Endoscopic ultrasound-guided drainage of a liver abscess with a self-expandable metal stent as rescue therapy after plastic stent misdeployment

Endoscopic ultrasound (EUS) is an alternative to percutaneous drainage of abdominal abscesses [1]. Percutaneous abscess drainage may be challenging in poorly accessible locations [2]. A 53-year-old woman underwent palliative biliary drainage for a Bismuth IIIb hilar cholangiocarcinoma. A transpapillary plastic biliary stent was placed by endoscopic retrograde cholangiopancreatography (ERCP) into the right hepatic duct and EUS-guided hepaticogastrostomy performed with a metal stent into the left hepatic duct. Four weeks later, a 5-cm subphrenic abscess was noted in liver segment II (▶Fig. 1). The abscess location was deemed unfavorable for percutaneous drainage. An EUS-guided approach was suggested instead. The abscess was imaged under linear EUS and punctured with a 19-G needle from the distal esophagus. Serial dilation with a 6F cystotome and 4-mm balloon dilation was performed (▶Fig. 2). A 7-Fr 5-cm double-pigtail stent (DPS) was then inadvertently deployed fully within the abscess (▶Fig. 3). A covered biliary self-expandable metal stent (SEMS) was placed across the tract from the gastroesophageal junction just below the Z line into the abscess, balloon-dilated to 10mm, and anchored to the esophageal wall with a hemostatic clip (▶Fig. 4, ▶Fig. 5). A 0.035-inch guidewire was coiled within the abscess. The echoendoscope was removed over the wire. An ultra-slim gastroscope was carefully advanced over the wire through the SEMS into the abscess. The DPS was grasped with a 5-F tripod forceps under endoscopic view and repositioned into the stomach under gentle traction (▶Video 1). A computed tomography (CT) scan performed 2 weeks later confirmed abscess resolution with in-situ SEMS and coaxial DPS. Both stents were removed 1 week later using a standard gastroscope. Drainage of high-grade hilar cholangiocarcinoma remains challenging. ERCP with transpapillary biliary stenting combined with left-sided EUS-guided hepatogastrostomy appears promising [3–4]. Misdeployment of a DPS within an acute collection is a potentially serious adverse event [5]. As in other related scenarios, placement of a fully covered SEMS bridged the puncture tract. This allowed transluminal access into the abscess similar to that provided by natural orifice transluminal endoscopic surgery (NOTES), and eventually DPS repositionE-Videos