Endoscopic trans-gastric drainage of a peri-splenic abscess after laparoscopic appendectomy for perforated appendicitis: a case report

Postoperative abscesses after perforated appendicitis occur in 10–30 % of pediatric patients, but not all are amenable to percutaneous drainage. A 4-year-old female presented with abdominal pain and vomiting and was diagnosed with perforated appendicitis with an associated pelvic abscess. She underwent laparoscopic appendectomy, during which a perforated appendix and diffuse peritoneal contamination were noted. Two 15-French Blake drains were placed intraoperatively. She was admitted to the pediatric intensive care unit (PICU) for close monitoring and received intravenous piperacillin-tazobactam. Drains were removed on postoperative day (POD) 6, and she was discharged on POD 10 with a peripherally inserted central catheter (PICC) for continued outpatient piperacillin-tazobactam infusions. Three days later, she returned with fever, loose stools, recurrent abdominal pain, and a white blood cell count of 45.9 bil/L. Computed tomography (CT) revealed a 4.3-cm peri-splenic abscess. Antibiotics were escalated to meropenem, vancomycin, and metronidazole. As no safe percutaneous access route was available, endoscopic ultrasound (EUS)-guided drainage was performed. Two 7-French, 5-cm double-pigtail plastic stents were placed into the collection. Abscess cultures from the EUS-guided trans-gastric drainage were almost fully suppressed with a few Streptococcus anginosus present. She recovered well, was discharged on post-procedure day 4, and completed 21 days of intravenous meropenem. Follow-up CT on post-procedure day 23 confirmed resolution. Stents were removed as an outpatient procedure 123 days after placement. Trans-gastric endoscopic ultrasound-guided drain placement seems to be an effective approach for upper abdominal abscesses that are not amenable to percutaneous drain placement.