Lumen-apposing metal stent for drainage of a perirectal abscess complicating endoscopic ultrasound-guided fine-needle biopsy

Abscess formation is a rare complication following lower gastrointestinal tract endoscopic ultrasound (EUS)-guided tissue acquisition ¹ . Transrectal EUS-guided drainage has been shown to be a safe and effective treatment for postsurgical and inflammatory pelvic fluid collections ^{2 3} . We report a case of an abscess complicating fine-needle biopsy (FNB) of a perirectal mass, successfully managed with EUS-guided transrectal drainage using a lumen-apposing metal stent (LAMS).

A 69-year-old man with a history of prostatectomy and radiotherapy for prostate cancer 4 years earlier, and proctosigmoidectomy with colostomy for rectosigmoid cancer 2 years earlier, underwent transrectal EUS-FNB of a perirectal mass suspected to represent a cancer recurrence. Two needle passes through the rectal stump yielded necrotic material without malignant features. Several days later, the patient presented with severe perirectal pain, leukocytosis, and elevated C-reactive protein. Computed tomography (CT) revealed a perirectal abscess, 50 mm × 45 mm in size, at the site of previously biopsied necrotic lesion ( Fig. 1 ). Due to its proximity to the rectal stump, transrectal EUS-guided drainage was performed ( Video 1 , Fig. 2 ). The abscess was punctured for culture using a 19-G FNA needle (EZ Shot 3 plus, Olympus), followed by placement of a 20 mm × 10 mm cautery-enhanced LAMS using a freehand technique (Hot Axios, Boston Scientific). The abscess cavity was irrigated with saline, and a 7-Fr, 5-cm double-pigtail plastic stent was placed coaxially through the LAMS. The patient experienced immediate pain relief, and his post-procedure course was uneventful. A follow-up CT scan two weeks later confirmed resolution of the abscess ( Fig. 3 ). Endoscopic examination through the LAMS revealed a collapsed, residual cavity lined with granulomatous tissue ( Fig. 4 ). Both stents were removed using rat-tooth forceps. The resulting wall defect was left to heal spontaneously ( Fig. 5 ). At 6-week follow-up, clinical and magnetic resonance imaging assessment confirmed full recovery.

Fig. 1.

Computed tomography image of a perirectal abscess (A) with an air-fluid level, located between the urinary bladder (B) and rectal stump (R), at the site of the previously biopsied perirectal necrotic lesion.

Fig. 2.

Endoscopic ultrasound image of the abscess (arrowheads), with mirror-image artifact (arrows) arising at the highly reflective interface between gas and fluid in the abscess cavity (asterisks).

Fig. 3.

Computed tomography image two weeks after drainage, showing the lumen apposing metal stent connecting the residual abscess cavity (asterisk) with the rectal stump (R). “U” denotes the urinary bladder.

Fig. 4.

Endoscopic image of the rectal stump 14 days after drainage. The residual abscess cavity lined with granulomatous tissue is seen through the lumen-apposing metal stent.

Fig. 5.

Endoscopic image of the rectal stump immediately after removal of the lumen-apposing metal stent. The resulting wall defect (asterisk) was left to heal spontaneously.

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Transrectal drainage of a perirectal abscess using endoscopic ultrasound-guided lumen-apposing metal stent.

Video 1

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