Therapeutic Echoendoscope Research Articles

Endoscopic drainage of malignant distal biliary obstruction. Will ERCP no longer be necessary?

We read with interest the Editorial by Vila et al. on the paradigm shift for endoscopic biliary drainage of malignant distal biliary obstruction (MDBO) which places Endoscopic Ultrasound (EUS) drainage as the first option instead of traditional ERCP drainage. The modern biliary endoscopist must have the duodenoscope in one hand and the therapeutic echoendoscope in the other. ERCP training alone is no longer appropriate because the goal is to drain the obstruction during a single session. That is why in more and more centers the patient signs a single consent for endoscopic biliary drainage, whether by ERCP, EUS or combined. Should EUS drainage be used first for MDBO without attempting ERCP? A possible protocol for endoscopic drainage of MDBO could be to start with the duodenoscope for ERCP. If the papilla of Vater is accessible, try cannulation considering the ESGE criteria for a difficult cannulation: more than 5 contacts with the papilla; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification. If biliary cannulation is not achieved, immediately switch to EUS drainage during the same session. Occasionally, the double guidewire technique or even transpancreatic biliary sphincterotomy could be used, but not needle-knife precut.

Diagnostic utility of EUS-guided tissue acquisition in children: A tertiary care center experience.

Background and Objectives:EUS is frequently utilized for tissue acquisition in adult patients. However, the literature is limited regarding the utility of EUS-guided fine-needle aspiration or biopsy (FNA or FNB) in children. In this study, we aim to evaluate the feasibility, safety, and diagnostic utility of EUS-FNA/FNB in children with various gastrointestinal diseases.Methods:The data of children (≤18 years) who underwent EUS-FNA/FNB from March 2014 to June 2020 were analyzed, retrospectively. The following parameters were analyzed: technical success, adverse events, and impact on the final diagnosis.Results:Sixty-seven children (32 – boys, 14.8 ± 2.9 years, range 8–18 years), underwent EUS-guided tissue acquisition procedures using standard therapeutic echoendoscope during the study period. The indications included solid pancreatic lesions in 29 (43.3%), mediastinal or abdominal lymphadenopathy in 30 (44.7%), cystic pancreatic lesions in 5 (7.5%), subepithelial lesions in 2 (3%), and retroperitoneal mass in 1 (1.5%). EUS-FNA and-FNB were performed in 42 and 25 children, respectively. All the procedures could be successfully performed and there was no major procedure-related adverse event. Minor adverse events included self-limiting throat pain (10) and abdominal pain (3), self-limited bleeding at puncture site (3), and transient fever (1). EUS-FNA/FNB provided a histopathological diagnosis in 59 (88.1%) children.Conclusion:EUS-guided tissue acquisition using standard echoendoscope is feasible and safe in the pediatric age group. EUS-FNA/FNB establishes diagnosis in majority of the children when performed for appropriate clinical indication.

973 OPEN SESAME: A NOVEL LUMEN APPOSING METAL STENT DEPLOYMENT SYSTEM FOR THE MANAGEMENT OF SHORT LUMINAL STRICTURES

The use of short, fully-covered lumen apposing metal stents (LAMS) has emerged as a novel therapeutic intervention in the management of short luminal strictures. Similar to self-expanding metal stents (SEMS), LAMS are self-expanding and removable. Unlike SEMS, LAMS have lumen-apposing proximal and distal flanges, which may limit the risk of migration. LAMS are designed to be deployed via a therapeutic echoendoscope. When LAMS deployment is attempted with a therapeutic gastroscope, the much longer length of the deployment catheter relative to the gastroscope and inability to luer lock the catheter in place result in unstable endoscopic visualization and need for a second operator. These difficulties predispose to inaccurate stent placement. We demonstrate a video series including four patients with disparate pathologies resulting in luminal strictures in whom we successfully implemented a novel, alternative LAMS deployment system. At bedside, the 10 mm x 15 mm LAMS, which was previously deployed from the catheter, is pulled with standard grasping forceps into the 3.7 mm accessory channel of the therapeutic gastroscope. The scope tip is then advanced to the stricture, and the LAMS is pushed out under fluoroscopy until the distal flange opens. As the scope is slowly withdrawn, the proximal flange is deployed under endoscopic visualization. The deployed stent is then dilated with a through the scope balloon to obtain maximal stent expansion. This technique is now demonstrated in the following patients: 1. A 70 year old woman with ulcerative colitis, status post total proctocolectomy with ileal pouch-anal anastomosis, complicated by refractory pouchitis and pouch-vaginal fistula, on infliximab, presented over a decade later for management of a refractory anastomotic stricture at the inflow tract to the pouch. 2. A 48 year old woman with disseminated tuberculosis and actinomyces complicated by esophageal fistula, status post partially covered esophageal stent placement, since removed, presented with odynophagia 2 months later secondary to an upper esophageal stricture refractory to balloon dilation. 3. A 63 year old woman with HBV cirrhosis status post esophageal variceal band ligation, complicated by mid-esophageal stricture formation less than 2 weeks later, who was initially treated with balloon dilation and fully covered SEMS placement, returned due to stricture recurrence following distal SEMS migration. 4. A 59 year old male with recurrent diverticulitis status post open sigmoidectomy complicated by anastomotic breakdown requiring a diverting loop ileostomy, developed a complete obstruction at the colorectal anastomosis refractory to balloon dilation. With use of our novel technique, we were able to easily and accurately place LAMS across these short luminal strictures, thus obtaining symptom alleviation for our patients and avoiding surgery.

Endoscopic Ultrasound-Guided Pancreatic Pseudocyst Drainage in Children

Background: Endoscopic drainage of pancreatic pseudocysts is well established in adults and known to be associated with complications including perforation and hemorrhage. One reason for this is that endoscopic drainage is a blind procedure and to overcome this, EUS guided drainage was established. However, there are limited data regarding this procedure in the pediatric age group. The reasons for this are the limited number of cases seen in children and the lack of experienced pediatric gastroenterologist with this technique. Add to this another technical limitation with EUS is that the therapeutic echo endoscope is 14.6 mm in diameter and has a rigid tip that restricts its use in young children. Patients, methods and results: This report describes a 4-year old child weighing 14 kg with a large pancreatic pseudocyst (8x8x12cm) that was treated successfully using adult endoscopic ultrasound scope (The Olympus EVIS LUCERA Ultrasound Gastrovideoscope GF-UCT 260, 14.6 mm distal tip). Conclusion: Endoscopic drainage of symptomatic pancreatic pseudocysts can be achieved safely and effectively in children using the adult EUS scope.

Endoscopic Ultrasound Directed Pseudocyst Drainage Without the Use of Fluoroscopy: A Case Series

Introduction: Endoscopic drainage of pancreatic pseudocysts is usually performed using fluoroscopy and a therapeutic duodenoscope. Endoscopic ultrasound (EUS) is often used to choose the puncture site and avoid penetrating a vessel. However, fluoroscopy and EUS equipment are typically in separate rooms making transport of EUS equipment difficult and cumbersome. Also, availability of a fluoroscopy suite can be an issue at many institutions. The aim of this study was to evaluate the technical feasibility and safety of EUS directed pseudocyst drainage without the use of fluoroscopy. Methods: Patients referred for pseudocyst drainage to one endosonographer between July 2005 and June 2015 were managed by cyst drainage using EUS guidance without the use of fluoroscopy. Technical success rate and complications were reviewed. In addition, previous attempts at drainage were recorded.17 procedures were performed using the Olympus GF-UC140P echoendoscope; 6 procedures were performed using Pentax therapeutic echoendoscope, 21 procedures were performed using Olympus therapeutic echoendoscope. In each case initial puncture was made using a 19G needle and fluid was aspirated. A .035 wire was passed through the needle into the cyst. The tract was dilated over the wire using a 4.5 to 6F graduated dilator; In 24 patients balloon dilation was then performed to 8 or 10 mm. 2 to 4 double pigtail stents were placed. Either 7Fx3cm or 5cm double pigtail stents were used. In 18 patients a 10 mmx4cm fully covered self expandable metal stent was placed (8 Wallflex & 10 Viabil stents). An ERCP trained nurse was required for the procedure. All procedures were performed only with a linear echoendoscope. Results: A total of 44 patients were managed with this technique. The procedure was unsuccessful in 1 of 44 patients due to difficulty with sedation. 5 patients had previous failed attempts at cyst drainage by ERCP experts using fluoroscopy and a therapeutic duodenoscope. EUS guided drainage was successful in all 5 of these patients. There were 4 complications: 1 patient had delayed bleeding requiring transfusion; this patient was known to have varices in the pseudocyst. 1 patient had stent migration into the cyst; this was removed at a later date without any untoward consequences. In 2 patients, one of the stents slipped out of the cyst; this was removed without any complications. Conclusion: EUS directed pseudocyst drainage without the use of fluoroscopy appears technically feasible and safe.

Single‐step versus two‐step endo–ultrasonography‐guided drainage of pancreatic pseudocyst

The aim of this prospective study was to compare the feasibility, technical success rate and complication between single-step endo-ultrasonography (EUS)-guided and two-step EUS-guided drainage technique for symptomatic pancreatic pseudocyst (PP). Twenty-one PP patients with clear intra-cystic fluid that needed to be drained were divided into two groups, depending on the availability of the therapeutic echoendoscope at the time of the procedure: Group 1 (13 patients) underwent a single-step EUS-guided endoscopic drainage and Group 2 (8 patients) underwent a two-step EUS-guided drainage technique. In Group 1 immediate technical success was achieved in 92.3% (12/13); two patients had recurrent PP and both were successfully treated by a second EUS-guided drainage. Clinical success was achieved in all cases. In Group 2 technical success was achieved in 75.0% of the patients (6/8). One patient (12.5%) bled 36 h after the procedure. Five out of 6 patients had long-term success. Clinical success was significantly greater in Group 1 (P < 0.05). The technique of single-step EUS-guided drainage was superior to the technique of a two-step EUS-guided drainage technique for PP drainage.

Sp704 Prototype Forward Viewing Linear Array Echoendoscope for Management of Upper GI Bleeding

Real time EUS imaging of submucosal arteries would be an advance in the management of upper GI bleeding, as it may allow for targeting of therapy and assessment of cessation of blood flow post therapy. However, curvilinear array echoendoscopes currently in use are inadequate. The oblique view limits endoscopic imaging and delivery of therapy. We present for the first time, in a human study, the feasibility of visualizing submucosal arteries with, and delivery of guided hemostatic therapy using a prototype forward-viewing echoendoscope. A 58 year old female patient presented with hematemesis, melena and a 4 gram drop in hemoglobin. She was admitted to the intensive care unit, and resuscitated with blood and IV fluid. Endoscopy was performed with a prototype forward-viewing therapeutic echoendoscope, XGIF-UCT160J-AL5; (Olympus Inc, Tokyo, Japan), which has a 90° US scanner with color Doppler, and a 3.7-mm working channel, without an elevator. An actively bleeding Dieulafoy lesion was seen in the post bulbar duodenum. Thermal therapy with a 10Fr heater probe was performed for hemostasis. Despite adequate post-treatment visual appearance, subsurface arterial blood flow was audible with a through-the-scope doppler ultrasound probe. High resolution endosonographic exam demonstrated multiple deep and superficial blood vessels with active blood flow. Superficial blood vessel's of upto 0.8 mm in diameter were seen at a depth of upto 3mm. Additional thermal therapy was applied with the heater probe with simultaneous endoscopic and sonographic visualization. Post treatment, doppler flow was absent at shallow depth, and sonographic exam of the the site demonstrated no superficial blood flow. Real-time sonographic imaging of submucosal blood flow in a bleeding lesion appears feasible with a forward-viewing echoendoscope. Precise targeting of therapy with this echoendoscope is a possibility. This could potentially improve efficacy of hemostasis in GI bleeding, leading to a decrease in re-bleeding rates, and mortality. Larger studies are necessary to delineate efficacy, appropriate indications and limitations of management of GI bleeding with this prototype echoendoscope.

Su1408 Endoscopic Ultrasound Directed Pseudocyst Drainage Without the Use of Fluoroscopy: A Case Series

Su1408 Endoscopic Ultrasound Directed Pseudocyst Drainage Without the Use of Fluoroscopy: A Case Series

Endoscopic Necrosectomy With Self-Expandable Metal Stent (SEMS) Drainage: A Novel Approach in the Treatment of Walled-Off Pancreatic Necrosis (WOPN)

Purpose: Pancreatic necrosis is a feared complication of acute pancreatitis with high morbidity and mortality. Recent literature has suggested the advantages of a minimally-invasive approach. Methods: Patients that had undergone cyst-gastrostomy with a SEMS prior to endoscopic necrosectomy for WOPN were retrospectively evaluated. Using a therapeutic echoendoscope, a 19-gauge FNA needle was used to puncture the WOPN. A 0.035-inch guide wire was advanced under direct visualization either with the aid of fluoroscopy or EUS. The tract was then dilated using a combination of needle-knife, Sohendra dilators (Wilson-Cook), and/or CRE balloon (Boston Scientific). A fully-covered or uncovered 10mm x 40mm SEMS was then deployed across the tract, and the WOPN was aggressively irrigated. After adequate drainage of the WOPN had occurred, a conventional gastroscope was used to remove the SEMS. A CRE balloon was used to dilate the tract up to 18 mm. The gastroscope was then introduced into the necroma and debrided using a combination of irrigation, forceps, Roth nets (US Endoscopy), and stone-retrieval baskets. The goal of each necrosectomy was to debride the walls of the necroma until pink granulation tissue was uncovered. At the conclusion of each necrosectomy, 7 or 10F plastic stents or nasobiliary drain were left in place with repeat necrosectomy performed at the endoscopist's discretion. Results: 11 total necrosectomies were performed on 4 patients. The mean age of the patients was 55 years. 3 of the 4 patients had sterile necrosis; 1 had infected necrosis. The mean size of the WOPN was 13.9cm prior to cyst-gastrostomy with SEMS. The mean time frame from the onset of acute pancreatitis until cyst-gastrostomy drainage was 108 days (range 24-237 days). The first endoscopic necrosectomy was performed a mean of 26 days after initial cyst-gastrostomy SEMS drainage (range 10-46 days). Significant improvement in symptoms was seen in all 4 patients, with 2 patients experiencing complete resolution of symptoms, 1 patient with near-complete resolution of symptoms, and 1 patient with partial resolution of symptoms. Complications from endoscopic necrosectomy included fever (1 patient), tachycardia (1 patient), persistent leukocytosis (1 patient), and prolonged procedure time (4 patients). There were no deaths. Conclusion: In a highly-selective patient population, optimal drainage using SEMS for cyst-gastrostomy may be advantageous to using a smaller diameter plastic stent prior to endoscopic necrosectomy. Prospective, randomized trials must be performed for validation.

Sp289: Experience with a Prototype Forward-Viewing Curvilinear Array Therapeutic Echoendoscope for Interventional EUS: A Case Series

Interventional EUS offers a minimally invasive alternative to surgical and/or radiologic interventions for treatment of pancreaticobiliary disorders. Procedures are typically performed with oblique-viewing echoendoscopes. These instruments have limitations when compared to forward-viewing endoscopes: impaired endoscopic visualization, difficult orientation for drainage procedures, and difficulty passing accessories through the endoscope channel. A prototype forward-viewing therapeutic echoendoscope (GIF UCT 160J-AL5; Olympus America Inc, Center Valley, PA) may potentially overcome these limitations.

Evaluation of hilar biliary strictures by using a newly developed forward-viewing therapeutic echoendoscope: preliminary results of an ongoing experience

Obtaining a definitive tissue diagnosis in patients with hilar biliary strictures (HBS) is often difficult. To describe our experience using a newly developed forward-viewing linear echoendoscope (FVL-EUS) with FNA as a primary diagnostic tool in patients with HBS. Case series. A tertiary care, academic medical center. Four patients with HBS who underwent the procedure. Performance of FNA with the FVL-EUS. Visualization and puncture of the primary lesion with a definitive tissue diagnosis was obtained in all of the 4 cases performed. Metastatic hilar cholangiocarcinoma and recurrent neuroendocrine tumor were diagnosed in 2 patients and followed by placement of a self-expandable metal stent, when possible. In the other 2 patients, a diagnosis of resectable hilar cholangiocarcinoma and poorly differentiated adenocarcinoma of unclear origin without evidence of vascular involvement was made, and plastic stents were placed before surgery; the first patient was found to have peritoneal metastases, and resection was aborted, and in the second patient, a gallbladder tumor was diagnosed in the surgical specimen. The small number of patients. These preliminary data suggest that FVL-EUS used as a primary tool for the evaluation of patients with HBS may be of value and should be further explored in properly designed studies with a meaningful number of patients.

Evaluation of hilar biliary strictures using a newly developed forward viewing therapeutic echoendoscope: preliminary results of an ongoing experience

Background and Aims: In patients with hilar biliary strictures (HBS), EUS-FNA has been used as a second-line procedure to establish a tissue diagnosis after negative ERCP sampling. The wide range of sensitivity (25% to 83%) reported may reflect the high skills required to sample the hilum, which can underestimate EUS performance if the sample size is small, as well as, difference in the equipment used and in the patients studied. A newly developed forward viewing linear echoendoscope (FVL-EES) has recently become available. During the initial practice with this scope, we found that clear view of the hilum could be obtained. We present our preliminary experience using this newly developed FVL-EUS scope as a primary tool to obtain tissue diagnosis and guide further management in patients with HBS.

Single-Scope EUS Guided Cyst Access, Debridement and Drainage Using a Novel Therapeutic Forward Viewing Echoendoscope

Background: Despite reports of successful endoscopic cystgastrotomies, there remain technical limitations related to current CLA echoendoscopes - namely the oblique angle properties that result in a weakened transfer of force, difficult deployment of larger-bore accessories and its tunneling in the gastric wall. In addition, and most importantly, the technique requires the use an additional endoscope to perform cyst debridement with its potential loss of access during endoscope exchange. A novel therapeutic echoendoscope that shifts the endoscopic and ultrasound orientation from oblique to forward viewing has recently been prototyped. Methods: Phase I/II study of pancreatic cyst drainage using a forward viewing echoendoscope. A standardized approach of cyst drainage technique, including cyst localization, needle puncture under doppler ultrasound guidance, guidewire insertion, balloon dilation, cyst debridement and stent placement with or without nasocystic catheter, were used in order to study the technical advantages and disadvantages of the forward viewing endoscope. Patients were followed to assess symptom and cyst resolution. Our local Institutional Review Board approved the study. Results: Six consecutive patients who were referred for pancreatic cyst drainage were enrolled. The majority of patients were men (83%) with a mean age of 50 ± 20 years and had developed a cyst due to acute pancreatitis of various etiologies. The mean size of the cysts was 10 cm (range 6 to 12 cm) and they were located predominantly in the pancreatic body (83%). We gained cyst access using a 19-gauge needle followed by balloon dilation in 2 patients and with a Cystotome in 4. All cysts had successful stent drainage. Direct cystoscopy and debridement were achieved in 4 cases. Inability to directly enter the cyst with the echoendoscope occurred due to cyst location in the distal stomach in one case and inadequate cyst adherence to the stomach wall in the other. Conclusion: The forward viewing echoendoscope showed a number of promising mechanical advantages for pancreatic cyst drainage. Its most compelling feature was the ability to perform imaging and endoscopic interventions with the same instrument - for single scope ultrasound guided cyst access, debridement and stent drainage.

Novel T-Bar Tissue Fastener Combined with Prototype Forward Viewing Therapeutic Echoendoscope: Preparing for “NOTES”

Novel T-Bar Tissue Fastener Combined with Prototype Forward Viewing Therapeutic Echoendoscope: Preparing for “NOTES”

Wire-guided pancreatic pseudocyst drainage by using a modified needle knife and therapeutic echoendoscope

Various methods to drain pancreatic pseudocysts by using EUS guidance have been reported in the literature. A new drainage technique is described that uses a modified needle knife advanced over a guidewire positioned in the pseudocyst by EUS guidance. Retrospective chart review. Academic medical center. Consecutive subjects from December 1, 2002, to January 10, 2005, with symptomatic pseudocysts in whom EUS-guided drainage was attempted. By using a therapeutic linear echoendoscope, a 19-gauge aspiration needle was inserted into the pseudocyst. A guidewire was placed through the needle, and a needle knife with the cutting wire protruding and bent was advanced over the guidewire to contact the stomach mucosa. The needle knife was then advanced by using electrocautery into the pseudocyst. The cystenterostomy was dilated by using a balloon over the guidewire. One to 4 stents were placed through the tract. Successful pseudocyst drainage. A total of 21 of 23 patients underwent technically successful pseudocyst drainage. One patient had self-limited hypotension during the procedure. Another patient had free intraperitoneal air after the procedure but correct stent placement. Retrospective analysis, small sample size. In this preliminary experience, wire-guided pseudocyst drainage with a modified needle knife appears effective and safe while allowing for a more controlled pseudocyst puncture.

A Single Therapeutic Echo Endoscope Used for Combined Transgastric and Transpapillary Drainage of a Pancreatic Abscess

The design of endoscopic ultrasound (EUS) instruments has been improved to provide a wide therapeutic channel and an elevator to facilitate the movement of needles and medical devices. These improvements make it possible to carry out combined ultrasound and endoscopic approaches in the pancreas and duodenal papilla, with ultrasound examination of surrounding fluid collections [1] [2] [3] [4] [5]. Cystogastrostomy is a particularly interesting field for therapeutic endosonography, with major advantages over conventional therapeutic endoscopy - including increased safety, access to distant collections, and differentiation of cystic lesions [5]. Although cystoenterostomy is an effective form of treatment, it does not provide treatment for impaired ductal drainage [3]. We report here on the use of a combined EUS and endoscopic retrograde cholangiopancreatography procedure using a single echo endoscope.

One Step Drainage of Pancreatic Pseudocysts with Multiple Stents Using a Large Channel Therapeutic Echoendoscope

One Step Drainage of Pancreatic Pseudocysts with Multiple Stents Using a Large Channel Therapeutic Echoendoscope

A CASE OF PANCREATIC PSEUDOCYST SUCCESSFULLY TREATED WITH ENDOSCOPIC CYSTGASTROSTOMY USING A NEW THERAPEUTIC ECHOENDOSCOPE

Aim: A case of an infected pancreatic pseudocyst in which cystgastrostomy was successfully performed with a new therapeutic echoendoscope and fluoroscopic guidance is presented.Methods: A curved linear array echoendoscope (GF‐UCT240‐AL5; Olympus) with an instrument channel 3.7 mm in diameter was used in combination with the Aloka SSD‐5000 display unit. It enabled endoscopic video viewing. The cyst puncture was performed using a 1‐mm diathermic needle housed in a 5 Fr Teflon tube. Following the endoscopic ultrasound (EUS)‐guided puncture, a 10 Fr stent was placed in the pancreatic pseudocyst without an exchange of endoscope.Results: The procedure was well tolerated for the patient and there were no complications. The cyst was resolved and the stent was removed 8 weeks later.Conclusion: This new therapeutic echoendoscope may provide a more effective, safer and less time‐consuming method of endoscopic pseudocyst drainage.

One Step Endoscopic Drainage of Pancreatic Pseudocysts: Use of a New Therapeutic Echo Endoscope

Background: Different methods have been proposed for pancreatic pseudocysts (PPC) drainage. We describe our experience in endoscopic drainage of PPC with a one step technique using a new therapeutic echo endoscope with a linear curved array transducer, a 3.7 mm working channel and an elevator (Olympus GF-UCT140-AL5). Methods: 12 patients (8 men, 4 women; mean age 53.9, range 28-77) were referred from October 2002 to October 2003 for endoscopic pseudocyst drainage. The mean size of the pancreatic cysts was 11.2 cm (6.5-25 cm). Either monitored anesthesia with Propofol or general anesthesia was used to sedate the patients. The Olympus GF-UCT140-AL5 was passed into the stomach; the optimal localization of the puncture site was determined. Color Doppler was used to rule out gastric varices and large vessels. Under real time ultrasound guidance a 19 gauge FNA needle (EchoTip, Wilson-Cook) was then inserted into the pseudocyst. A 0.025″ Jagwire (Boston Scientific) was passed through the needle under fluoroscopy and coiled into the pseudocyst. A Needle Knife (HPC-3) was introduced over the wire. Under EUS and endoscopic guidance an electrosurgical puncture was performed using the Needle Knife. The tract was dilated with a 10 mm balloon followed by the placement of 1 to 3 10-Fr double pigtail stents. The stents were removed in 1 to 3 months after the resolution of the cyst. Results: Drainage was not attempted on 2 patients due to large gastric varices on the first and a malignant mass in the cyst of the second, both diagnosed only by EUS. Drainage was attempted on 10 patients; placement of the 10-Fr double pigtail stents was successful in 9 patients. In one case drainage could not be achieved. In one other patient with a large cyst and internal debris surgery was required for a cyst infection that did not resolve with endoscopic management. 8/10 patients had complete resolution of their symptoms and cysts. One patient required 2 procedures due to the presence of debris in the cyst. There were no significant bleeding or other complications noted. Conclusion:In our experience EUS is essential prior to endoscopic drainage of PPC as it affected the clinical management of 2/12 patients. Endoscopic drainage of PPC using the new therapeutic echo endoscope with EUS guided wire placement and puncture allows a safe one step procedure without exchanging scopes.

Drainage of deep pelvic abscesses using therapeutic echo endoscopy.

The purpose of this study was to evaluate the clinical efficacy of endosonographically guided transrectal aspiration and drainage by plastic stent of deep pelvic abscesses, using a therapeutic echo endoscope device. Between September 2000 and June 2001, 12 patients (nine men, three women, mean age 67 years) were treated for a perirectal or a pelvic abscess using an endoscopic ultrasound (EUS) technique. The drainage of these fluid collections was performed under EUS guidance, using therapeutic EUS scopes with a large working channel. No major complication occurred during this study. Transrectal stent insertion succeeded in nine patients. In three patients, only aspiration was possible. Among the nine patients in whom a stent was successfully introduced into the fluid collection, complete drainage without relapse was achieved in eight patients (mean follow-up 10.6 months, range 6-14 months). The stent was removed endoscopically after 3 to 6 months. Drainage was incomplete in one patient (with a large abscess, diameter > 8 cm), who subsequently underwent surgical drainage. However, two out of the three patients in whom aspiration alone was performed developed a recurrence of the abscess and required surgical treatment. EUS-guided drainage of deep pelvic abscesses could offer an alternative treatment to surgery in the management of these postoperative complications.