EUS-guided drainage of a mediastinal abscess.

A 61-year-old man with esophageal adenocarcinoma underwent minimally invasive esophagectomy and gastric pull-through. The initial postoperative course was without adverse events, and he was discharged home. However, on day 7 the patient was readmitted with fever, rapid atrial fibrillation, and leukocytosis. Chest CT scan revealed a 6.3 cm 4.6 cm mediastinal abscess adjacent to the gastric pull-through (Fig. 1; Video 1, available online at www. giejournal.org). EUS-guided drainage was performed. The echoendoscope was positioned within the stomach, and the mediastinal collection was well visualized endosonographically. The abscess was punctured with a 19-G needle while Doppler flow imaging was used to avoid the mediastinal vessels. A 0.035-inch guidewire was coiled within the abscess. The tract was dilated with a 4.4F catheter. A double-lumen catheter was advanced over the guidewire into the collection. A second 0.035-inch guidewire was passed through the second lumen of the catheter to facilitate the placement of 2 wires within the mediastinal abscess. Two 7F 5cm double pigtail catheters were then advanced over the wires and placed across the tract. The patient experienced rapid resolution of symptoms. He was afebrile and in normal sinus rhythm with downtrending white blood cell count the next day. A repeated CT scan in 4 weeks confirmed resolution of the abscess. Upper endoscopy was performed to remove the pigtail stents with a snare. EUS-guided drainage of a mediastinal abscess was safely performed. The small diameter of the stents prevented the need for large tract dilatation, which can be associated with bleeding. Successful stent placement, resolution of the collection, and stent removal was achieved over a 4-week period and avoided and prevented the need for repeated invasive surgery. The patient remains well at 3-month follow-up.