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| LETTER TO EDITOR |
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| Year : 2017 | Volume
: 6
| Issue : 6 | Page : 418-419 |
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Large liver abscess after endoscopic ultrasound-guided fiducial placement
Galab M Hassan, Sarto C Paquin, Anand V Sahai
Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| Date of Submission | 22-Mar-2016 |
| Date of Acceptance | 09-Feb-2017 |
| Date of Web Publication | 15-Dec-2017 |
Correspondence Address:
Dr. Galab M Hassan
Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Hopital Saint-Luc, Porte 8400, 1058 St Denis, Montreal, Qc H2X 3J4
Canada
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/eus.eus_17_17
How to cite this article:
Hassan GM, Paquin SC, Sahai AV. Large liver abscess after endoscopic ultrasound-guided fiducial placement. Endosc Ultrasound 2017;6:418-9 |
Dear Editor,
Endoscopic ultrasound-guided fiducial placement (EUS-FP), performed to facilitate stereotactic body radiation therapy, is feasible and safe.[1],[2] Antibioprophylaxis is not recommended currently by existing guidelines.[3] We report the first case of a large liver abscess and sepsis after EUS-FP.
A 67-year-old female with colon cancer and a single, metastatic, 3 cm left lobar liver lesion was referred for EUS-FP. A single fiducial was back-loaded into the 19-gauge needle (Cook, EchoTip ®); the tip was then sealed with sterile bone wax [Figure 1] and [Figure 2]. After placement of the first fiducial, the needle was then withdrawn from the scope to back-load the next fiducial. Three fiducials were placed in total using this method. No prophylactic antibiotics were administered. | Figure 1: Under sterile conditions, the fiducial is back-loaded into the needle tip
Click here to view |
Six weeks postprocedure, the patient was admitted to the intensive care unit with abdominal pain and septic shock. Computed tomography scan revealed a 10 cm intrahepatic/perigastric abscess in the region where the fiducials had been placed. All resolved with antibiotics and percutaneous drainage. Our institution has performed 43 EUS-FP to date, with only one reported infectious complication (Case #38). We now administer antibioprophylaxis to all patients undergoing EUS-FP.
The role of prophylactic antibiotics for EUS-FP was unclear.[3] To the best of our knowledge, only two infectious complications have been reported previously; one cholangitis after EUS-FP of porta hepatis nodes and [4] one cholangitis after EUS-FP for pancreatic head cancer.[3] In both cases, it was uncertain if the infection was related to the procedure or to malignant biliary obstruction. Recent studies with EUS-FP did not systematically administer antibioprophylaxis.[4],[5]
In conclusion, postprocedural liver abscess is a possible complication of EUS-FP. Excessive manipulation of the needle, related to the “semi-sterile” back-loading technique, is probably responsible for our reported complication. Therefore, we believe that antibioprophylaxis pre- and post-EUS-FP in these conditions is a reasonable recommendation, and guidelines for prophylaxis should be amended appropriately. EUS-FP infectious risk could likely also be reduced using a needle that allows placement of multiple fiducials, without manual back-loading.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Varadarajulu S, Trevino JM, Shen S, et al. The use of endoscopic ultrasound-guided gold markers in image-guided radiation therapy of pancreatic cancers: A case series. Endoscopy 2010;42:423-5.  [ PUBMED] |
| 2. | Pishvaian AC, Collins B, Gagnon G, et al. EUS-guided fiducial placement for CyberKnife radiotherapy of mediastinal and abdominal malignancies. Gastrointest Endosc 2006;64:412-7. [ PUBMED] |
| 3. | Varadarajulu S. Antibiotic prophylaxis is recommended for endoscopic ultrasound-guided fiducial placements. J Clin Gastroenterol 2011;45:179. [ PUBMED] |
| 4. | Machiels M, van Hooft J, Jin P, et al. Endoscopy/EUS-guided fiducial marker placement in patients with esophageal cancer: A comparative analysis of 3 types of markers. Gastrointest Endosc 2015;82:641-9. [ PUBMED] |
| 5. | Chandran S, Vaughan R, Efthymiou M, et al. A pilot study of EUS-guided fiducial insertion for the multidisciplinary management of gastric cancer. Endosc Int Open 2014;2:E153-9. [ PUBMED] |
[Figure 1], [Figure 2]
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