EUS-guided drainage of liver abscess drainage

Liver abscesses smaller than 5cm are usually treated with systemic antibiotics alone. Drainage is required for abscesses larger than 5cm, or when not responding to antibiotic therapy, even if smaller than 5cm. The first line drainage procedure has been percutaneous ultrasound guided drainage. Surgical drainage may be required when the abscess is inaccessible or when percutaneous drainage is inadequate, such as in the context of multi-loculated abscesses. However, surgical drainage is associated with significantly higher morbidity. EUS-guided drainage has been reported in the context of abscesses in the caudate or left lobe of liver, or which had ruptured from the left lobe, forming a subphrenic collection. In those instances, percutaneous drainage was not feasible due to limited window of access. The technique is similar to pseudocyst drainage and can be summarized as follows: 1) visualize the abscess collection with a therapeutic echoendoscope; 2) use a 19G needle to puncture the abscess cavity under Doppler ultrasound guidance; 3) insert a guidewire into the cavity under fluoroscopic guidance; 4) dilate the puncture tract with co-axial or balloon dilators; 5) insert 7Fr to 10Fr double pigtail stents (either single or double, depending on the abscess size) for transluminal drainage. Cross-sectional imaging is then performed to document abscess resolution before stent removal. Currently 7 cases have been reported in the literature with 100% technical and clinical success. Although these preliminary reports appear promising, its indication remains limited, given the ease of percutaneous drainage.