Complicated diverticulitis occurs in 12 % of all diverticulitis cases [1 ]. Radiological drainage is the first-line therapy in cases of large diverticulitis-associated
abscess [2 ]. However, the pelvic location renders the radiological access challenging. Lower
endoscopic ultrasound (EUS)-guided drainage, using an electrocautery-enhanced lumen-apposing
metal stent (LAMS), is a feasible and safe alternative method for drainage of pelvic
collections [3 ]
[4 ]
[5 ]. We present a case of a diverticulitis-associated abscess successfully treated using
EUS-guided LAMS.
A 57-year-old man presented to the emergency room with abdominal pain and fever. His
medical history revealed chronic obstructive pulmonary disease Gold IV. On admission,
computed tomography (CT) scan showed a complicated acute diverticulitis Hinchey II
with a pelvic abscess of 5 cm ([Fig. 1 ]). The pelvic location of the abscess did not allow for radiological drainage and
general anesthesia was contraindicated due to the patient’s pulmonary disease. EUS-guided
drainage of the pelvic abscess was performed under spinal anesthesia ([Video 1 ]).
Fig. 1 Computed tomography scan showing complicated diverticulitis Hinchey II with an abscess
(red arrow).
Video 1 Endoscopic management of complicated diverticulitis Hinchey II.
The diverticulitis-associated abscess was punctured freehand ([Fig. 2 a ]) using the electrocautery-enhanced LAMS (10 × 10 mm; pure cut mode, effect 4). After
deployment of the proximal flange ([Fig. 2 b ]), a 0.035-inch guidewire was introduced through the LAMS into the abscess ([Fig. 2 c ]). Then, the LAMS was deployed to drain the abscess into the lumen of the colon.
Finally a double-pigtail stent was inserted through the LAMS to avoid LAMS obstruction
([Fig. 2 d ]). No adverse events were reported.
Fig. 2 Endoscopic ultrasound (EUS)-guided drainage of diverticulitis-associated abscess
using an electrocautery-enhanced lumen-apposing metal stent (LAMS). a Direct puncture with the electrocautery-enhanced LAMS (purple arrow) into the pelvic
abscess (red arrow) under EUS control. b Deployment of the proximal flange of the LAMS (purple arrow) into the abscess lumen
(red arrow) under EUS control. c Introduction of a guidewire (green arrow) through the LAMS (pink arrow) into the
abscess. d A double-pigtail stent (blue arrow) was inserted through the LAMS (pink arrow).
Follow-up CT scan 2 weeks later showed complete resolution of the abscess. The LAMS
was removed and the residual fistula was closed using clips. Follow-up CT scan and
endoscopy at 2 months showed complete resolution of the abscess without fistula.
This case highlights the advantage of LAMS for drainage of a diverticulitis-associated
abscess and its successful outcome without recurrence. Moreover, in patients with
contraindication for general anesthesia, this procedure can be performed under spinal
anesthesia. Prospective studies are needed to determine the role of EUS-guided drainage
of diverticulitis-associated abscess using LAMS.
Endoscopy_UCTN_Code_TTT_1AS_2AZ
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