Endoscopic ultrasound-guided transgastric drainage for omental bursa abscess complicating appendicitis with diffuse peritonitis.

ment for intra−abdominal abscess, al− though operative mortality is high [1]. Percutaneous drainage is another option but is associated with significant morbid− ity due to the relatively long route used for catheter placement [1,2]. Endoscopic ultrasound (EUS)−guided drainage is po− tentially safe and effective for intra−ab− dominal abscess. We report a case of omental bursa abscess complicating ap− pendicitis with diffuse peritonitis that was successfully and safely drained under EUS guidance. A 28−year−old woman underwent appen− dectomy and surgical irrigation drainage of Pouch of Douglas, left subphrenic space, and right iliac fossa for appendici− tis with diffuse peritonitis. Postoperative− ly after 2 weeks, the patient continued to have a high fever with elevated C−reactive protein. Computed tomography revealed a 5−cm omental bursa abscess adjacent to the stomach ( l" Fig. 1). The decision to perform EUS−guided drainage was made to avoid further open surgery. The abscess was visualized with a curvilinear echoendoscope (GF UC 2000P, Olympus Co., Tokyo, Japan) before being punctured with a 19−gauge Echotip Ultra needle (Cook Endoscopy, Winston−Salem, North Carolina, USA) (l" Fig. 2). A 480−cm−long, 0.035−inch guide wire (Cook Endoscopy) was inserted into the abscess before the needle was removed, followed by place− ment of a 7 Fr naso−abscess Teflon cathe− ter (Cook Endoscopy). A 5−cm−long 10 Fr double pigtail Teflon stent (Cook Endos− copy) was also inserted adjacent to the naso−abscess catheter to enable irrigation (l" Fig. 3). There were no procedure− related complications. The catheter was removed after 1 week, when purulent material had ceased to drain from the catheter. The stent was removed 4 weeks later when CT showed complete abscess resolution. The patient was asymptomat− ic without any evidence of abscess recur− rence at 2 months follow−up. EUS−guided drainage of omental bursa abscess complicating appendicitis with diffuse peritonitis is safe and effective and could be an alternative therapy to surgery and percutaneous drainage.