Endoscopic ultrasound-guided drainage of a right liver abscess with a self-expandable metallic stent.

Percutaneous drainage is one of the first options for the treatmentof liver abscesses [1]. However, this method has several limitations, such as the requirement for external drainage and the risk for self-removal of the tube. On the other hand, endoscopic ultrasound (EUS)-guided drainage of liver abscesses overcomes both of these limitations. In addition, EUS-guided liver abscess drainage with a self-expandable metallic stent (SEMS) has a greater effect than percutaneous drainage, and leakage of the infected fluid is not likely to occur. To date, only a few cases of EUS-guided liver abscess drainage with a SEMS have been reported [2]. Furthermore, EUSguided drainage of an abscess in the right hepatic lobe has not previously been reported. Herein, we describe our technique for performing EUS-guided drainage of an abscess of the right hepatic lobe with a SEMS. An 81-year old woman was admitted to our hospital with fever and abdominal pain. Computed tomography revealed a liver abscess with a maximum diameter of 64mm in the right hepatic lobe parenchyma (●" Fig.1, ●" Fig.2). The patient had previously undergone metallic stent placement in the right hepatic bile duct because of unresectable cholangiocarcinoma. In addition, she had dementia; therefore, to avoid the risk for self-removal of the tube, we selected a transluminal approach with EUS. First, the echoendoscope was advanced into the duodenum, and with counterclockwise rotation the right hepatic lobe was visualized.We punctured the liver abscess with a 19-gauge fine-needle aspiration needle (Medi-Globe GmbH, Rosenheim, Germany), and the infected fluid was aspirated. Next, contrast mediumwas injected (●" Fig.3), and a 0.025-inch guidewire (VisiGlide; Olympus Medical Systems, Tokyo, Japan) was inserted. After the fistula had been dilated with a 4-mm Hurricane Balloon Dilatation Catheter (Boston Scientific, Tokyo, Japan), the stent delivery system was inserted. Finally, we successfully placed a fully covered SEMS (Bonastent, 10mm×10cm; Standard SciTech, Seoul, Korea) from the liver abscess Fig.3 The liver abscess was punctured with a 19-gauge fineneedle aspiration needle, and contrast medium was injected. Inset Endoscopic ultrasound-guided image showing a huge liver abscess. Fig.2 Coronal computed tomographic scan of the liver abscess.