Endoscopic transgastric drainage of a postoperative intra-abdominal abscess after colon surgery Martin D. Zielinski, MD, Robert R. Cima, MD, FACS, FASCRS, Todd H. Baron, MD, FASGE Rochester, Minnesota, USA Approaches to postoperative intra-abdominal abscesses have focused on percutaneous or surgical drainage; how- ever, surgical procedures are associated with high mortality rates and there are anatomic locations that are not accessi- ble via percutaneous techniques. Transmural endoscopic drainage of pancreatic and nonpancreatic fluid collections have been reported. 1-4 We describe a patient with an intra- abdominal abscess causing sepsis after colon surgery that was successfully drained by using endoscopic transmural therapy. CASE REPORT A 57-year-old man with multiple comorbidities under- went a hand-assisted right hemicolectomy with an ileo- colic anastomosis for stage IIa colon cancer. On postoperative day 7, leukocytosis and peritonitis devel- oped, requiring re-exploration. An anastomotic leak with significant feculent contamination was identified. The anastomosis was resected, and a new ileocolic anastomosis was created along with a diverting loop ileostomy. Thir- teen days later, hypoxemic respiratory failure with hypo- tension developed in the patient. A CT scan revealed a subphrenic abscess immediately adjacent to the stomach along with a separate left paracolic gutter abscess (Fig. 1). Because of a hostile abdomen and lack of a window for percutaneous drainage without traversing the pleural space, endoscopic transgastric drainage was performed for the subphrenic abscess. In the endoscopy suite with the patient in the supine position, a therapeutic channel duodenoscope was passed into the stomach where a large extrinsic com- pressive mass was seen. A 19-gauge needle (BAN-19; Cook Medical, Winston-Salem, NC) was used to enter the cavity (Fig. 2A). Purulent, malodorous fluid was aspi- rated. A guidewire was advanced through the needle and coiled within the collection. An 8-mm balloon dilation of the gastric wall was performed (Fig. 2B). Two 10F, 5-cm long double-pigtail stents were placed in the cavity with the proximal ends within the stomach (Fig. 2C). Abscess cultures grew mixed gram-negative organisms. The left paracolic gutter abscess was drained percutaneously. The patient’s hemodynamic and respiratory status improved over the next 48 hours. Repeat endoscopy with contrast injection into the cavity 2 weeks after drainage demonstrated near resolution but with extension through the diaphragm and the presence of a bronchial fistula (Fig. 3). The endoscopic stent was repositioned. The pa- tient clinically improved over the intervening weeks with resolution of the abscess and fistula and subsequent ileos- tomy reversal 7 months later. DISCUSSION Intra-abdominal abscesses are generally the result of bowel leakage, either related to primary perforations or surgical complications. Traditional management has been reoperation, including 12th rib resection, for source control. 5,6 However, laparotomy is associated with a mor- tality rate as high as 40%. 7 Percutaneous approaches de- crease the mortality rate to 11% but require a window into the fluid collection. 6 Access to the subdiaphragmatic spaces can be difficult because the pleural cavity generally needs to be traversed, leading to a high rate of empyema formation. 8 Because the stomach lies adjacent to these spaces, it is a route for transgastric drainage techniques, with and without EUS guidance. This approach has been used to drain infected postoperative bilomas and abscesses from small-bowel perforations in addition to perisplenic, perigastric, peripancreatic, and perirectal abscesses. 1-4 Figure 1. Abdominal CT scan showing a large collection that causes ex- trinsic compression of the stomach. A small amount of air is seen within the cavity. 880 GASTROINTESTINAL ENDOSCOPY Volume 71, No. 4 : 2010 www.giejournal.org