Troubleshooting the migration of a double-pigtail plastic stent into a pelvic abscess (with videos).

Abstract

The usefulness of EUS pelvic abscess drainage (EUS-PAD) for treating pelvic abscesses (PA) has recently been reported;[1] however, the procedure is often difficult to perform due to limited working space and field of view of that particular anatomical location. During EUS-related drainage, stent placement must be confirmed by both endoscopic and fluoroscopic images, to avoid risk of occurrence of misplacement.[2] A 70-year-old Japanese female with morbid obesity presented with PA secondary to a perforated appendicitis. Abdominal computed tomography revealed size of the PA to be125.3 mm that had originated from the appendix through the retroperitoneum [Figure 1a-c]. EUS-PAD was performed using a convex EUS scope. The abscess was punctured through the rectum using a 19-gauge needle [Figure 1d]. Two guidewires were inserted and coiled in the cavity, and the puncture tract was dilated using an 8-mm balloon dilator. Since the endoscope was inserted through a narrow and short space, it could easily shift position and slip out of the body. Due to the patient’s high obesity, the radiographic permeability was low, which made placing the double-pigtail plastic stent (DPPS) difficult. The DPPSs placement was finally performed, but under poor both endoscopic and fluoroscopy image. During placement of the second DPPS, it was observed that the first DPPS had strayed into the PA cavity [Figure 1e and Video 1]. After two DPPSs were placed incompletely, we proceeded to reposition the first DPPS that had migrated to the wrong position. After we dilated the puncture site using an 8-mm balloon dilator, a 5.8-mm endoscope was inserted into the cavity. The position of the migrated DPPS could be confirmed and its pigtail edge was re-inserted into the rectum using a 1.8-mm-diameter retrieval net [Figure 2]. No complications with the EUS-PAD procedures were encountered, and the patient’s symptoms improved gradually thereafter [Video 2]. Here, we present a procedure for dealing with an erroneously migrated DPPS during EUS-PAD. Additionally, the technique of direct insertion and drainage using a thin endoscope into the PA cavity, which was performed to retrieve the stray DPPS, may be useful in aggressive treatments of PA.Figure 1: Abdominal computed tomography revealed a pelvic abscess (a) with an air bubble of 125.3 mm that originated from an appendiceal perforation (b) and traversing the retroperitoneum (c; arrowhead). Endoscopic-ultrasound pelvic abscess drainage using a convex endoscopic-ultrasound scope. The abscess (outlined with asterisks) was punctured using a 19-gauge needle through the rectum (d). The first DPPS strayed into the pelvic cavity during the placement of the second DPPS (e; arrowhead). DPPS: Double-pigtail plastic stentFigure 2: Replacement of the migrated DPPSs following incomplete placement of two DPPSs. An esophagogastroduodenoscopy scope was inserted to place a guidewire into the PA cavity, and the puncture tract dilated using an 8-mm balloon dilator (a). Subsequent insertion of a 5.8-mm endoscope into the abscess cavity (b). A large amount of purulent fluid in the PA cavity, and the surface of the cavity with effusion, erythema, and purulent fluid (c). After aspiration of sufficient purulent fluid, the migrated DPPS was identified (d; arrow). DPPS: Double-pigtail plastic stent, PA: Pelvic abscesses {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_8datqvv1"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 2","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_hvyt4t8t"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.