EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series

Abstract

Background and aims: Pelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. A percutaneous approach to deep PFCs could be challenging and result in a longer, painful recovery. The transvaginal approach has been considered easy but is limited by the difficulty of leaving a stent in place. The transrectal approach has been described, but issues related to fecal contamination were hypothesized. Data on EUS-guided transrectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes. The aim of this study was to evaluate the safety and efficacy of EUS-TRD with LAMSs in patients with PFCs.

Methods: A retrospective analysis of a prospectively maintained database on therapeutic EUS was conducted. All EUS-TRD procedures were included.

Results: Five patients (2 male, age 44-89 years) were included. Four patients had postoperative PFCs, and 1 presented with a pelvic abscess complicating acute diverticulitis. Two of 5 had fecal diversion; the remaining 3 had unaltered large-bowel anatomy. One case had a concomitant abdominal collection, treated with percutaneous drainage in the same session. An electrocautery-enhanced LAMS delivery system (15 × 10 mm) was used in all cases. EUS-TRD was performed with the direct-puncture technique and lasted less than 10 minutes in 4 cases; in the remaining case, needle puncture and LAMS placement over a guidewire was required, and the procedure length was 14 minutes. The clinical success rate was 100%. LAMSs were removed after a median of 14 (range, 12-24) days. One patient reported partial proximal LAMS migration after 24 days (mild adverse event). No PFC recurrence was observed.

Conclusion: EUS-TRD with LAMSs is a safe and effective technique for treatment of PFCs. The use of 15- × 10-mm LAMSs allows rapid PFC resolution. EUS-TRD could be performed not only in patients with fecal diversion but also in cases of unaltered anatomy.

Keywords: EUS-TRD, EUS-guided trans-rectal drainage; LAMS, lumen-apposing metal stent; PFC, pelvic fluid collection.

Figure 1

CT scan showing the presence of an 8-cm pelvic fluid collection with gas content (arrow).

Figure 2

EUS image showing the deep pelvic collection adjacent to the anterior rectal wall. The collection was accessed with the electrocautery-enhanced tip of the lumen-apposing metal stent delivery system, and the distal flange was released under EUS control.

Figure 3

Lumen-apposing metal stents weeks after EUS-guided transrectal drainage. The cavity disappeared and the presence of granulation tissue was observed. No sign of residual infection or pus was present.

Figure 4

Endoscopy confirming the disappearance of pelvic fluid collection after lumen-apposing metal stent removal.

Figure 5

Nine-month follow-up CT scan showing complete resolution of the pelvic fluid collection.

Figure 6

CT scan performed 3 weeks after EUS-guided transrectal drainage showing resolution of the collection and suspected stent proximal migration.

Figure 7

Endoscopic image (forward-view echoendoscope) confirming proximal stent migration with small residual tract allowing grasping of the stent with forceps.

Figure 8

EUS image (forward-view echoendoscope) showing the dislodged lumen-apposing metal stent in the cavity.

Figure 9

Endoscopic image of the residual tract and cavity after stent removal. No sign of adverse events (ie, perforation) except mild trauma to the tract.