EFFECTIVENESS OF INTRA-SCOPE CHANNEL PLASTIC STENT RELEASE IN ENDOSCOPIC ULTRASOUND-GUIDED PELVIC ABSCESS DRAINAGE

Eficácia da liberação de stent plástico intra-canal em drenagem endoscópica guiada por ultra-som do abscesso pélvico

Keywords

Abscess

endoscopic ultrasound

pelvic abscess drainage

plastic stent; rectal carcinoma

A 68-year-old Japanese man was admitted to our hospital with severe anal pain and fever. Computed tomography revealed pelvic abscess (PA) around a rectal carcinoma. The distance between the anal verge and tumor was 45 mm. Endoscopic ultrasound-guided pelvic abscess drainage (EUS-PAD) was planned, before the operation for excision of the carcinoma. EUS-PAD was performed using a convex EUS scope (Figure 1). The abscess was punctured with a 19-gauge needle via the rectum, 40 mm from the anal verge. Two guidewires were inserted through the needle and coiled into the abscess cavity. Thereafter, two double-pigtail plastic stents (DPPS; 7-Fr, 4 and 7-cm long) were put into the abscess¹.

FIGURE 1
Computed tomography reveals a pelvic abscess (A; asterisk) around the rectal carcinoma (B; asterisk). Endoscopic ultrasound-guided pelvic abscess drainage (EUS-PAD) planned to avoid the tumor before the carcinoma operation, and the tumor margin is confirmed (C) with esophagogastroduodenoscopy and the clips placed to avoid puncture of the tumor (D). A pelvic abscess confirmed using EUS (E; asterisk).

Since the endoscope was inserted into a narrow and short space, we anticipated that it could easily shift its position and exit the body through the rectum. To keep the endoscope in a stable position during DPPS placement, we performed the intra-scope channel stent release method as follows: 1) the inner sheath was pulled out of the DPPS, leaving only the guidewire; 2) the guidewire was pulled out, leaving only a soft tip within the DPPS, and the DPPS was pushed straight into the abscess; 3) the axis of the DPPS was changed; and 4) the DPPS was pushed and released to bend (Figure 2). After DPPS insertion, a large amount of purulent material started to drain into the colon (Figure 3). This procedure was performed safely without complications (E-VIDEO ^*). The patient was able to safely undergo laparoscopic rectum amputation operation for rectal cancer as scheduled after the PA had steadily healed. The surgical specimen had a negative radial margin.

FIGURE 2.
Schema of the intra-scope channel plastic stent release in endoscopic ultrasound-guided pelvic abscess drainage (EUS-PAD). The patient presented with a pelvic abscess around a rectal carcinoma (a). EUS-PAD was performed using a convex EUS scope to avoid direct puncture of the tumor (b).

FIGURE 3
Fluoroscopic images show that the double-pigtail plastic stent (DPPS) was bent and released (a; arrow). After insertion of the DPPSs, a large amount of purulent material drains into the colon (b).

Rectal cancer with PA formation requires local control by adequate preoperative drainage and resection, with proper selection of the drainage route, prior to radical surgery². Percutaneous drainage through the perineum can cause dissemination of tumor cells, thereby encouraging local recurrence³. Conversely, transrectal drainage prevents dissemination within the shortest distance to the abscess and uses a less invasive procedure⁴.

In the present case, a lower rectal carcinoma with abscess formation was resected en bloc, including the abscess and drainage route, at the time of radical resection. We are of the opinion that the EUS-PAD procedure is an effective procedure for control of PAs associated with rectal carcinomas, and our stent-release method is an especially useful technique for carrying out the procedure in a limited space.

REFERENCES

• ¹
  Soga K, Majima A. Effective endoscopic ultrasound-guided transrectal drainage of a perianal abscess. Arq Gastroenterol. 2022;59:317-8. doi: 10.1590/S0004-2803.202202000-56.
  » https://doi.org/10.1590/S0004-2803.202202000-56
• ²
  Gupta PJ. Rectal cancer presenting as ischio-rectal abscess and Fournier’s gangrene-a case report. Eur Rev Med Pharmacol Sci. 2010;14:139-40.
• ³
  Ryall C. Cancer infection and cancer recurrence. A danger to avoid in cancer operations. Lancet. 1907;170:1311-16.
• ⁴
  Nishina Y, Ohta H, Terada Y, Akabori H, Kitamura N, Nagai N, et al. Successful treatment of rectal cancer with pelvic abscess using transrectal drainage followed by laparoscopic radical resection: a case report. J Surg Case Rep. 2022;2022:rjac284.

• *
  E-VIDEO: https://youtu.be/HSBJ_ x20QDA

• Disclosure of funding: no funding received

Publication Dates

• Publication in this collection
  12 May 2023
• Date of issue
  Jan-Mar 2023

History

• Received
  19 Aug 2022
• Accepted
  13 Jan 2023