Introduction
First-line approach for complicated acute diverticulitis is conservative treatment with bowel rest and systemic antibiotics. The presence of pericolic, mesocolic, or distant (usually deep pelvic) abscess ≥4 cm (1a or II stages according to Hinchey classification) represents an indication for drainage, either trans-abdominal, trans-gluteal, trans-rectal, or trans-vaginal. Endoscopic-ultrasound-guided pelvic abscess drainage (EUS-PAD) with lumen-apposing metal stents (LAMS) has been reported as a safe and effective alternative approach for complicated diverticular disease.
Aims & Methods
We aimed to assess the safety and efficacy of EUS-PAD with LAMS in a homogeneous population of patients with acute diverticulitis complicated by a pericolic, mesocolic, or pelvic abscess. A multicenter study was conducted from 2019-2023 retrieving all consecutive patients who underwent EUS drainage attempts for complicated acute diverticulitis in three referral centers. All cases have been considered suitable for EUS-PAD by local multidisciplinary teams. Continuous variables are expressed as median [interquartile range].
Results
Sixty-six patients underwent EUS assessment with interventional intent; however, in 13 cases, no sign (no. 5) or a small abscess (no. 8) was found. Finally, 53 patients (29 female 54.7%) with a median age of 74 [62-83] year-old were considered. Most cases (no. 40, 75.5%) had a pelvic abscess (Hinchey stage II) while 13 (24.5%) had a para-colonic abscess (stage 1b); thirty-one (58.5%) did not receive any antiplatelet or anticoagulant agent, while 10 (18.9%) were on low molecular weight heparin, and 12 (22.6%) on antiplatelet agents. No patient had fecal diversion. The median abscess size was 50 [40-60] mm. EUS-PAD have been conducted under conscious sedation in 14 (26.4%), deep sedation in 12 cases (22.6%), or general anesthesia in 27 cases (50.9%) with electrocautery-enhanced LAMS (Hot Axios, Boston Scientific, US). Six patients (11.3%) underwent concomitant percutaneous drainage, while in one case (1.9%) two LAMS have been used. In 34 cases (64.2%) trans-rectal EUS-PAD was performed, in 19 (35.8%) a trans-colonic route was required. Technical success was achieved in 49 (92.5%). A trend toward a higher technical success rate was observed for the trans-rectal route (odd ratio 6.19; 95% C.I 0.60 - 64.3; P 0.13); abscess size ≥50 mm was independently related to a higher technical success rate (OR 18.0 [1.63 - 198]; P 0.02). Stent size was 6x8mm (no. 2), 8x8 mm (no. 11), 10x10mm (no. 20), 15x10mm (no. 15), and 15x15mm (no. 1). Clinical success rate was 88.7%. The incidence of adverse events was 3.8%, with 1 minor procedural bleeding (AGREE II) and one late proximal migration (AGREE IIIa). LAMS were removed after a median of 19 [14-28] days and substituted with a double pigtail plastic stent in 9 cases. Patients were followed for 12 [8-12] months. Four (7.5%) patients underwent urgent Hartmann sigmoidectomy; during follow-up 12 (22.6%) patients required elective surgery; finally, 2 (3.8%) patients presented recurrent diverticular abscesses. No procedure-related or disease-specific mortality was observed during follow-up.
Conclusion
EUS-guided pelvic abscess drainage (EUS-PAD) with LAMS could be considered a safe and effective approach among conservative treatments for complicated acute diverticulitis.
EUS drainage with LAMS was confirmed as an effective treatment modality for encapsulated collections larger than 5 cm and close to colonic wall; trans-rectal approach seems safer while no difference in stent size were observed in terms of safety and efficacy.
References
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Disclosure
Andrea Lisotti had a proctorship contract with Boston Scientific in 2021 and 2022.
