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Endoscopic management of hepatic abscess after EUS-guided hepaticogastrostomy

      A 55-year-old woman with metastatic pancreatic adenocarcinoma and biliary obstruction underwent unsuccessful ERCP. EUS-guided biliary drainage was performed, with placement of hepaticogastrostomy stents. After the procedure, the patient’s liver chemistry profile improved. Interval CT demonstrated a left hepatic lobe abscess extending along the lesser curvature of the stomach adjacent to the hepaticogastrostomy. The patient declined percutaneous drainage, and EUS-guided hepatic abscess drainage was performed (Video 1, available online at www.giejournal.org). A 15-mm lumen-apposing metal stent (LAMS) with electrocautery-enhanced delivery system was deployed with the distal flange in the cavity and the proximal flange in the stomach. Pus drained after deployment of the stent. The lumen of the stent was dilated to 15 mm, and plastic stents were placed through the LAMS for anchoring. Follow-up CT scan 2 weeks later demonstrated interval resolution of the abscess (Fig. 1). The abscess drainage stents were removed endoscopically. Inspection of the cavity showed granulation tissue. The fistulous tract was closed with a hemostatic clip to prevent the entry of gastric contents into the cavity. The hepaticogastrostomy stents were left in place. The patient was seen at a follow-up visit 1 month later and had no evidence of recurrence. This case highlights the endoscopic management of an abscess after EUS-guided hepaticogastrostomy. EUS-guided biliary drainage procedures are being performed with increasing frequency, and understanding the management of the adverse events is paramount.
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      Figure 1CT scan axial (A) and coronal (B) images of left hepatic lobe abscess (yellow circle) after EUS-guided hepaticogastrostomy. CT scan axial (C) and coronal (D) images with resolution of abscess after EUS-guided placement of drainage stents (yellow arrow).
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