Endoscopic ultrasound-guided transgastric pyogenic liver abscess drainage using a drill dilator

Percutaneous transhepatic drainage (PTD) is the gold standard treatment for pyogenic liver abscess [1], but PTD can be challenging where a pyogenic liver abscess is located at a site that is difficult to access via the percutaneous approach and in patients with severe dementia, in whom self-removal of the tube is a risk. An endoscopic ultrasound (EUS)-guided procedure offers internal drainage via a transluminal approach and may be an alternative option in such cases. Several studies have reported the clinical benefits of EUS-guided access for pyogenic liver abscesses [2] [3] [4]; however, this technique requires tract dilation prior to metal stent deployment. In patients with a pyogenic liver abscess, severe inflammation can cause the cystic wall to become thickened and hardened and this can make tract dilation challenging. A novel drill dilator has recently become available in Japan (Tornus ES; Asahi Intecc) ([Fig. 1]) [5]. This allows a tract to be easily dilated using a clockwise rotation of the device handle, without force needing to be applied. We herein describe EUS-guided transgastric pyogenic liver abscess drainage using a drill dilator.

Fig. 1 Photograph of the novel drill dilator (Tornus ES; Asahi Intecc).

An 89-year-old man was admitted to our hospital for treatment of a pyogenic liver abscess ([Fig. 2]). The percutaneous approach was difficult because the abscess was located at segment 4 and the caudate lobe, with intervening vessels, and EUS-guided access was therefore selected. The abscess was punctured from the stomach using a 19G needle and contrast medium was injected. Balloon catheter insertion was attempted after deployment of a 0.025-inch guidewire ([Fig. 3 a]); however, the procedure failed because the wall of the abscess was extremely hard. We then attempted drill dilator insertion and easily achieved successful tract dilation ([Fig. 3 b]). Finally, a partially covered self-expandable metal stent was deployed from the pyogenic liver abscess to the stomach, with no adverse events ([Fig. 3 c]; [Video 1]).

Fig. 2 Computed tomography scan showing a pyogenic liver abscess at segment 4 and the caudate lobe.

Fig. 3 Fluoroscopic images showing: a a 0.025-inch guidewire deployed after puncture of the pyogenic liver abscess with a 19G needle; b the drill dilator being easily inserted under endoscopic ultrasound guidance; c transgastric drainage of the abscess with a self-expandable metal stent (inset, endoscopic view).

Video 1 Endoscopic ultrasound-guided drainage of a pyogenic liver abscess using a novel drill dilator.

In conclusion, a drill dilator appears to be useful for pyogenic liver abscess drainage, as well as for bile duct dilation.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Singh S, Chaudhary P, Saxena N. et al. Treatment of liver abscess: prospective randomized comparison of catheter drainage and needle aspiration. Ann Gastroenterol 2013; 26: 332-339
• 2 Ogura T, Masuda D, Saori O. et al. Clinical outcome of endoscopic ultrasound-guided liver abscess drainage using self-expandable covered metallic stent (with video). Dig Dis Sci 2016; 61: 303-308
• 3 Tonozuka R, Itoi T, Tsuchiya T. et al. EUS-guided drainage of hepatic abscess and infected biloma using short and long metal stents (with videos). Gastrointest Endosc 2015; 81: 1463-1469
• 4 Rana SS, Ahmed S, Sharma R. et al. Safety and efficacy of EUS-guided drainage of liver abscess: A single-center experience. Endosc Ultrasound 2020; 9: 350-351
• 5 Yamada M, Hara K, Haba S. et al. Endoscopic ultrasound-guided hepaticogastrostomy using a novel drill dilator. Endoscopy 2022;

Publication History

Article published online:
16 January 2023