Post written by Andrea Lisotti, MD, from the Gastroenterology Unit, Hospital of Imola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.

Pelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. Percutaneous approach for deep PFC could be challenging and could result in longer and painful recovery; trans-vaginal approach was considered easy but limited by the difficulty to leave a stent in place. Trans-rectal approach was described but issues related to fecal contamination were hypothesized. Data on EUS-guided trans-rectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes.

We report 5 cases, 4 with post-operative PFC and the remaining with pelvic abscess complicating acute diverticulitis. EUS-TRD was performed with the “direct-puncture” technique and lasted <10 minutes in 4 cases; in the remaining case, needle puncture and LAMS placement over a guidewire was required and the procedure length was 14 minutes. Electrocautery-enhanced LAMS delivery-system (15 x 10 mm) was used in all cases. Clinical success was achieved in all cases. LAMSs were removed after a median of 14 (12-24) days. One patient reported partial proximal LAMS migration after 24 days (mild adverse event). No PFC recurrence was observed. No patient required surgery or any other additional treatment.

Our study suggests that EUS-TRD with an electrocautery-enhanced LAMS delivery system is safe and effective for the treatment of post-operative or inflammatory PFCs. The use of a 15- x 10-mm LAMS allowed a rapid radiological and clinical PFC resolution; we suggest close monitoring in cases of LAMSs left in place for more than 3 weeks, for the possible risk of proximal stent migration. Despite their large caliber, 15- x 10-mm LAMSs could be used not only in patients with fecal diversion but also in cases of unaltered large bowel anatomy. In particular, no issues with fecal contamination into the cavity and tract closure after stent removal were encountered. Large prospective studies are required to confirm these findings.

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