Endoscopic ultrasonography (EUS)-guided cystogastrostomy with covered self-expandable metal stent (SEMS) for simple liver cyst or abscess

• Published in: Zeitschrift für Gastroenterologie
• Main Authors: Pap, A, Tarpay, A, Szmola, R, Burai, M, Pozsar, J
• Format: Conference Proceeding
• Language: English
• Published: 16.05.2013
• ISSN: 0044-2771; 1439-7803
• DOI: 10.1055/s-0033-1347501

Symptomatic, simple liver cysts can be treated by surgical deroofing or by repeated aspiration with/or without alcohol instillation but relapse of the cyst with secondary infection is frequent. Similarly, biliary abscess is a life-threatening complication with urgent need of biliary and cyst decompression. EUS guided cystogastrostomy seems to be a safe technique for complete resolution of both disorders at least in the left lobe of liver. Case 1. A 84 years old female patient with multiorgan comorbidities (diabetes mellitus, hypertony, arteriosclerosis with coronary stenosis and ventricular extrasystole) presented with a 10 cm diameter giant cyst in the left lobe of liver. Echinococcus haemagglutination proved to be negative. EUS demonstrated somewhat muddy content of the cyst with only 0,5 cm liver parenchyma at the stomach. EUS guided puncture, sampling for CEA (23.8 ug/ml), CA19 – 9 (754.6 U/ml), amylase (30 U/l), cytology (granulocytes, macrophages, lymphocytes), culture (E.coli) was performed with some bleeding from the hepatic parenchyma or cyst wall which stopped by a 10 F nasocystic drain placement and lavage with 40 mg of Gentamycin and aminocaproic acid (Acepramin). Transabdominal US demonstrated collapsed cyst on the next day and a wire assisted exchange of the nasocystic drain for covered metal stent (Leufen pseudocyst-stent, 3 cm long, 25 – 15 mm diameter) was performed through a Jumbo duodenoscope's working channel followed by 5 F nasocystic drain-replacement for 1% jodine perfusion until culture data for targeted antibiotic treatment had arrived. No fever or other sign of infection appeared although bacterial culture demonstrated further, more resistent strains in the cyst at the second endoscopy. Follow-up transabdominal USs demonstrated collapsed cyst and recovered liver parenchyma. At 6 weeks the metal stent has spontaneously left with some fibrosis indicating the place of the previous cyst. Case 2. 57 years old alcoholic and havy smoker male had a diagnosis of chronic calcifying pancratitis with duodenal stenosis, hyperplasia of papilla Vateri, bile duct dilatations with CEA and CA19 – 9 elevations and obstructive liver enzymes already 6 years ago. CT demonstrated the benign nature of the disease and duodenoscopy with histology supported it. Continued smoking and mild alcohol consumption resulted in progressive calcification and further elevations of liver enzymes with microlithiasis in the gall bladder. ERCP with papillotomy demonstrated „chain of lakes” lesion with intraductal and parenchymal calcifications and mild, curved stenosis of common bile duct at the entrance to the pancreas. Pancreatic citrate lavage and triple 10 F biliary stenting with 3 day nasobiliary lavage resulted in temporary recovery for 5 months but obstruction of stents with duodenal stenosis indicated relapse of the disease and need for surgery. Pancreatic head resection with choledocho-jejunostomy was proposed but only cholecystectomy and biliary stent replacement with one 10 F plastic stent was performed. After 16 months relapse-free period the patient presented with a 73 mm liver abscess and a patent biliary stent Urgent ERCP demonstrated severe cholangitis with resistent bacteria temporary solved with further 10 F drain and nasobiliary lavage. EUS guided cysto-gastrostomy was performed in 2 steps with a 4 cm long partially covered Wallstent (Boston Scientific) as described above. The SEMS was removed from the recovered abscess at 1 month and another SEMS (Endo-Technik Covered Biliary Stent 10 × 50 mm) replaced biliary stents 6 weeks later because prestenotic dilatation of hepatic ducts (20 mm) appeared again. Histology confirmed fibrosis with reactive dysplasia at the papillary level. In further one month the liver enzymes and CRP have almost normalized and the liver abscess and cholangitis recovered totally. Biliary SEMS planned to be removed at 4 – 6 months looking forward a second opinion about pancratic resection. Conclusion: These are the first cases of simple hepatic cyst and biliary abscess treated by EUS- guided endoscopic cystogastrostomy with SEMS in the literature. The technique described seems to be feasible even in one step with fully covered SEMS spontaneonsly migrating at the best time.