EUS-guided transesophageal, transgastric, and transcolonic drainage of intra-abdominal fluid

CASE STUDIES

EUS-guided transesophageal, transgastric, and transcolonicdrainage of intra-abdominal fluid collections and abscesses

Cyrus Piraka, MD, Raj J. Shah, MD, Norio Fukami, MD, Krishnavel V. Chathadi, MD, Yang K. Chen, MD

Aurora, Colorado, USA

Background: The therapeutic role of EUS is evolving. We report our experience with EUS-guided transesopha-geal, transgastric, and transcolonic drainage of various intra-abdominal fluid collections.

Objective: To determine the technical feasibility and clinical outcomes of EUS-guided drainage.

Design: Prospective case series.

Setting: Academic tertiary referral center.

Patients: Patients referred for endoscopic drainage of intra-abdominal fluid collections; pancreatic pseudocystsamenable to conventional transgastric or transduodenal drainage were excluded.

Interventions: Single-step EUS-guided drainage of fluid collections by using a therapeutic linear-array echoen-doscope with fluoroscopic guidance.

Main Outcome Measurements: Technical success, relief of symptoms, and procedural complications.

Results: Nine consecutive patients deemed appropriate for EUS-guided drainage of intra-abdominal fluidcollections included transesophageal drainage of pseudocysts (n Z 2), transgastric drainage of biloma (n Z 2)and upper intra-abdominal abscesses (n Z 2), transcolonic drainage of diverticular abscess (n Z 1), Crohn’s abscess(n Z 1), and postoperative hematoma (n Z 1). Endoscopic drainage was successful in all patients. Confirmationof complete resolution of the target fluid collection and symptom relief was achieved in 8 (89%) of 9 patients. Pneu-mothorax and mediastinitis developed in 1 patient after transesophageal drainage, which resolved with chesttube and medical therapy. During multiple stent placement, one of the stents was fully deployed into the abscesscavity in 2 patients; both were successfully retrieved either endoscopically (Crohn’s abscess) or at the time ofprimary colonic resection (diverticular abscess).

Limitation: Limited number of patients.

Conclusions: EUS-guided transenteric drainage of bilomas, hematomas, abscesses, and inflammatory fluidcollections is technically feasible and generally results in complete drainage and symptom relief. Proceduralcomplications may be minimized with more experience.

EUS-assisted and EUS-guided transgastric or transduo-denal drainage has gained acceptance in the therapy ofsymptomatic pancreatic pseudocysts.1-10 The therapeuticindications for EUS are evolving.11-13 We report 9 cases

Abbreviations: CRE, controlled radial expansion; FNI, fine-needle injec-

tion; MRI, magnetic resonance imaging.

DISCLOSURE: All authors disclosed no financial relationships relevant

to this publication.

Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy

0016-5107/$36.00

doi:10.1016/j.gie.2009.04.049

786 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 4 : 2009

of EUS-guided transesophageal, transgastric, and transco-lonic drainage of abdominal and pelvic fluid collectionsof various causes.

PATIENTS AND METHODS

Nine consecutive patients with abdominal and pelvicfluid collections secondary to various causes deemedappropriate for endoscopic drainage were included.Patients with pancreatic pseudocysts amenable to conven-tional or EUS-guided transgastric or transduodenaldrainage were excluded from this series. The procedures

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Piraka et al EUS-guided drainage of intra-abdominal fluid collections and abscesses

were performed with the patients under general anesthe-sia. All patients gave written informed consent to undergothe procedure. Institutional review board approval wasobtained for data collection and follow-up of thesepatients. Patients were followed prospectively for clinicaloutcomes and complications after endoscopic drainage.

Figure 1. A, Case 2. A 20 � 10-cm pseudocyst visualized with linear EUS.

B, Case 2. Endoscopic view of stent within the esophagus. C, Case 2.

Fluoroscopic view of transesophageal pseudocyst stenting.

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EUS procedureAll procedures are performed by using a linear-array

echoendoscope with a 3.7-mm operating channel (Olym-pus America, Center Valley, Pa). Antibiotic prophylaxis isgiven routinely. After endosonographic localization andevaluation of the fluid collection and surrounding struc-tures, an appropriate site is selected for drainage; ingeneral, this area is in the closest apposition to the fluid col-lection with no intervening vessels. The fluid cavity is en-tered by using a 19-gauge EUS-FNA needle, and a fluidsample for analysis is obtained if indicated. A 0.035-inchguidewire with a hydrophilic tip is advanced through theneedle and into the fluid collection. The wire is generouslylooped within the cavity, and the needle is removed. Thewire position is confirmed by fluoroscopy. A needle-knifecannula is then advanced over the guidewire to create a tractinto the fluid cavity. If it easily traverses the luminal wall intothe cavity, then needle-knife electrocautery is not applied,because the initial goal is simply to dilate the tract to allowpassage of a dilating balloon. Once the cannula enters thefluid collection, the needle-knife is retracted and the can-nula removed over the guidewire. An 8- or 10-mm dilatingballoon catheter is advanced over the wire to enlarge thetract. Then 1 or more double pigtail stents are deployedover the wire and left in place for 4 to 12 weeks. Two short10F stents are used when space allows. Alternately, 2 stentsand/or 7F stents are used for smaller fluid collections.

RESULTS

Case reportsTransesophageal pseudocyst drainage. Case 1. A

36-year-old woman with alcohol-induced chronic pancreati-tis presented with recurrent abdominal pain. EUS revealed2 adjacent pseudocysts in the pancreatic body, both greaterthan 50 mm in size. One pseudocyst was drained transgastri-cally; the other extended to the chest, and the point of op-timal access for endoscopic drainage was at the distalesophagus. No free air was seen in the chest or abdomen af-ter placement of two 10F double-pigtail stents. Severalhours later, the patient reported chest pain. A CT scanshowed a contained esophageal perforation, mediastinitis,and pneumothorax. The patient recovered with nonopera-tive management. EUS at 3 months confirmed completepseudocyst resolution, and the stents were removed.

Case 2. A 60-year-old man developed acute pancreatitiswhile on azathioprine for myasthenia gravis. A 200 �100-mm pseudocyst with a single compartment, and noassociated mass was identified (Fig. 1A). Because thecyst wall was closest to the distal esophagus, two 10F �3-cm double pigtail stents were placed just proximal tothe gastroesophageal junction (Fig. 1B and C). The painimmediately subsided after the cyst esophagostomy. Thepatient died several weeks later of a recurrent pulmonary

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EUS-guided drainage of intra-abdominal fluid collections and abscesses Piraka et al

Figure 2. A, Case 3. CT of fluid collection anterior and posterior to the stomach. B, Case 3. CT of fluid collection anterior to the stomach. C, Case 3.

Endoscopic image of a bulge into the anterior aspect of the stomach. D, Case 3. Endoscopic image of a transgastric stent. E, Case 3. Endoscopic view 2

weeks after stent placement. Bulge has resolved. F, Case 3. CT demonstrates resolution of abscesses.

embolism before complete resolution of the pseudocystcould be confirmed.

Transgastric abscess drainage. Case 3. A 54-year-old woman reported abdominal pain and low-grade fever


3 months after a traumatic rupture of the spleen. Gastros-copy revealed a submucosal bulge on the posterior wall ofthe proximal gastric body associated with spontaneousdrainage of purulent material. A CT scan revealed fluid

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Figure 3. A, Case 9. CT showing perirectal fluid collection. B, Case 9. Linear EUS of a 50 � 43-mm perirectal fluid collection. C, Case 9. EUS-guided

needle aspiration. Simultaneous fluoroscopic image (inset). D, Case 9. CT demonstrates resolution of the hematoma.

collections anterior and posterior to the proximal gastricbody (Fig. 2A and B). After a course of oral antibiotics,the posterior fluid collection resolved, but the anteriorfluid collection increased in size and had a well-organizedcapsule. On EUS, a bulge was noted at the anterior gastricwall (Fig. 2C). The fluid collection measured 66 mm inmaximal diameter with hyperechoic internal debris. Cyst-gastrostomy was performed (Fig. 2D). Cultures of thepurulent fluid grew Staphylococcus epidermis. CT con-firmed complete drainage of the abscess by day 4. Symp-toms resolved, and the stent was removed 2 weeks later(Fig. 2E and F). CT at 8 months confirmed sustained reso-lution of the abscess.

Case 4. A subphrenic fluid collection after subtotalcolectomy developed in a 44-year-old man with chroniculcerative colitis. CT-guided FNA grew Enterococcus fae-cium. EUS identified a gastric bulge and 3 discrete fluidcollections. One small fluid collection located within thesubmucosa of the gastric antrum was completely aspiratedwith a 19-gauge needle, yielding 2 mL of thick purulentmaterial. A 30 � 25-mm abscess located anterior to the

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pancreatic body was drained with two 7F double-pigtailstents. A third abscess measuring 85 � 50 mm, located ad-jacent to the pancreatic tail and spleen, was drained byplacing two 10F double pigtail stents. A 7F nasocystictube was also left in place for 48 hours of intermittentirrigation. Cultures from all 3 abscesses grew Enterococ-cus organisms and Candida albicans. The patientreceived 2 weeks of intravenously administered vancomy-cin and oral antibiotics and fluconazole for a total of8 weeks. EUS 6 weeks later confirmed resolution of allabscesses. The patient remained asymptomatic at3.3-year follow-up.

Biloma drainage. Case 5. A 35-year-old woman pre-sented with postprandial epigastric pain, nausea, andvomiting 1 week after an open cholecystectomy. CT scanshowed a 15 � 17 � 6-cm fluid collection without anenhancing wall extending into the gallbladder fossa andinto the foramen of Winslow, Morrison’s pouch, and leftsubdiaphragmatic space. ERCP revealed no contrast leak-age. EUS-guided trangastric drainage was performedwith placement of two 10F double pigtail stents. The bil-ious fluid had a bilirubin level of 5.5 mg/dL, consistent



TABLE 1. EUS-guided drainage of intra-abdominal fluid collections and abscesses

Patient Age (y)/sex Indication Drainage site Outcome Complications

1 36/F Recurrent painful pseudocyst Transesophageal Resolution Pneumothorax, mediastinitis

2 60/M Painful pseudocyst Transesophageal Immediate pain relief None

3 54/F Perigastric abscess (splenic rupture) Transgastric Resolution None

4 44/M Perigastric abscesses (postoperative) Transgastric Resolution None

5 35/F Biloma Transgastric Resolution None

6 49/M Biloma Transgastric Resolution None

7 61/M Diverticular abscess Transcolonic Resolution Stent migration

8 15/M Crohn’s abscess Transcolonic Resolution Stent migration

9 47/F Perirectal hematoma (postoperative) Transcolonic Resolution None

F, Female; M, male.

with a biloma. EUS confirmed complete resolution 6 weekslater, and the stents were removed. The patient remainedsymptom free at 12 months.

Case 6. A 49-year-old man with stage IV rectal adenocarci-noma developed a biloma after left hepatectomy for met-astatic disease. ERCP showed extravasation of contrastfrom the cut surface of the liver and a short stenosis atthe origin of the right hepatic duct, treated with balloondilation and placement of an 8.5F biliary stent. EUS-guidedtransgastric drainage of a 59 � 52-mm biloma was per-formed at the same encounter with placement of two10F double pigtail stents. EUS 4 weeks after drainage con-firmed complete resolution of the biloma. The patientremained asymptomatic at 16-week follow-up.

Transcolonic drainage of abscesses and hema-toma. Case 7. A 61-year-old man presented with divertic-ulitis and a perirectosigmoid abscess. Percutaneous andtransgluteal drainage was not attempted because ofoverlying bowel and bladder and the risk of the spreadof infection, respectively. To avoid a 2-stage operation,EUS-guided abscess drainage was offered. The 70 �50-mm abscess was associated with a visible bulge in thedistal sigmoid colon. Two 10F 3-cm double pigtail stentswere placed with resulting profuse drainage of pus; cul-tures grew mixed gram-negative rod species and Strepto-coccus anginosis. Oral clindamycin and levofloxacinwere given for 2 weeks. CT scan 11 days after the proce-dure showed nearly complete resolution of the abscess,and 1 stent was removed. The patient underwent sigmoidcolectomy with primary anastomosis 23 days later; the sec-ond stent was removed at surgery. The patient continuedto do well at 1-year follow-up.

Case 8. A 15-year-old boy with Crohn’s disease presentedwith worsening abdominal pain, fever, and chills. Serial CTscans demonstrated inflammatory changes in the terminal


ileum and a deep pelvic abscess increasing in size despitebroad-spectrum antibiotics. The abscess was not accessi-ble to percutaneous drainage, and the consensus was toavoid surgery. EUS-guided transrectal drainage was accom-plished by placing three 10F, 3-cm–long double pigtailstents into the 71 � 36-mm abscess. One of the stents mi-grated completely into the cavity immediately after de-ployment; the other stents were in good position.Symptoms resolved quickly. The patient resumed a regulardiet and was discharged on oral antibiotic therapy.

Three weeks later, EUS revealed no residual fluid. Twostents were removed, but the third stent was completelyinside the cavity. The tract was dilated to 10 mm, andthe stent was successfully retrieved by using a standardgastroscope with a rat-tooth forceps. No residual fluid orpus was found, but the cavity was noted to be only par-tially walled off, and some of the peritoneal cavity contentswere visualized. One hour after the procedure, the patientdeveloped severe lower abdominal pain. Pneumoperito-neum was noted on x-ray films, and the patient wastreated with antibiotics.

Six days later, an ileocecal resection was performedelectively, removing approximately 15 cm of intestine.The terminal ileum was tightly adherent to the anteriorsurface of the rectosigmoid colon. A hole in the rectumcorresponding to the endoscopic drainage site was over-sewn. There was minimal abdominal contamination andno evidence of any purulent material in the pelvis. As a pre-caution, an end-ileostomy was performed, and a drain wasplaced in the presacral space. With subsequent reanasto-mosis, the patient continues to do well at 28 months offollow-up.

Case 9. A 47-year-old woman was admitted for abdominalpain, fever, and malaise after surgical lysis of adhesions. ACT scan revealed a 5.3 � 5.5-cm fluid collection immedi-ately anterior to the rectum and rectosigmoid (Fig. 3A).

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A CT-guided percutaneous approach was deemed difficult.EUS identified a 50 � 43-mm hypoechoic fluid collectionwith multiple internal septations (Fig. 3B). Forty millilitersof dark brown and bloody fluid was evacuated by usinga 19-gauge FNA needle (Fig. 3C), completely drainingthe old hematoma; stent placement was believed to be un-necessary. Fluid cultures and Gram stain results were neg-ative. The pain rapidly improved, and the patient wasdischarged the next day. A CT scan 3 weeks later showedcomplete resolution of the fluid collection (Fig. 3D).

DISCUSSION

We describe 9 cases in which EUS played a therapeuticrole in the drainage of thoracic, abdominal, and pelvicfluid collections (Table 1). These cases demonstrate thetechnical feasibility of EUS-guided drainage of virtuallyany fluid collection, be it mediastinal, intra-abdominal,or pelvic, as long as it is adjacent to the GI lumen andwithin the reach of an echoendoscope. Our study isunique in its breadth of indications, including the first re-ported cases of endoscopic transcolonic drainage of a peri-rectal hematoma and of a Crohn’s abscess that permittedsubsequent primary bowel resection.

Symptomatic pancreatic pseudocysts that extend intothe mediastinum are usually treated surgically becausepercutaneous drainage may not be feasible. Our studylends support to the efficacy of transesophageal drainage,although it must be done cautiously given the potentialfor significant complications. Pneumomediastinum isa complication unique to a transesophageal approach,so careful patient selection and identification of themost appropriate puncture site are particularly important.Because a visible bulge is typically not present at this loca-tion, EUS guidance is critical; the proximity of thoracic ves-sels makes precise needle passage mandatory.

Bilomas may occur as a complication of cholecystec-tomy or other hepatobiliary surgery and/or after a trau-matic liver laceration. Conventional managementincludes addressing the underlying source of leakageand placement of a percutaneous drain. Shami et al14 re-ported EUS-guided drainage of 5 patients with bilomas.Both of our patients did well after EUS-guided drainage.

Intra-abdominal abscesses are classically treated withsurgical or percutaneous drainage plus antibiotic therapy.Diverticular abscesses usually require partial colectomy aswell. We include in this series the first reported case of en-doscopic drainage of an abscess related to Crohn’s disease.Our experience and other case reports15-19 suggest thatEUS-guided drainage of intra-abdominal abscesses viaa transgastric or transrectal approach is safe and effective.

Percutaneous drainage of fluid collections is not alwaystechnically feasible. EUS-guided drainage is an attractivealternative because it does not require external tubes ordrains and may convert a 2-step operation into a singlesurgical procedure or may allow us to avoid surgery alto-

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gether. Complications may occur, including leakage, pneu-moperitoneum, pneumomediastinum, bleeding, infection,and failure to drain. EUS guidance decreases the risk of in-jury to intervening vasculature and helps the endosocop-ist find the optimal puncture site based on the degree ofapposition between the cyst or fluid collection and the gutwall. A short distance between the fluid collection and vis-cus (generally !1-2 cm), lack of intervening ascites, andmaturity of the fluid cavity provide reassurance that therisk of leakage at the puncture site is minimized. Multiplestents may facilitate more complete drainage through oraround the stents. Finally, the risk versus benefit in any in-dividual patient between endoscopic and nonendoscopicapproaches must be weighed on a case-by-case basis.

Although the techniques described in this case series aresimilar to single-step EUS-guided pseudocyst gastro-stomy,20,21 in our experience, these cases tend to be techni-cally more challenging and risky. Previous experience withthis technique in more routine cases is recommended be-fore attempting to do EUS-guided drainage of these specialtypes of fluid collections. Currently, standard ERCP acces-sories are used for these complex procedures. A new gener-ation of dedicated tools and accessories is needed tofacilitate performing these procedures with greater easeand safety and to further expand the role of therapeuticEUS.

REFERENCES

1. Fazel A. An endoscopic perspective on pancreatic pseudocysts.

Curr Gastroenterol Rep 2005;7:107-13.

2. Giovannini M. Endoscopic ultrasound-guided pancreatic pseudocyst

drainage. Gastrointest Endosc Clin N Am 2005;15:179-88, xi.

3. Sriram PV, Kaffes AJ, Reddy DN. Endoscopic ultrasound-guided drain-

age of pancreatic pseudocysts complicated by portal hypertension or

by intervening vessels. Endoscopy 2005;37:231-5.

4. Giovannini M. Endoscopic ultrasound-guided pancreatic pseudocyst

drainage. Gastrointest Endosc Clin N Am 2005;15:179-88.

5. Yamaguchi T, Ishihara T, Tadenuma H, et al. Use of a Soehendra stent

retriever to treat pancreatic pseudocyst with EUS-guided cystogas-

trostomy. Endoscopy 2004;36:755.

6. Vosoghi M, Sial S, Garrett B, et al. EUS-guided pancreatic pseudocyst

drainage: review and experience at Harbor-UCLA Medical Center.

Med Gen Med 2002;4:2.

7. De Palma GD, Galloro G, Puzziello A, et al. Endoscopic drainage of

pancreatic pseudocysts: a long-term follow-up study of 49 patients.

Hepatogastroenterology 2002;49:1113-5.

8. Norton ID, Clain JE, Wiersema MJ, et al. Utility of endoscopic ultraso-

nography in endoscopic drainage of pancreatic pseudocysts in

selected patients. Mayo Clin Proc 2001;76:794-8.

9. Giovannini M, Pesenti C, Rolland AL, et al. Endoscopic ultrasound-

guided drainage of pancreatic pseudocysts or pancreatic abscesses

using a therapeutic echo endoscope. Endoscopy 2001;33:473-7.

10. Shami VM, Parmar KS, Waxman I. Clinical impact of endoscopic ultra-

sound and endoscopic ultrasound-guided fine-needle aspiration in

the management of rectal carcinoma. Dis Colon Rectum 2004;47:

59-65.

11. Gress F, Schmitt C, Sherman S, et al. A prospective randomized

comparison of endoscopic ultrasound- and computed tomography-

guided celiac plexus block for managing chronic pancreatitis pain.

Am J Gastroenterol 1999;94:900-5.



12. Abedi M, Zfass AM. Endoscopic ultrasound-guided (neurolytic) celiac

plexus block. J Clin Gastroenterol 2001;32:390-3.

13. Bhutani MS. Endoscopic ultrasound guided antitumor therapy. Endos-

copy 2003;35:S54-6.

14. Shami VM, Talreja JP, Mahajan A, et al. EUS-guided drainage of bilo-

mas: a new alternative? Gastrointest Endosc 2008;67:136-40.

15. Lee DH, Cash BD, Craig M, et al. Endoscopic therapy of a splenic

abscess: definitive treatment via EUS-guided transgastric drainage.

Gastrointest Endosc 2006;64:631-4.

16. Kruger M, Schneider AS, Manns MP, et al. Endoscopic management of

pancreatic pseudocysts or abscesses after an EUS-guided 1-step

procedure for initial access. Gastrointest Endosc 2006;63:409-16.

17. Giovannini M, Pesenti C, Rolland AL, et al. Endoscopic ultrasound-

guided drainage of pancreatic pseudocysts or pancreatic abscesses

using a therapeutic echo endoscope. Endoscopy 2001;33:473-7.

18. Seewald S, Imazu H, Omar S, et al. EUS-guided drainage of hepatic

abscess. Gastrointest Endosc 2005;61:495-8.


19. Seewald S, Brand B, Omar S, et al. EUS-guided drainage of subphrenic

abscess. Gastrointest Endosc 2004;59:578-80.

20. Piraka C, Chen YK. Pseudocyst drainage: ERCP, and EUS approaches.

Tech Gastrointest Endosc 2007;9:169-75.

21. Antillon MR, Shah RJ, Stiegmann G, et al. Single-step endoscopic ultra-

sound guided drainage of simple and complicated pancreatic pseudo-

cysts. Gastrointest Endosc 2006;63:797.

Received November 20, 2008. Accepted April 27, 2009.

Current affiliations: Division of Gastroenterology (C.P.), University of

Michigan, Ann Arbor, Michigan, Division of Gastroenterology and

Hepatology (R.J.S., N.F., K.V.C., Y.K.C.), University of Colorado Denver,

Aurora, Colorado, USA.

Reprint requests: Yang K. Chen, MD, AOP Gastroenterology, University of

Colorado Hospital, MS F735 1635 Aurora Court, Room 2.031, Aurora, CO

80045.

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EUS-guided transesophageal, transgastric, and transcolonic drainage of intra-abdominal fluid