2134 Drainage of a Mediastinal Abscess After Esophagectomy Using a Lumen-Apposing Metal Stent

Abstract

INTRODUCTION: Endoscopic ultrasound (EUS) is an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy1. Therapeutic EUS has found a role in management of pancreatic fluid collections, biliary and pancreatic duct drainage, and drainage of mediastinal and intra-abdominal abscesses and collections1. We present a case of a mediastinal abscess drainage after esophagectomy using a Lumen-apposing metal. To our knowledge, this is the second case using a Lumen-apposing metal stent for mediastinal collections2. CASE DESCRIPTION/METHODS: Case Summary: This is a case of a 75-year-old man with esophageal adenocarcinoma s/p transhiatal esophagectomy complicated by recurrent pleural effusions, ischemic colitis requiring right hemicolectomy and end ileostomy who presented to the ED from rehab because of abnormal lab findings of hypernatremia and leukocytosis. During his hospital stay, the patient developed persistent fevers and leukocytosis. A CT scan of the chest revealed a large posterior mediastinal collection adjacent to the gastric pull-through that coursed inferiorly into the peritoneum. The collection measured 8 cm × 4.1 cm x 12 cm in size and was presumed to be the source of infection. The case was discussed amongst the surgical oncologist, thoracic surgeon, interventional radiologist, and advanced endoscopists. Options for drainage included repeat surgery, percutaneous drain placement, and endoscopic drainage. The consensus opinion was to drain the collection internally by endoscopic ultrasound. The patient underwent a successful EUS-guided abscess drainage with a lumen apposing metal stent. The patient drastically improved after internal drainage with the lumen apposing metal stent. Fevers and leukocystosis resolved. Follow-up CT scan of the chest 10 days later demonstrated a resolution of the mediastinal collection. DISCUSSION: Conclusion: Although developed for drainage of pancreatic fluid collections, this case demonstrates that lumen apposing metal stents can be safely used to drain mediastinal collections. Our literature review identified one other case that utilized a lumen-apposing metal stent to drain a mediastinal abscess2. This stent seems to be useful and safe for mediastinal drainage. We recommend a multidisciplinary discussion with surgeons and radiologists when dealing with large mediastinal collections that require drainage.