超声内镜引导下穿刺引流对肝脓肿和腹盆腔脓肿的临床价值(含视频)

Clinical Value of Endoscopic Ultrasound-Guided Drainage for Hepatic and Abdominopelvic Abscesses (with video)

摘要:

为探讨超声内镜引导下穿刺引流对常规穿刺引流困难的肝脓肿和腹盆腔脓肿的临床价值，回顾2015年1月至2023年11月于苏州大学附属第二医院该类患者资料，共12例。结果显示，12例患者中包括肝脓肿4例、腹盆腔脓肿8例。术前患者均有发热，伴不同程度的腹痛。肝脓肿患者中肝左叶脓肿2例、肝尾状叶脓肿2例，其中2例患者合并糖尿病。腹盆腔脓肿患者中腹腔脓肿3例（胃溃疡穿孔相关脓肿2例、小网膜囊脓肿1例）、盆腔脓肿4例（子宫肌瘤手术相关、阑尾炎手术相关、腹盆腔硬化瘤术后复发相关、无相关脓肿各1例）、腹盆腔巨大囊肿合并感染1例。12例患者共行超声内镜引导下穿刺13次（1例腹盆腔较大囊肿合并感染患者行经胃、经直肠共2次穿刺），穿刺针均成功刺入脓腔。4例肝脓肿患者，行超声内镜引导下抽吸+冲洗术，脓液基本完全抽吸，术后72 h内患者发热、腹痛缓解。7例腹盆腔脓肿患者，行超声内镜引导下抽吸+冲洗术，其中5例脓液基本完全抽吸，2例由于脓液黏稠，脓液抽吸量少，引流效果不佳（1例继续抗感染治疗后体温恢复正常；1例穿刺术后仍反复发热，2周后出现感染性休克、死亡）。1例腹盆腔硬化瘤术后复发患者，腹盆腔多发脓肿，腹腔脓肿行CT引导下经皮穿刺引流，术后仍反复发热，盆腔脓肿无安全常规穿刺引流路径，行超声内镜引导下球囊扩张+双猪尾支架、鼻胆管置入引流，术后48 h患者体温恢复正常、腹痛缓解，术后7 d复查CT提示脓腔基本消失后取出支架。总的脓肿引流有效率为83.3%（10/12），抽吸+冲洗脓肿引流有效率为81.8%（9/11），所有患者未见操作相关并发症发生。随访3个月，10例超声内镜引流有效者未见脓肿复发，1例超声内镜未有效引流的盆腔脓肿患者随访中脓肿自行吸收，未见脓肿复发。可见，超声内镜引导下穿刺引流对部分常规穿刺引流困难的肝脓肿和腹盆腔脓肿具有一定的临床价值，可减少该类患者再行外科手术的风险。

Abstract:

To investigate the clinical value of endoscopic ultrasound (EUS)-guided drainage for hepatic and abdominopelvic abscesses that are challenging for conventional drainage, we retrospectively analyzed data from 12 patients treated at the Second Affiliated Hospital of Soochow University from January 2015 to November 2023. The cohort included 4 cases of hepatic abscesses and 8 cases of abdominopelvic abscesses. All patients presented with preoperative fever and varying degrees of abdominal pain. Among the liver abscesses, 2 were located in the left hepatic lobe and 2 in the caudate lobe, with 2 patients complicated by diabetes. The abdominopelvic abscesses comprised 3 abdominal abscesses (2 related to gastric ulcer perforation, 1 in minor omental sac), 4 pelvic abscesses (1 related to hysteromyoma surgery, 1 related to appendicitis surgery, 1 related to postoperative recurrence of abdominopelvic sclerosing tumor, and 1 with no related disease), and 1 infected giant abdominopelvic cyst. A total of 13 EUS-guided drainage procedures were performed, including dual transgastric and transrectal punctures in the infected giant cyst case. Successful puncture into the abscess cavity was achieved in all cases. For the 4 liver abscesses, EUS-guided aspiration and irrigation resulted in near-complete evacuation, with resolution of fever and abdominal pain within 72 hours. Among 7 abdominopelvic abscess cases treated with aspiration and irrigation, 5 achieved substantial drainage while 2 showed limited efficacy due to viscous pus (1 resolved with continued antibiotics, 1 progressed to septic shock and mortality). One patient with recurrent abdominopelvic sclerosing tumor had multiple abscesses in the abdomen and pelvis, and CT-guided percutaneous drainage was performed for abdominal abscess, but the fever was still repeated, and there was no safe routine puncture drainage path for pelvic abscess. Endoscopic ultrasound guided balloon dilation plus double pig tail and nasobiliary duct drainage were performed. The patient"s temperature returned to normal and abdominal pain was relieved 48 hours after operation. Abdominal and pelvic CT examination 7 days after operation indicated that the pus cavity had mostly disappeared, and the stent was removed. The total effective rate of abscess drainage was 83.3% (10/12), and the effective rate of aspiration and irrigation was 81.8% (9/11), and no operation-related complications occurred. During the 3-month follow-up, 10 successfully drained cases showed no recurrence. One initially ineffective pelvic abscess resolved spontaneously. This study demonstrates that EUS-guided drainage serves as a valuable alternative for select liver and abdominopelvic abscesses refractory to conventional approaches, potentially reducing the risk of surgical intervention.