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

A retrospective analysis of a prospectively maintained database was conducted; all patients with a PFC who underwent EUS-TRD from November 2018 to January 2020 were included. All cases underwent CT imaging before the EUS procedure. All were discussed by the Hospital Multidisciplinary Team, including at least 1 gastroenterologist, 1 surgeon, 1 oncologist, and 1 radiologist. Because percutaneous drainage was deemed not feasible by an interventional radiologist, EUS-TRD was indicated. Written informed consent for the interventional EUS procedure was obtained from all patients and clearly specified the procedure and the off-label use of LAMSs. The protocol was evaluated by the institutional review board and conducted according to local policy on retrospective studies. All procedures were conducted in our endoscopic suite. A curvilinear-array echoendoscope (GF-UCT-180; Olympus, Tokyo, Japan) with a dedicated ultrasound processor (EU-ME2; Olympus) was used. Patients were placed in the left lateral decubitus position under continuous cardiopulmonary parameter monitoring. An electrocautery-enhanced LAMS delivery system (Hot-Axios; Boston Scientific, Marlborough, Mass, USA) was used in conjunction with the ERBE VIO 300D electrosurgical unit using pure cut mode (AUTOCUT mode, effect 5, power 100 W). Procedures were done under EUS guidance only, without fluoroscopic assistance. Oral feeding was resumed after 12 hours. Antibiotic treatment was maintained until clinical and biochemical resolution of sepsis. A CT scan was planned after 2 weeks. Stent removal was done after radiologic findings of PFC resolution using an operative gastroscope and a Rat Tooth Alligator Jaw forceps (FG-42L-1; Olympus).

Five patients (2 male; age 44-89 years) underwent EUS-TRD during the study period. Baseline characteristics, procedural details, and clinical outcomes are summarized in Table 1 . Table 1 Detailed description of patients baseline characteristics, EUS-TRD procedures and outcomes. Patient Condition Indication for drainage Fecal diversion Type of sedation Stent type Technique Stent removal Adverse events Technical success Clinical success Outcome Patient characteristics EUS-TRD Procedure outcomes Male, 88 years old Pelvic collection after Hartmann resection for diverticulitis Sepsis not responsive to antibiotics Percutaneous drainage not feasible Surgery contraindicated Yes Conscious sedation Hot Axios 15 × 10 mm Direct puncture Intrachannel release 20 days No Yes Yes Discharged in 20 days Follow-up unremarkable Female, 89 years old Abdominal (100 × 60 mm) and pelvic (80 × 50 mm) fluid collections after open surgery because of adhesive bowel obstruction Sepsis not responsive to antibiotics Surgery contraindicated No Conscious sedation Hot Axios 15 × 10 mm (pelvic) 14F plastic pigtail drainage Direct puncture Intrachannel release US-guided percutaneous drainage (Seldinger technique) 14 days (LAMS) 28 days (pigtail) No Yes Yes Pigtail catheter removed after 1 month Follow-up unremarkable Female, 85 years old Acute diverticulitis complicated by microperforation and abscess Percutaneous drainage not feasible (bowel loop interposition) Surgery contraindicated because of peritoneal metastasis from ovarian cancer No Conscious sedation Hot Axios 15 × 10 mm Direct puncture Intrachannel release 24 days Yes (mild— proximal migration) Yes Yes Collection resolved Medical treatment for diverticular disease Development of peritoneal carcinomatosis from ovarian cancer Female, 81 years old Pelvic collection after Hartmann resection for diverticulitis Percutaneous drainage not feasible Surgery contraindicated Yes Deep sedation Hot Axios 15 × 10 mm Needle puncture and guidewire insertion Intrachannel release 12 days No Yes Yes Collection resolved Follow-up unremarkable Male, 44 years old Systemic sepsis and pelvic fluid collection after urinary diversion and cystectomy for complicated posttraumatic neurogenic bladder Difficult percutaneous approach (distinguish collection from bowel loop because of bladder absence) Surgery as a back-up strategy No Conscious sedation Hot Axios 15 × 10 mm Direct puncture Intrachannel release 13 days No Yes Yes Symptoms dissipated after 3 days Patient discharged after 13 days EUS-TRD , EUS-guided transrectal drainage; LAMS , lumen-apposing metal stent. Detailed description of patients baseline characteristics, EUS-TRD procedures and outcomes. EUS-TRD , EUS-guided transrectal drainage; LAMS , lumen-apposing metal stent. In detail, 4 patients had postoperative PFCs (Hartmann’s resection for acute diverticulitis in 2 cases, open surgery because of adhesive bowel obstruction and cystectomy for neurogenic bladder in the other 2 cases). The remaining patient presented with acute diverticulitis complicated by microperforation and deep pelvic abscess (case 3); in this case, surgery was contraindicated because of the presence of peritoneal metastasis from ovarian cancer. Among the 5 patients who underwent EUS-TRD, 2 had fecal diversion and 3 had unaltered large-bowel anatomy. One patient (case 2) had a concomitant abdominal abscess and underwent percutaneous drainage with a 14F pigtail catheter under ultrasound guidance in the same session ( Figure 1 , Figure 2 , Figure 3 , Figure 4 , Figure 5 ). 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. CT scan showing the presence of an 8-cm pelvic fluid collection with gas content (arrow) . 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. 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. Endoscopy confirming the disappearance of pelvic fluid collection after lumen-apposing metal stent removal. Nine-month follow-up CT scan showing complete resolution of the pelvic fluid collection. No procedure required general anesthesia; 4 of 5 were conducted with the patient under conscious sedation (fentanyl plus midazolam), and 1 was conducted with the patient under deep sedation (propofol). In all cases, a 15- × 10-mm LAMS (Hot Axios; Boston Scientific) was used ( Video 1 , available online at www.VideoGIE.org ). In all but 1 case, the direct puncture technique was used. In the remaining case (case 4), we measured a 9 mm- to 10-mm distance between the PFC and rectal wall. To stabilize the position and to have a backup strategy in case of stent placement failure, we previously accessed the PFC with a 19-gauge FNA needle (Expect Slimline; Boston Scientific) and inserted a 0.035-in guidewire (Jagwire; Boston Scientific); the LAMS was placed over the guidewire. The technical success rate was 100%; the procedure length (scope-in to scope-out) was <10 minutes in all but 1 case that required puncture and guidewire placement (14 minutes). Complete PFC resolution was seen on CT 2 weeks after the procedure in 3 cases and 3 weeks after the procedure in the other 2 cases. LAMSs were removed after a median of 14 days (range, 12-24). In case 3, CT performed after 21 days showed resolution of the PFC; however, stent migration was suspected ( Fig. 6 ). Urgent stent removal was done with a forward-view echoendoscope (TGF-UC180J; Olympus). Endoscopic and EUS view confirmed partial proximal LAMS migration ( Figs. 7 and 8 ); however, a small residual orifice was still present, allowing grasping and extraction of the LAMS with the rat-tooth forceps. Endoscopic control showed no signs of perforation ( Fig. 9 ), and the patient remained well after the procedure. The clinical success rate, defined as PFC resolution with no need for antibiotic treatment or any other intervention, was 100%. No PFC recurrence was observed after a follow-up of 14 (2-16) months. Patient 3 developed peritoneal carcinomatosis from underlying known ovarian cancer but did not show signs or symptoms related to recurrent diverticulitis or PFC at 4-month follow-up. 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. CT scan performed 3 weeks after EUS-guided transrectal drainage showing resolution of the collection and suspected stent proximal migration. Endoscopic image (forward-view echoendoscope) confirming proximal stent migration with small residual tract allowing grasping of the stent with forceps. EUS image (forward-view echoendoscope) showing the dislodged lumen-apposing metal stent in the cavity. Endoscopic image of the residual tract and cavity after stent removal. No sign of adverse events (ie, perforation) except mild trauma to the tract.

All authors disclosed no financial relationships.

Our study suggests that EUS-TRD with an electrocautery-enhanced LAMS delivery system is safe and effective for the treatment of postoperative or inflammatory PFCs. The electrocautery-enhanced LAMS delivery system allows a single-passage, exchange-free technique, reducing the risk of procedural adverse events (ie, leak, dislodgement, or perforation). The use of a 15- × 10-mm LAMS allowed rapid radiologic and clinical PFC resolution. We suggest close monitoring for a LAMS left in place for more than 3 weeks, owing to possible risk of proximal stent migration. Despite its large caliber, 15- × 10-mm LAMSs could be used not only in patients with fecal diversion but also in those with unaltered large-bowel anatomy. In particular, no issue with fecal contamination was encountered because large stent caliber and intrinsic negative luminal pressure ensure adequate drainage of PFC content. Spontaneous tract closure after stent removal was confirmed on follow-up CT. Large prospective studies are required to confirm these findings.