Drainage Of Intra-abdominal Fluid Collections Research Articles

Use of Lumen-apposing Metal Stents for Endoscopic Drainage of Intra-abdominal Fluid Collections in Pediatric Patients.

Intraabdominal fluid collections that previously required surgical intervention can now be drained with less invasive techniques. The use of lumen-apposing metal stents (LAMS) to treat pancreatic pseudocysts and perirectal abscesses has been shown to be a safe and effective technique in adults. We aim to evaluate the indications, outcomes, and complications of the use of LAMS in pediatric patients at our institution. A retrospective chart review was performed to study patients up to 18 years of age at the Children's Hospital at Montefiore who underwent drainage of intraabdominal fluid collections with the use of LAMS. The main outcome measures were technical and clinical success and associated adverse events with LAMS placement. Seven patients (2 girls) ranging from 9 to 18 years were identified. Four patients had perirectal abscess postperforated appendicitis and 3 patients had pancreatic pseudocysts. All of the patients had complete resolution of the collections, with no recurrence, and our technical and clinical success rate was 100%. Only 1 patient had mild bleeding after placement that spontaneously resolved. Our study demonstrates the efficacy and safety of the use of LAMS for the drainage of intraabdominal fluid collections in pediatric patients, although the number of patients included is limited.

Lumen-apposing metal stents for endoscopic ultrasonography-guided interventions.

Lumen-apposing metal stents (LAMS) are integrated in a single-step delivery platform and can be deployed under endoscopic ultrasound-guidance for the drainage of intra-abdominal fluid collections, decompression of obstructed ductal systems, establishment of anastomosis or creation of fistulous tracts between organs that can facilitate further endoscopic interventions if required. A unique feature of LAMS is their ability to approximate the adjoining structures, thereby minimizing the potential for leak and perforation. Consequently, the innovation has advanced our ability to carry out complex therapeutic interventions and obviate the need for high-risk surgical procedures, particularly in morbid patients. However, a keen awareness of the technical design of LAMS and its implication on treatment effect is important to minimize adverse events and to improve clinical outcomes. This review outlines the technical approach to placement of LAMS, procedural challenges, adverse events, current clinical indications and emerging applications.

Lumen Apposing Metal Stents (LAMSs) for Drainage of Pancreatic and Gallbladder Collections: A Meta-analysis.

Endoscopic ultrasound-guided transmural drainage using lumen apposing metal stents (LAMSs) is becoming a popular and promising therapeutic approach for drainage of intra-abdominal fluid collections. There has been an increasing number of studies evaluating LAMS for drainage of pancreatic pseudocysts (PP), walled-off pancreatic necrosis (WOPN), and gallbladder (GB) drainage. The aim of this meta-analysis is to analyze the literature to date regarding the clinical success, technical success, and adverse events of LAMS in treatment of pancreatic fluid collections and GB drainage. A comprehensive search of multiple literature databases through November 2016 was performed. Human studies with at least 10 subjects that examined the clinical success, technical success, and adverse events of LAMS in treating PP, WOPN, and GB drainage were included. A total of 993 patients (608-WOPN; 204-PP; 181-GB drainage) underwent drainage from 20 trials. For drainage of WOPN, the pooled technical success was 98.9% [95% confidence interval (CI): 98.2% to 99.7%] and clinical success was 90% (95% CI: 87% to 93%) (τ=0.001). For drainage of PP, the pooled technical success was 97% (95% CI: 95% to 99%) and clinical success was 98% (95% CI: 96% to 100%), (τ=0.001). For GB drainage, the pooled technical success was 95% (95% CI: 91% to 99%) and clinical success was 93% (95% CI: 90% to 97%), (τ=0.001). Total adverse events occurred in 11% of patients with higher complication rates observed in GB drainage. There was no evidence of publication bias in this meta-analysis. Endoscopic ultrasound-guided transmural drainage using LAMS is becoming a widely accepted therapeutic approach for the treatment of PP, WOPN, and GB drainage with high clinical and technical success rates and acceptable adverse events. Further prospective randomized trials reporting long-term clinical efficacy and cost-effectiveness are needed to validate LAMS as a therapeutic modality for pancreatic and GB collections.

Endoscopic ultrasonography-guided drainage of intra-abdominal fluid collection after liver transplantation: a case series of six patients.

Intra-abdominal fluid collection associated with infection is a major complication after liver transplantation (LT). However, post-LT recipients are at high risk for requiring various interventions and surgeries, due to their poor, immunosuppressed conditions. We herein describe six patients with symptomatic or growing intra-abdominal fluid collection after LT who underwent endoscopic ultrasonography (EUS)-guided drainage. There were five males and one female, and the median age was 47years (24-60years). All procedures were technically and clinically successful in all patients. The median number of endoscopic sessions was 2.5 (1-4 sessions) until resolution. Procedure-related adverse events occurred in two patients and included peritonitis, bleeding, and stent migration, which improved conservatively or endoscopically. During the median follow-up period of 63months (17-110months), recurrence occurred in one patient. EUS-guided drainage is an effective and safe treatment for intra-abdominal fluid collection even in post-LT recipients.

Past, Present, and Future of Gastrointestinal Stents: New Endoscopic Ultrasonography-Guided Metal Stents and Future Developments

Innovations in stent technology and technological advances in endoscopic ultrasonography have led to rapid expansion of their use in the field of gastrointestinal diseases. In particular, endoscopic ultrasonography-guided metal stent insertion has been used for the management of pancreatic fluid collection, bile duct drainage, gallbladder decompression, and gastric bypass. Endoscopic ultrasonography-guided drainage of intra-abdominal fluid collections using a plastic or metal stent is well established. Because of the various limitations—such as stent migration, injury and bleeding in the lumen—recently developed, fully covered self-expanding metal stents or lumen-apposing metal stents have been introduced for those fluids management. This article reviews the recent literature on newly developed endoscopic ultrasonography-guided metal stents and the efficacy thereof.

Percutaneous cholecystostomy in acute cholecystitis; a retrospective analysis of a large series of 104 patients

BackgroundThe purpose of this study was to evaluate the clinical course and possible benefit of a percutaneous cholecystostomy in patients with acute cholecystitis.MethodsRetrospective study of 104 patients with severe cholecystitis or cholecystitis not responding to antibiotic therapy treated with percutaneous drainage of the gall bladder (PC) during the period 2007 – 2013. Primary outcome was relief of cholecystitis, complications following the procedure and need for later cholecystectomy.ResultsThere were 57 men and 47 women with a median age of 73,5 years (range 22 – 96). 43% of the patients were ASA III or IV and 91% had cholecystitis Grade 2 or 3. About 60% of the patients had severe comorbidity (cardiovascular disease or active cancer). Drain insertion was successful in all but one patient and complications were mild, apart from two patients that needed percutaneous drainage of intraabdominal fluid collection due to bile leakage. The drain was left in place for 1 – 75 days (median 6,5). When evaluated clinically and by blood tests (CRP and white blood cell counts) we found resolution of symptoms in 101 patients (97,2%), whereas 2 patients had no obvious effect of drainage. Four patients died within 30 days, no deaths were related to the drainage procedure. Follow-up after drainage was median 12 months (range 0 – 78). During that time cholecystectomy was performed in 30 patients and 24 patients had died. Following cholecystectomy, two had died, both from cancer and more than one year after the operation.ConclusionPatients with acute cholecystitis were promptly relieved from their symptoms following PC. There were only minor complications following the procedure and only about 30% of the patients had a later cholecystectomy.

Endoscopic ultrasonography‐guided transgastric drainage of infectious biloma following radiofrequency ablation for hepatocellular carcinoma

An 87-year-old woman was diagnosed with a 22-mm diameter hepatocellular carcinoma in segment II and treated by percutaneous ultrasound-guided radiofrequency ablation (RFA). Six months later, she presented to the emergency room complaining of high fever and general malaise. Computed tomography (CT) images showed a 96 ¥ 60-mm fluid collection in the left lobe of the liver (Fig. 1). She was diagnosed with sepsis due to biloma infection caused by RFAmediated bile duct disruption. Because the biloma was adjacent to the stomach, we carried out endoscopic ultrasonography (EUS)-guided transgastric drainage of the biloma. A discharge of pus was observed following the creation of internal and external fistulas between the biloma and stomach using a 7-Fr double-pigtail stent and a 7.5-Fr singlepigtail tube (Fig. 2) and cultures of the purulent fluid grew Escherichia coli. A CT scan obtained 4 weeks after drainage confirmed complete resolution of the biloma and the patient recovered uneventfully. Although biloma formation related to bile duct disruption is a frequent complication of RFA, biloma infection complicated with bacteremia is very rare. Bilomas are usually treated by either percutaneous drainage or surgery. This patient, however, was very elderly and had advanced dementia, so it was difficult for her to keep still during percutaneous puncture. In addition, the risk for self-removal of the drainage tube was considered to be high. The utility of EUSguided drainage of intra-abdominal fluid collections is well documented, whereas there have been a small number of reports on EUS-guided drainage of bilomas. The biloma in this patient was located adjacent to the stomach; therefore, EUS-guided drainage was considered to be a promising alternative and was successfully carried out. In summary, the risk of biloma infection should be considered, especially in putative immune-compromised older patients. Moreover, careful attention must be paid to the possibility of delayed biloma infection even 6 months after RFA.

Feasibility of EUS-guided Transmural Drainage of Intra-abdominal Fluid Collections Without Fluoroscopy: Avoiding Exposure to Radiation

Purpose: Transmural drainage of intra-abdominal fluid collections, including cysts, has become common. Traditionally, fluoroscopic guidance has been used for these procedures. Due to the potential adverse effects of radiation exposure associated with most guidance techniques, we evaluated the feasibility of performing transmural drainage using endosonography for guidance, avoiding unnecessary fluoroscopic radiation exposure. Methods: A retrospective study of four non-consecutive patients with symptomatic intra-abdominal fluid collections who were evaluated for endoscopic ultrasound-guided (EUS) transmural drainage from November 2006 to January 2008. These four patients underwent single-step EUS-guided drainage without fluoroscopic guidance. After IRB approval, patients were identified and medical charts extensively reviewed. Outcomes evaluated included technical success, complications, and recurrence of the intra-abdominal fluid collection. Results: Four patients were treated from November 2006 to January 2008. The average age of the patients was 53±26 years (range 17-80 years) and all four patients were males. All patients had a symptomatic intra-abdominal fluid collection which was located in the tail of the pancreas for one patient, in the head of the pancreas for one patient, in the body of the pancreas for one patient, and in the lesser sac for one patient. In one patient, the intra-abdominal fluid collection was found to be infected. Only one patient had no significant co-morbidities (17 years-old), while the other three patients had significant co-morbidities. Technical success was achieved in all four patients. No complications were observed during the procedures. No recurrences of the lesions have occurred during a mean follow-up of approximately 14 weeks. Conclusion: Transmural drainage of symptomatic intra-abdominal fluid accumulations with endosonography is a feasible alternative to radiation-based guidance techniques. Further studies will be necessary to determine if the success rate will remain high while avoiding radiation exposure during these procedures.

EUS-guided transesophageal, transgastric, and transcolonic drainage of intra-abdominal fluid collections and abscesses

The therapeutic role of EUS is evolving. We report our experience with EUS-guided transesophageal, transgastric, and transcolonic drainage of various intra-abdominal fluid collections. To determine the technical feasibility and clinical outcomes of EUS-guided drainage. Prospective case series. Academic tertiary referral center. Patients referred for endoscopic drainage of intra-abdominal fluid collections; pancreatic pseudocysts amenable to conventional transgastric or transduodenal drainage were excluded. Single-step EUS-guided drainage of fluid collections by using a therapeutic linear-array echoendoscope with fluoroscopic guidance. Technical success, relief of symptoms, and procedural complications. Nine consecutive patients deemed appropriate for EUS-guided drainage of intra-abdominal fluid collections included transesophageal drainage of pseudocysts (n = 2), transgastric drainage of biloma (n = 2) and upper intra-abdominal abscesses (n = 2), transcolonic drainage of diverticular abscess (n = 1), Crohn's abscess (n = 1), and postoperative hematoma (n = 1). Endoscopic drainage was successful in all patients. Confirmation of complete resolution of the target fluid collection and symptom relief was achieved in 8 (89%) of 9 patients. Pneumothorax and mediastinitis developed in 1 patient after transesophageal drainage, which resolved with chest tube and medical therapy. During multiple stent placement, one of the stents was fully deployed into the abscess cavity in 2 patients; both were successfully retrieved either endoscopically (Crohn's abscess) or at the time of primary colonic resection (diverticular abscess). Limited number of patients. EUS-guided transenteric drainage of bilomas, hematomas, abscesses, and inflammatory fluid collections is technically feasible and generally results in complete drainage and symptom relief. Procedural complications may be minimized with more experience.

Percutaneous drainage of abdominal fluid collections in children.

Percutaneous drainage of intraabdominal fluid collections was performed in 13 children. After initial diagnosis with either sonography or computed tomography, a smallbore aspiration needle (22 gauge) was guided into the collection, usually by sonography. In five patients, complete evacuation was possible using the aspirating needle alone. In seven others, the fluid was successfully drained via a catheter introduced percutaneously. In one patient, surgery was required for complete evacuation of a hematoma containing large blood clots. There were no complications.

Percutaneous catheter drainage of intraabdominal fluid collections including infected biliary ducts and gallbladders

Sixty-five abscesses, including 6 infected biliary systems and 15 sterile fluid collections, were treated by percutaneous catheter drainage in 77 febrile patients who were evaluated by computerized tomograhy or ultrasonography for intraabdominal infection. Percutaneous catheter drainage and systemic antibiotic administration without surgery provided satisfactory control of infection in 52 of 65 abscesses (80 percent). Catheter drainage followed by surgical exploration for abscess control was performed in an additional 5 of the 65 abscesses (7 percent). Nine deaths (14 percent) occurred in the abscess group of 64 patients. In 15 patients, aspirations, Gram stain, and culture of the abnormal fluid collection revealed sterile fluid. Drainage with a single catheter allowed complete resolution in 14 of 15 sterile collections. Surgery was performed electively in one patient with a fistula from a pancreatic pseudocyst in the small bowel. No deaths occurred in the noninfected group of 15 patients, 2 of whom underwent drainage of coexisting abscesses.