LAUSR

Percutaneous transhepatic drainage (PTD) is the gold standard treatment for pyogenic liver abscess [1], but PTD can be challenging where a pyogenic liver abscess is located at a site that is difficult to access via the percutaneous approach and in patients with severe dementia, in whom self-removal of the tube is a risk. An endoscopic ultrasound (EUS)-guided procedure offers internal drainage via a transluminal approach and may be an alternative option in such cases. Several studies have reported the clinical benefits of EUS-guided access for pyogenic liver abscesses [2–4]; however, this technique requires tract dilation prior to metal stent deployment. In patients with a pyogenic liver abscess, severe inflammation can cause the cystic wall to become thickened and hardened and this can make tract dilation challenging. A novel drill dilator has recently become available in Japan (Tornus ES; Asahi Intecc) (▶Fig. 1) [5]. This allows a tract to be easily dilated using a clockwise rotation of the device handle, without force needing to be applied. We herein describe EUS-guided transgastric pyogenic liver abscess drainage using a drill dilator. An 89-year-old man was admitted to our hospital for treatment of a pyogenic liver abscess (▶Fig. 2). The percutaneous approach was difficult because the abscess was located at segment 4 and the caudate lobe, with intervening vessels, and EUS-guided access was therefore selected. The abscess was punctured from the stomach using a 19G needle and contrast medium was injected. Balloon catheter insertion was attempted after deployment of a 0.025-inch guidewire (▶Fig. 3 a); however, the procedure failed because the wall of the abscess was extremely hard. We then attempted drill dilator insertion and easily achieved successful tract dilation (▶Fig. 3 b). Finally, a partially covered self-expandable metal stent was deployed from the pyogenic liver abscess to the stomach, with no adverse events (▶Fig. 3 c; ▶Video 1). In conclusion, a drill dilator appears to be useful for pyogenic liver abscess drainage, as well as for bile duct dilation.