view of the self-expandable metal stent in the distal esophagus clipped to the mucosa.

Video 1 Radiological view of the insertion through the self-expandable metal stent of an ultra-thin gastroscope with a tripod grasping forceps repositioning the previously misdeployed double-pigtail stent.

A computed tomography (CT) scan performed 2 weeks later confirmed abscess resolution with in-situ SEMS and coaxial DPS. Both stents were removed 1 week later using a standard gastroscope.

Drainage of high-grade hilar cholangiocarcinoma remains challenging. ERCP with transpapillary biliary stenting combined with left-sided EUS-guided hepatogastrostomy appears promising [3] [4]. Misdeployment of a DPS within an acute collection is a potentially serious adverse event [5]. As in other related scenarios, placement of a fully covered SEMS bridged the puncture tract. This allowed transluminal access into the abscess similar to that provided by natural orifice transluminal endoscopic surgery (NOTES), and eventually DPS repositioning and successful transluminal abscess drainage.

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Competing interests

Dr. Manuel Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic and M.I.Tech.

• References

• 1 Carbajo AY, Brunie Vegas FJ, García-Alonso FJ. et al. Retrospective cohort study comparing endoscopic ultrasound-guided and percutaneous drainage of upper abdominal abscesses. Dig Endosc 2019; 31: 431-438
• 2 Chin YK, Asokkumar R. Endoscopic ultrasound-guided drainage of difficult-to-access liver abscesses. SAGE Open Med 2020; 8: 205031212092127
• 3 Sundaram S, Dhir V. EUS-guided biliary drainage for malignant hilar biliary obstruction: A concise review. Endosc Ultrasound 2021; 10: 154-160
• 4 Kongkam P, Orprayoon T, Boonmee C. et al. ERCP plus endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage for malignant hilar biliary obstruction: A multicenter observational open-label study. Endoscopy 2021; 53: 55-62
• 5 Vinay Chandrasekhara A, Barthet M, Devière J. et al. Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: Systematic review and meta-analysis. Endosc Int Open 2020; 8: E1639-E1653

Publication History

Article published online:
14 December 2022