2199 Endoscopic Ultrasound-Guided Transrectal Drainage of a Tubo-Ovarian Abscess via a Lumen-Apposing Metal Stent

Abstract

INTRODUCTION: Tubo-ovarian abscess (TOA) is a potentially lethal condition requiring a combination of medical and surgical intervention. Endoscopic ultrasound (EUS)-guided drainage is a known modality for safe and effective management of pelvic collections, but its role in TOA drainage is not well documented. We present a case of a TOA treated successfully with EUS-guided transrectal drainage using a lumen apposing metal stent (LAMS). CASE DESCRIPTION/METHODS: A 45-year-old woman presented to the hospital with a 4-day history of left lower quadrant abdominal pain. Her medical history included a right-sided TOA treated with antibiotics one year ago, type II diabetes mellitus, and obesity. She was tachycardic and tachypneic on arrival with a leukocytosis and elevated inflammatory markers. Computed tomography (CT) revealed a 11.3 × 10.3 × 9.4 cm complex cystic structure within the left adnexa consistent with a TOA (Image 1). Due to worsening leukocytosis and abdominal pain, interventional radiology was consulted but could not find a safe window for percutaneous drainage. A rectal EUS subsequently revealed a 50 × 45 mm abscess 20 cm from the anal verge (Image 2). A 19-gauge EZ-Shot 3 FNA needle was advanced with return of purulent fluid. After injection of 15 cc ionic contrast to delineate the abscess and confirm positioning, EUS-guided transrectal drainage of the TOA with placement of a 15 × 10 mm AXIOS stent (Boston Scientific, Marlborough, MA, USA) was successfully performed. The distal flange was deployed within the abscess cavity and the proximal flange was deployed within the rectal lumen with copious amounts of purulent drainage through the AXIOS stent (Image 3). Repeat CT performed one week later revealed significant interval decrease in the size of the TOA. DISCUSSION: EUS-guided drainage of pelvic collections has been established as a lower-risk alternative to surgical interventions, especially for collections greater than 4 cm and within a 1-2 cm reach of the EUS transducer. Furthermore, use of LAMS can facilitate drainage through a wider conduit, promoting rapid evacuation and source control. To our knowledge, this is the first reported case of successful EUS-guided transrectal drainage of a TOA using a LAMS.