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Brief Report Endoscopic ultrasound-guided transrectal drainage of deep pelvic abscesses is safe and effective in children
Christopher A. Bouvette1,*orcid, Jalal Gondal1,*orcid, Rachel Davis2orcid, Alessandra Landmann3orcid, Amir Rumman4orcid

DOI: https://doi.org/10.5946/ce.2024.262
Published online: April 3, 2025

1Department of Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, USA

2Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK, USA

3Division of Pediatric Surgery, Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK, USA

4Section of Digestive Diseases & Nutrition, Department of Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, USA

Correspondence: Christopher A. Bouvette Department of Medicine, University of Oklahoma College of Medicine, 800 Stanton L. Young Blvd AAT 6300, Oklahoma City, OK 73104, USA E-mail: Christopher.a.bouvette@gmail.com
*Christopher A. Bouvette and Jalal Gondal contributed equally as co-first authors.
• Received: September 27, 2024   • Revised: November 8, 2024   • Accepted: November 17, 2024

© 2025 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Deep pelvic abscesses (DPAs) are conventionally managed with percutaneous or surgical intervention. In children, DPAs most commonly result from perforated appendicitis. The increased use of endoscopic ultrasound (EUS)-guided drainage in adults has generated interest in the application of this technique in pediatric patients.1 In the present study, we report five cases of DPA in children that were successfully managed with EUS-guided transrectal drainage (EUS-TRD) with an electrocautery-enhanced lumen-apposing metal stent (LAMS). The aim of our study was to elucidate the technical feasibility, safety, and effectiveness of using EUS-TDR with LAMS for DPA in the pediatric population.
We retrospectively reviewed a single-center case series to assess the safety and utility of transrectal drainage of DPAs in patients <18 years of age. The study methodology was approved and overseen by the University of Oklahoma Health Sciences Center Institutional Review Board (IRB00000588, 16995), and the waiver of informed consent was also approved. In this study, DPAs were defined as radiographically evident loculated fluid collections within the pelvic brim with concomitant systemic toxicity (fever, leukocytosis, and/or hypotension). In all patients, percutaneous drainage was considered infeasible owing to the proximity to pelvic structures. Single-operator transrectal drainage was performed under deep sedation with propofol following completion of a magnesium citrate enema. Transrectal endosonography was performed using a curvilinear array echoendoscope. Next, transrectal drainage was performed using an electrocautery-enhanced 10×10 mm LAMS. The LAMS remained in place until radiographic resolution of the abscess (mean duration, 30 days; range, 18–43 days), followed by endoscopic removal (Fig. 1). Our primary aim was to determine the rate of technical success. In addition, we assessed the rate of recurrence and peri- and post-procedural complications.
This study included six patients (mean age, 12 years; age range, 9–17 years). The etiology of the abscesses was as follows: perforated appendicitis in five patients and penetrating gunshot wound with bowel injury in one patient. The average abscess dimensions were determined to be 59×45 mm using computed tomography (CT). Transrectal drainage was performed successfully in five patients (technical success; 5/6 patients, 83.3%). One patient had no safe window for transrectal drainage due to an interposed small bowel and the removal of fluid was managed with surgical drainage instead. Post-procedure antibiotics were provided for a total of 10 d. All patients had complete resolution without recurrence (mean follow-up time, 164 days; range, 47–265 days). No peri- or post-procedural complications occurred (technical success, 5/6 [83.3%]; clinical success, 5/5 [100%]) (Table 1).
In adults, DPAs can occur following trauma, abdominal surgery, or more often in the setting of varied inflammatory states such as pelvic inflammatory disease, diverticulitis, and inflammatory bowel disease. In children, the most common etiology is late gangrenous or perforated appendicitis.2 Antibiotic treatment alone is an option for management; however, previous studies suggest that patients receiving image-guided drainage require surgery less frequently than those who administered antibiotics alone. In the absence of indications for urgent and/or emergent surgery, percutaneous drainage remains the primary standard of care. Alternatively, in patients with an unfavorable percutaneous approach, transrectal and transvaginal approaches augmented using CT guidance may be considered.3 Even with well-defined techniques, managing DPAs remains problematic owing to its proximity to pelvic organs, bones, and complex neurovasculature. In addition, these techniques only allow for external drainage, making their success reliant on daily catheter care, which is frequently associated with discomfort.
The use of EUS-guided drainage has expanded rapidly in adults and children for the removal of fluid from the pancreaticobiliary tract and draining of varied abdominal fluid collections. Recent studies have shown EUS-TRD with LAMS to be a safe and effective method for the treatment of pelvic fluid collections in adult patients.4-6 In addition, these studies highlight the potential of EUS-TRD in improving the lengthy and painful recovery period associated with percutaneous procedures. In previous descriptions of the transrectal approach, hypotheses of fecal contamination have been presented, although clinical outcomes suggest this occurrence to be non-threatening and well-mitigatable with perioperative antibiotics.1,5 Although transrectal drainage of pelvic collections is well described, data on pediatric populations are limited. Our study suggests this treatment option to be viable when controlled by experts. We demonstrated significant technical and clinical success without adverse events across a pediatric cohort.
Navigating DPA management continues to be a clinical challenge for both patients and physicians. This case series suggests that EUS-TRD with electrocautery-enhanced LAMS offers a technically feasible, safe, and effective approach when applied in the treatment of DPAs in children. The use of a minimally invasive technique in the pediatric population may significantly improve the recovery period, as well as circumvent an operative abdomen in select cases. Overall, EUS-TRD with LAMS offers a less invasive alternative to percutaneous or surgical drainage and may be a reasonable treatment option in cases where percutaneous drainage is infeasible. However, the findings of this study are limited by the small sample size. Future studies should expand upon prior reports of the applications of this intervention and perform further evaluations. Prospective studies having larger sample sizes are required to verify the findings reported here.
Fig. 1.
Treatment protocol (patient no. 2). Images obtained at the time of index colonoscopy. Endoscopic ultrasound images showing 90×55 mm collection in the perirectal space, where a lumen-apposing metal stent (LAMS, Hot AXIOS Stent and Electrocautery-Enhanced Delivery System, Boston Scientific) was delivered using the freehand technique. This resulted in ample return of thick pus. (A–D) Images obtained at the time of follow-up colonoscopy. LAMS was well seated at the time of inspection and subsequently dilated with at 10 mm×4 cm balloon dilation catheter. (E) Trace pus was aspirated from the orifice. (F) The cavity was then intubated, revealing smooth mature walls without remnant necrosis (G).
ce-2024-262f1.jpg
Table 1.
Patient demographics & clinical characteristics
Case Indication Size (mm) Prior intervention LAMS saddle length × diameter (mm) Duration (day) Platelet count (10³/μL)/INR
1 Perforated appendicitis 55×40 Diagnostic laparotomy with 19 Fr drain 10×10 43 290/2.0
2 Perforated appendicitis 90×55 -  10×10 18 471/1.4
3 Gunshot wound 60×27 Diagnostic laparotomy, colocolonic anastomosis 10×10 42 391/1.7
4 Perforated appendicitis 40×34 - 10×10 33 335/1.3
5 Perforated appendicitis 50×45 - 10×10 15 332/1.4
6 Perforated appendicitis 60×66 - - - 220/1.5

LAMS, lumen-apposing metal stent; INR, international normalized ratio; -, no prior intervention(s).

  • 1. Lisotti A, Cominardi A, Bacchilega I, et al. EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series. VideoGIE 2020;5:380–385.ArticlePubMedPMC
  • 2. Miyauchi H, Okata Y, Hatakeyama T, et al. Analysis of predictive factors for perforated appendicitis in children. Pediatr Int 2020;62:711–715.ArticlePubMedPDF
  • 3. De Filippo M, Puglisi S, D'Amuri F, et al. CT-guided percutaneous drainage of abdominopelvic collections: a pictorial essay. Radiol Med 2021;126:1561–1570.ArticlePubMedPMCPDF
  • 4. Dhindsa BS, Naga Y, Saghir SM, et al. EUS-guided pelvic drainage: A systematic review and meta-analysis. Endosc Ultrasound 2021;10:185–190.ArticlePubMedPMC
  • 5. Liu S, Tian Z, Jiang Y, et al. Endoscopic ultrasound-guided drainage to abdominal abscess: a systematic review and meta-analysis. J Minim Access Surg 2022;18:489–496.ArticlePubMedPMC
  • 6. Fernández-Urién I, Elosua A, Bernad B, et al. EUS-guided drainage of a pelvic abscess. VideoGIE 2019;4:274–275.ArticlePubMedPMC

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      Endoscopic ultrasound-guided transrectal drainage of deep pelvic abscesses is safe and effective in children
      Image
      Fig. 1. Treatment protocol (patient no. 2). Images obtained at the time of index colonoscopy. Endoscopic ultrasound images showing 90×55 mm collection in the perirectal space, where a lumen-apposing metal stent (LAMS, Hot AXIOS Stent and Electrocautery-Enhanced Delivery System, Boston Scientific) was delivered using the freehand technique. This resulted in ample return of thick pus. (A–D) Images obtained at the time of follow-up colonoscopy. LAMS was well seated at the time of inspection and subsequently dilated with at 10 mm×4 cm balloon dilation catheter. (E) Trace pus was aspirated from the orifice. (F) The cavity was then intubated, revealing smooth mature walls without remnant necrosis (G).

      Fig. 1.

      Endoscopic ultrasound-guided transrectal drainage of deep pelvic abscesses is safe and effective in children
      Case Indication Size (mm) Prior intervention LAMS saddle length × diameter (mm) Duration (day) Platelet count (10³/μL)/INR
      1 Perforated appendicitis 55×40 Diagnostic laparotomy with 19 Fr drain 10×10 43 290/2.0
      2 Perforated appendicitis 90×55 -  10×10 18 471/1.4
      3 Gunshot wound 60×27 Diagnostic laparotomy, colocolonic anastomosis 10×10 42 391/1.7
      4 Perforated appendicitis 40×34 - 10×10 33 335/1.3
      5 Perforated appendicitis 50×45 - 10×10 15 332/1.4
      6 Perforated appendicitis 60×66 - - - 220/1.5
      Table 1. Patient demographics & clinical characteristics

      LAMS, lumen-apposing metal stent; INR, international normalized ratio; -, no prior intervention(s).

      Table 1.

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