A 67-year-old woman was admitted to the hospital for the first time due to obstructive
jaundice. Cholecystectomy and choledochotomy with T-drainage were carried out, and
6 days after the operation, an exploratory laparotomy and retroperitoneal necrosectomy
were done due to acute hemorrhagic necrotic pancreatitis. One month later, endoscopic
ultrasonography (EUS) and multislice computed tomography demonstrated an encapsulated
left subphrenic abscess, 10 cm in diameter (Figure [1], [2]). It was decided to carry out EUS-guided drainage, as the abscess was directly adjacent
to the stomach and it was considered that EUS would provide a much shorter and safer
approach. The procedure was conducted with the Giovannini drainage set and with linear-array
ultrasound guidance (Figure [3]). After the drainage, the patient’s fever ceased, the C-reactive protein level dropped
significantly, and the white blood count showed normal values. The next day, transabdominal
ultrasonography demonstrated a residual crescent-shaped abscess cavity measuring 44
× 59 mm. Six days after the drainage, a check-up endoscopy showed that the stent was
patent (Figure [4]). Unfortunately, the patient died of multiple organ failure 8 days after the drainage
procedure.
Figure 1 Multislice computed tomography of the well-encapsulated left-sided subphrenic abscess
adjacent to the stomach.
Figure 2 a Endoscopic ultrasonography provided good visualization of the subphrenic abscess.
b Positioning of the guide wire in the abscess.
Figure 3 Endoscopic view of the gastric fundus, with pus draining through the catheter.
Figure 4 Six days after the drainage procedure, a check-up esophagogastroduodenoscopy shows
that the stent is patent in the gastric fundus.
EUS-guided pseudocystogastrostomy has become almost a routine procedure at some centers
[1]
[2]
[3]. Seewald et al. have described successful EUS-guided drainage of left-sided subphrenic
and hepatic abscesses [3]
[4]. EUS should be regarded as a first-choice method for draining left-sided subphrenic
abscesses, especially in critically ill patients. The usual complication of abscess
drainage is blockage of the stent, and many authors have therefore suggested that
several stents should be placed.
In the present case, the patient’s clinical status improved dramatically after the
initial single-stent drainage. The intention was to place a nasocystic drain as a
second step, to ensure constant irrigation with a saline infusion, which we consider
to be the best option for improving stent patency. Unfortunately, the patient’s clinical
condition suddenly deteriorated.
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