Safety and efficacy of EUS-guided pelvic abscess drainage with lumen-apposing metal stents for complicated acute diverticulitis

Background and Aims: EUS-guided pelvic abscess drainage (EUS-PAD) with a lumen-apposing metal stent (LAMS) is an alternative approach for postsurgical and inflammatory pelvic collections. This study assessed the safety and efficacy of EUS-PAD with an LAMS in a large population of complicated acute diverticulitis (AD). Methods: Data were retrieved on consecutive patients who underwent EUS drainage attempts for complicated AD from 2019 to 2023 in 3 referral centers. All cases have been considered suitable for EUS-PAD after multidisciplinary discussion. Continuous variables are expressed as median (IQR). Results: Data on 66 patients were retrieved; in 13 cases, EUS-PAD was not indicated because no or small abscess was found. Fifty-three patients (29 female subjects; age, 74 [62-83] years) were finally included. Forty (75.5%) patients had a pelvic abscess, and 13 (24.5%) had a para-colonic abscess, with a median size of 50 (40-60) mm. Transrectal and transcolonic EUS-PAD procedures were performed in 34 (64.2%) and 19 (35.8%) cases, respectively. Technical and clinical success rates were 92.5% and 88.7%; incidence of adverse events was 3.8% (1 bleeding, 1 late migration). LAMSs were removed after 19 (14-28) days. Median follow-up was 12 (8-12) months. Four (7.5%) patients underwent an urgent Hartmann sigmoidectomy, and 12 (22.6%) patients required elective surgery; 2 (3.8%) patients presented with recurrent diverticular abscesses. No procedure-related or disease-specific mortality was observed. Conclusions: EUS-PAD could be considered a safe and effective rescue strategy in case of a failed or contraindicated percutaneous approach for the management of complicated AD to reduce the need for urgent surgery. Comparative data are necessary to confirm these observations.