Transrectal endoscopic ultrasound-guided drainage of pelvic abscess with placement of a fully covered self-expandable metal stent

Pelvic abscess developed in an 88-year-old woman (Case 1) following a Hartmann’s procedure for a perforated diverticulum and in a 78-year-old woman (Case 2) after diverticulitis ([Fig. 1]). Conservative management was unsuccessful in the first patient due to advanced age and in the second patient due to severe co-morbidities.

Fig. 1 Computed tomography showing a pelvic abscess. a Case 1. b Case 2.

Both patients underwent transrectal endoscopic ultrasound (EUS)-guided drainage of the pelvic abscess using the same technique, with placement of a transmural fully covered self-expandable metal stent (SEMS) ([Video 1]). Briefly, a 19-gauge needle was introduced into the collection using a linear echoendoscope. A 0.035-inch wire was then positioned in the cavity and a pre-cut needle-knife was used to create a fistula. A 10 × 40 mm fully covered SEMS (WallFlex; Microvasive Endoscopy, Boston Scientific Corp., Natick, Massachusetts, USA) was then placed over the guide wire.

Transrectal endoscopic ultrasound-guided drainage of pelvic abscess with placement of a fully covered self-expandable metal stent.

After the procedure, the patients improved substantially and were discharged home after 5 and 6 days, respectively.

In both patients, computed tomography (CT) of the pelvis 2 weeks later showed resolution of the abscess ([Fig. 2]). The fully covered SEMSs were then removed by rectoscopy a week later.

Fig. 2 Computed tomography 2 weeks after drainage, showing resolution of the abscess with transrectal stents visible within the abscess cavity and rectum. a Case 1. b Case 2.

A follow-up CT 1 month later revealed complete resolution of the abscess in both patients without recurrence ([Fig. 3]).

Fig. 3 Computed tomography 1 month after stent removal showing resolution without recurrence of the pelvic abscess. a Case 1. b Case 2.

Recently, EUS-guided drainage has been proposed as a minimally invasive alternative for the drainage of pelvic abscesses [1] [2] [3]. Taking into account the available published data, a drainage catheter and one or two plastic stents for each lesion seem to be the best endoscopic approach [1] [2] [3]. Fully covered SEMSs have also recently been adopted for the drainage of infected pancreatic fluid collections with good results [4].

To the best of our knowledge, these are the first two cases of a fully covered SEMS used for transrectal EUS-guided drainage of pelvic abscesses. We think that the use of these stents can give good results for the drainage of pelvic abscesses.

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• References

• 1 Giovannini M, Bories E, Moutardier V et al. Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy 2003; 35: 511-514
• 2 Trevino JM, Drelichman ER, Varadarajulu S. Modified technique for EUS-guided drainage of pelvic abscess (with video). Gastrointest Endosc 2008; 68: 1215-1219
• 3 Varadarajulu S, Drelichman ER. Effectiveness of EUS in drainage of pelvic abscesses in 25 consecutive patients (with video). Gastrointest Endosc 2009; 70: 1121-1127
• 4 Fabbri C, Luigiano C, Cennamo V et al. Endoscopic ultrasound-guided transmural drainage of infected pancreatic fluid collections with placement of covered self-expanding metal stents: a case series. Endoscopy 2012; 44: 429-433