- Email: [email protected]
EUS-guided drainage of pelvic abscess (with video)
NEW METHODS: Clinical Endoscopy
EUS-guided drainage of pelvic abscess (with video) Shyam Varadarajulu, MD, Ernesto R. Drelichman, MD Birmingham, Alabama, USA
Background: Although pelvic abscesses have traditionally been drained by surgery or under radiologic guidance, a small subset of patients who are not candidates for these interventions require an alternate mode of drainage. Objective: Evaluate the efficacy of EUS for drainage of pelvic abscesses that could not be drained under US or CT guidance. Design: Prospective case series. Setting: Tertiary referral center. Patients: Four patients underwent EUS-guided drainage of pelvic abscesses that were not amenable for drainage by US and/or CT guidance. Interventions: A 10F drainage catheter was deployed in the abscess cavity under EUS guidance in all patients. The catheters were flushed periodically until resolution of the abscess was confirmed by CT imaging. Main Outcome Measurements: Resolution of a pelvic abscess on follow-up CT and improvement in clinical symptoms. Results: A drainage catheter was successfully placed in all 4 patients. The mean size of the abscess was 68 72 mm. There were no procedure-related complications. One patient died of worsening congestive heart failure 48 hours after the procedure. The abscesses resolved in the remaining 3 patients within a mean duration of 6 days, with complete symptom relief. Limitations: A small number of patients and short duration of follow-up. Conclusions: EUS-guided placement of drainage catheter is a minimally invasive technique for draining pelvic abscesses that are within the reach of the echoendoscope.
The development of a pelvic abscess is a well-recognized postoperative complication in patients undergoing low anterior resection for rectal cancer and after obstetrical surgery or colonic perforation.1 Rupture of a pelvic abscess is a life-threatening emergency, and every attempt should be made to avoid this complication. Traditionally, these abscesses are drained via the percutaneous, transrectal, or transvaginal route under US or CT guidance, with successful outcomes.1-4 The transvaginal route, although semisterile, is ideally suited to drain pelvic abscesses because of the proximity of the vaginal fornices to the pelvic-fluid collections. In a recent study, the
feasibility of US-guided transrectal aspiration of pelvic abscesses was assessed in 15 women in whom intravenous antibiotic therapy had failed and whose abscesses were not suitable for colpotomy drainage or transabdominal or transvaginal US-guided aspiration.4 Purulent material was aspirated from the abscesses in 14 of the 15 women. These 14 women were successfully treated with real-time US-guided transrectal drainage. The report generated interest that led to the evolution of EUS-guided drainage of pelvic abscesses.5 In this report, a new technique is described for draining pelvic abscesses under EUS guidance.
PATIENTS AND METHODS Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.02.054
This is a prospective study of all patients who underwent EUS-guided drainage of pelvic abscesses over a
372 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 2 : 2007
www.giejournal.org
Varadarajulu & Drelichman
EUS-guided drainage of pelvic abscess
Capsule Summary What is already known on this topic d
Pelvic abscesses traditionally are drained via the percutaneous, transrectal, or transvaginal route under US or CT guidance, with successful outcomes.
What this study adds to our knowledge d
Figure 1. CT of the pelvis, revealing an 8 6-cm abscess cavity (straight line).
Four patients underwent successful, uncomplicated EUS-guided drainage of pelvic abscesses that were not amenable to drainage by US or CT guidance.
12 hours before the procedure. Patients were instructed to void urine immediately before the procedure, because a distended bladder may impair visualization of the pelvic abscess during EUS. All patients were administered amoxicillin plus clavulanic acid, 2 g, before the intervention and were continued on oral antibiotics for 5 days. Conscious sedation was administered by using a combination of intravenous midazolam, meperidine, and diazepam. Procedural and informed consents were obtained from all patients before EUS, and the study was approved by the institutional review board of our hospital.
Procedural technique
6-month period from November 2005 to May 2006. Patients met criteria for inclusion in the study if an adequate window could not be found to drain the abscess via the percutaneous, transvaginal, or transabdominal routes by using US and/or CT guidance. Patients with coagulation disorders, a rectocele, or multiloculated pelvic abscess on CT were excluded from the study. All patients were referred for EUS by GI surgeons or interventional radiologists. To obtain a clear understanding of the pelvic anatomy and the location of the abscess, a dedicated pelvic CT (Fig. 1) was performed before EUS in all patients. All procedures were performed in a EUS unit with fluoroscopic capability to enable visualization of wire exchanges and drain placement within the abscess. The distal colon and rectum were prepared by administration of a tap water and phosphate enema. In addition, in patients with an intact colon, polyethylene glycol was administered orally
EUS-guided drainage of a pelvic abscess comprised the following steps (Video 1, available online at www.giejournal. org): 1. The pelvic abscess was first located (Fig. 2) by using a curved linear-array echoendoscope (GF-UCT 140; Olympus America Corp, Melville, NY), with a working channel of 3.7 mm. 2. After ensuring the absence of intervening vasculature by using Doppler studies, under EUS guidance, a 19-gauge needle (EchoTip; Cook Endoscopy, Winston-Salem, NC) was used to puncture the abscess cavity to gain access to the fluid collection (Fig. 2). After removal of the stylet, normal saline solution was flushed into the abscess by using a 10-mL syringe and reaspirated to clean out the cavity of as much pus as possible. 3. A sample of the aspirate was sent for Gram staining and culture. 4. A 0.035-inch guidewire was then passed via the 19gauge needle and coiled into the abscess cavity. 5. A 5F ERCP cannula was passed over the guidewire to dilate the tract between the rectum and the abscess cavity. This was then further dilated by passing a 10F ERCP inner guiding catheter over the guidewire. The tract was further dilated by using an 8-mm over-thewire biliary balloon followed by dilation by using large diameter (10-14 mm) through-the-scope balloons (Fig. 3A and B, Fig. 4). 6. A 10F, 80-cm, single-pigtail drain (Flexima; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) was
www.giejournal.org
Volume 66, No. 2 : 2007 GASTROINTESTINAL ENDOSCOPY 373
Figure 2. Endoscopic view of passage of a 19-gauge needle, under EUS guidance, into the pelvic abscess to facilitate drainage.
EUS-guided drainage of pelvic abscess
Varadarajulu & Drelichman
Figure 4. Drainage of pus into the rectum after dilation.
Figure 3. A and B, The tract is dilated by using an 8-mm over-the-wire biliary balloon followed by dilation with large diameter (10-14 mm) through-the-scope balloons.
then deployed over the guidewire into the abscess to facilitate drainage of pus (Fig. 5). The drain was flushed with 50 mL of normal saline solution every 8 hours until the aspirate was clear. The drain was secured to the patient’s gluteal region with tape. 7. The drain was discontinued after verification of abscess resolution on a follow-up CT (Fig. 6).
of the abscess was perirectal in 3 patients and pericolonic (sigmoid) in 1 patient (25 cm above the dentate line). None of the abscesses caused luminal compression that could be visualized at endoscopy. The mean size of the abscess in the 4 patients was 68 72 mm. The procedure was technically successful in all patients. Characteristics of the abscess and outcomes of individual patients are shown in Table 1. Three patients who had fever became afebrile within 24 hours after drainage. The fluid aspirate was sterile in 3 patients and contained Escherichia coli in 1 patient. No procedure-related complications were encountered in any patient. One patient who underwent treatment for congestive heart failure died from cardiac decompensation 48 hours after the procedure. The other 3 patients experienced immediate symptom relief after abscess drainage. At follow-up CT, which was performed when the aspirate was clear, complete resolution of the abscess was noted in all 3 patients. The mean duration for abscess resolution was 6 days (range 4-8 days). All cases were managed as inpatients. The mobility of patients was not restricted in any manner because of placement of transrectal drainage catheters. A follow-up CT obtained in all patients at 3-month follow-up revealed no pelvic abscess recurrence.
RESULTS
DISCUSSION
Of the 6 patients referred for EUS-guided drainage of pelvic abscess, 2 were excluded: 1 patient had a large rectocele and another had a multiloculated fluid collection with immature walls. The remaining 4 patients (3 men; mean age, 54 years [range 48-56 years]) underwent EUSguided drainage of a pelvic abscess. In 3 patients, the abscess developed after low anterior resection for rectal cancer, and, in 1 patient, the abscess developed as a complication after resection for sigmoid diverticulitis. Location
This study demonstrated that EUS-guided drainage of pelvic abscess is technically feasible, with a good outcome in carefully selected patients. The technique permits the endoscopist to precisely locate the area of contact between the abscess and the digestive tract. This is important, particularly when the abscess does not cause any luminal compression. Although a high success rate has been reported for US- or CT-guided drainage of pelvic abscess,1,2 a small proportion of patients are not candidates
374 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 2 : 2007
www.giejournal.org
Varadarajulu & Drelichman
EUS-guided drainage of pelvic abscess
Figure 5. Fluoroscopic image, showing a drainage catheter in the pelvic abscess cavity.
Figure 6. Repeat CT of the pelvis at 1 week, showing marked reduction in size of the abscess cavity.
TABLE 1. Clinical features and outcomes of individual patients who underwent EUS-guided drainage of pelvic abscess
No.
Abscess location
Etiology
1
Perirectal
LAR
70 68
None
Resolution at day 4
2
Perirectal
LAR
62 82
None
Resolution at day 6
3
Perirectal
LAR
71 66
None
Resolution at day 8
68 72
None
Death at day 2y
4
Pericolonic* Diverticulitis
Abscess size (mm) Complications
Outcome
LAR, Low anterior resection for rectal cancer. *Location was perisigmoid, 25 cm above the dentate line. yFrom worsening heart failure.
for such procedures because of a lack of an adequate window for drainage. In a study of 12 patients with deep pelvic abscesses in whom EUS-guided transrectal stent (8.5F/10F) placement was attempted, Giovanninni et al5 reported a technical success rate of 75%, with resolution of the abscess in 8 of 12 patients. Stent placement failed in 3 patients, because the abscess was located O20 mm from the tip of the transducer. The mean duration of stent placement was 4.3 months (range 3-6 months). With the exception of 2 patients (largest abscess measured 85 83 mm), others had a pelvic abscess that was smaller than 60 mm. The outcome was unsuccessful in the patient with largest abscess, and he eventually required surgical drainage. In another report, EUS guidance was used to gain access to a diverticular abscess for placement of transmural stents as a bridge to surgery. The patient, however, had a submucosal bulge that was evident at endoscopy.6
Although not reported, transrectal stents can potentially clog easily, particularly with fecal matter or pus, and when left long term can cause perirectal pain or can migrate spontaneously. The current technique reported by us enables continued access to the abscess cavity for flushing and drainage of the infected fluid collection. This is particularly important when the abscess cavity is filled with thick fluid. Also, the chance of infecting a sterile abscess is remote with transrectal drain placement than with stent placement.7 As shown in the present series, unlike a stent, the drain can be removed in a shorter period of time, because continued therapy will potentially resolve the abscess faster. It is unambiguously stated in the radiology literature that percutaneous catheters are better suited for drainage of deep-seated abscesses.8 In this series, we adopted to ‘‘burrow’’ rather than ‘‘puncture’’ with a needle knife to establish a tract between the abscess and the rectum. Perforation has been reported as
www.giejournal.org
Volume 66, No. 2 : 2007 GASTROINTESTINAL ENDOSCOPY 375
EUS-guided drainage of pelvic abscess
a complication during EUS-guided drainage of pancreatic pseudocysts by using the needle-knife technique.8,9 It can sometimes be challenging to control the direction of the cut when using needle-knife catheters, leading to inadvertent perforation. Although this could be minimized by using an over-the-wire needle knife, the needle, when deployed, often points in a tangential angle because of its thin caliber, leading to an undesirable incision. We routinely dilate the wall of the pancreatic pseudocyst, after gaining access with a 19-gauge needle and passing a 0.035-inch guidewire, by using a 4.5F to 5F ERCP catheter and then by using a 10F ERCP inner guiding catheter. This facilitates subsequent passage of 6- to 8-mm biliary balloon dilators and through-the-scope balloons for further dilation of the pseudocyst wall. We have experienced no complications with this technique while managing patients with pancreatic pseudocysts. This is particularly relevant in the management of pelvic abscesses where the rectum, unlike the stomach, is immobile and permits easier access to the abscess cavity. In summary, a pelvic abscess is a serious postsurgical complication that hitherto was drained only by surgery or under radiologic guidance. When pelvic abscesses are within the reach of the echoendoscope, drainage catheters can be safely placed under EUS guidance with successful outcomes. Comparative studies with a larger number of patients will help to identify cases that benefit the most from this technique.
Varadarajulu & Drelichman
REFERENCES 1. Hovsepian DM. Transrectal and transvaginal abscess drainage. J Vasc Interv Radiol 1997;4:501-15. 2. Brusciano L, Maffettone V, Napolitano V, et al. Management of colorectal emergencies: percutaneous abscess drainage. Ann Ital Chir 2004;75: 593-7. 3. Benigno BB. Medical and surgical management of pelvic abscess. Clin Obstet Gynecol 1981;24:1187-97. 4. Nelson AL, Sinow RM, Oliak D. Transrectal ultrasonographically guided drainage of gynecologic pelvic abscesses. Am J Obstet Gynecol 2000;6: 1382-8. 5. Giovanninni M, Bories E, Moutardier V, et al. Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy 2003;35: 511-4. 6. Attwell AR, McIntyre RC, Antillon MR, et al. EUS-guided drainage of a diverticular abscess as an adjunct to surgical therapy. Gastrointest Endosc 2003;58:612-6. 7. Maher MM, Gervais DA, Kalra MK, et al. The inaccessible or undrainable abscess: how to drain it. Radiographics 2004;24:717-35. 8. Azar RR, Oh YS, Janec EM, et al. Wire-guided pancreatic pseudocyst drainage by using a modified needle knife and therapeutic echoendoscope. Gastrointest Endosc 2006;63:688-92. 9. Kahaleh M, Shami VM, Conaway MR, et al. Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage. Endoscopy 2006;38:355-9.
Received August 23, 2006. Accepted February 27, 2007.
DISCLOSURE
Current affiliations: Division of Gastroenterology-Hepatology (S.V.), Division of Gastrointestinal Surgery (E.R.D.), University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA.
The authors do not have any relevant disclosures to make.
Reprint requests: Shyam Varadarajulu, MD, Division of GastroenterologyHepatology, University of Alabama at Birmingham Medical Center, 410 LHRB, 1530 3rd Ave S, Birmingham, AL 35294.
376 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 2 : 2007
www.giejournal.org
EUS-guided drainage of pelvic abscess (with video) Shyam Varadarajulu, MD, Ernesto R. Drelichman, MD Birmingham, Alabama, USA
Background: Although pelvic abscesses have traditionally been drained by surgery or under radiologic guidance, a small subset of patients who are not candidates for these interventions require an alternate mode of drainage. Objective: Evaluate the efficacy of EUS for drainage of pelvic abscesses that could not be drained under US or CT guidance. Design: Prospective case series. Setting: Tertiary referral center. Patients: Four patients underwent EUS-guided drainage of pelvic abscesses that were not amenable for drainage by US and/or CT guidance. Interventions: A 10F drainage catheter was deployed in the abscess cavity under EUS guidance in all patients. The catheters were flushed periodically until resolution of the abscess was confirmed by CT imaging. Main Outcome Measurements: Resolution of a pelvic abscess on follow-up CT and improvement in clinical symptoms. Results: A drainage catheter was successfully placed in all 4 patients. The mean size of the abscess was 68 72 mm. There were no procedure-related complications. One patient died of worsening congestive heart failure 48 hours after the procedure. The abscesses resolved in the remaining 3 patients within a mean duration of 6 days, with complete symptom relief. Limitations: A small number of patients and short duration of follow-up. Conclusions: EUS-guided placement of drainage catheter is a minimally invasive technique for draining pelvic abscesses that are within the reach of the echoendoscope.
The development of a pelvic abscess is a well-recognized postoperative complication in patients undergoing low anterior resection for rectal cancer and after obstetrical surgery or colonic perforation.1 Rupture of a pelvic abscess is a life-threatening emergency, and every attempt should be made to avoid this complication. Traditionally, these abscesses are drained via the percutaneous, transrectal, or transvaginal route under US or CT guidance, with successful outcomes.1-4 The transvaginal route, although semisterile, is ideally suited to drain pelvic abscesses because of the proximity of the vaginal fornices to the pelvic-fluid collections. In a recent study, the
feasibility of US-guided transrectal aspiration of pelvic abscesses was assessed in 15 women in whom intravenous antibiotic therapy had failed and whose abscesses were not suitable for colpotomy drainage or transabdominal or transvaginal US-guided aspiration.4 Purulent material was aspirated from the abscesses in 14 of the 15 women. These 14 women were successfully treated with real-time US-guided transrectal drainage. The report generated interest that led to the evolution of EUS-guided drainage of pelvic abscesses.5 In this report, a new technique is described for draining pelvic abscesses under EUS guidance.
PATIENTS AND METHODS Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.02.054
This is a prospective study of all patients who underwent EUS-guided drainage of pelvic abscesses over a
372 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 2 : 2007
www.giejournal.org
Varadarajulu & Drelichman
EUS-guided drainage of pelvic abscess
Capsule Summary What is already known on this topic d
Pelvic abscesses traditionally are drained via the percutaneous, transrectal, or transvaginal route under US or CT guidance, with successful outcomes.
What this study adds to our knowledge d
Figure 1. CT of the pelvis, revealing an 8 6-cm abscess cavity (straight line).
Four patients underwent successful, uncomplicated EUS-guided drainage of pelvic abscesses that were not amenable to drainage by US or CT guidance.
12 hours before the procedure. Patients were instructed to void urine immediately before the procedure, because a distended bladder may impair visualization of the pelvic abscess during EUS. All patients were administered amoxicillin plus clavulanic acid, 2 g, before the intervention and were continued on oral antibiotics for 5 days. Conscious sedation was administered by using a combination of intravenous midazolam, meperidine, and diazepam. Procedural and informed consents were obtained from all patients before EUS, and the study was approved by the institutional review board of our hospital.
Procedural technique
6-month period from November 2005 to May 2006. Patients met criteria for inclusion in the study if an adequate window could not be found to drain the abscess via the percutaneous, transvaginal, or transabdominal routes by using US and/or CT guidance. Patients with coagulation disorders, a rectocele, or multiloculated pelvic abscess on CT were excluded from the study. All patients were referred for EUS by GI surgeons or interventional radiologists. To obtain a clear understanding of the pelvic anatomy and the location of the abscess, a dedicated pelvic CT (Fig. 1) was performed before EUS in all patients. All procedures were performed in a EUS unit with fluoroscopic capability to enable visualization of wire exchanges and drain placement within the abscess. The distal colon and rectum were prepared by administration of a tap water and phosphate enema. In addition, in patients with an intact colon, polyethylene glycol was administered orally
EUS-guided drainage of a pelvic abscess comprised the following steps (Video 1, available online at www.giejournal. org): 1. The pelvic abscess was first located (Fig. 2) by using a curved linear-array echoendoscope (GF-UCT 140; Olympus America Corp, Melville, NY), with a working channel of 3.7 mm. 2. After ensuring the absence of intervening vasculature by using Doppler studies, under EUS guidance, a 19-gauge needle (EchoTip; Cook Endoscopy, Winston-Salem, NC) was used to puncture the abscess cavity to gain access to the fluid collection (Fig. 2). After removal of the stylet, normal saline solution was flushed into the abscess by using a 10-mL syringe and reaspirated to clean out the cavity of as much pus as possible. 3. A sample of the aspirate was sent for Gram staining and culture. 4. A 0.035-inch guidewire was then passed via the 19gauge needle and coiled into the abscess cavity. 5. A 5F ERCP cannula was passed over the guidewire to dilate the tract between the rectum and the abscess cavity. This was then further dilated by passing a 10F ERCP inner guiding catheter over the guidewire. The tract was further dilated by using an 8-mm over-thewire biliary balloon followed by dilation by using large diameter (10-14 mm) through-the-scope balloons (Fig. 3A and B, Fig. 4). 6. A 10F, 80-cm, single-pigtail drain (Flexima; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) was
www.giejournal.org
Volume 66, No. 2 : 2007 GASTROINTESTINAL ENDOSCOPY 373
Figure 2. Endoscopic view of passage of a 19-gauge needle, under EUS guidance, into the pelvic abscess to facilitate drainage.
EUS-guided drainage of pelvic abscess
Varadarajulu & Drelichman
Figure 4. Drainage of pus into the rectum after dilation.
Figure 3. A and B, The tract is dilated by using an 8-mm over-the-wire biliary balloon followed by dilation with large diameter (10-14 mm) through-the-scope balloons.
then deployed over the guidewire into the abscess to facilitate drainage of pus (Fig. 5). The drain was flushed with 50 mL of normal saline solution every 8 hours until the aspirate was clear. The drain was secured to the patient’s gluteal region with tape. 7. The drain was discontinued after verification of abscess resolution on a follow-up CT (Fig. 6).
of the abscess was perirectal in 3 patients and pericolonic (sigmoid) in 1 patient (25 cm above the dentate line). None of the abscesses caused luminal compression that could be visualized at endoscopy. The mean size of the abscess in the 4 patients was 68 72 mm. The procedure was technically successful in all patients. Characteristics of the abscess and outcomes of individual patients are shown in Table 1. Three patients who had fever became afebrile within 24 hours after drainage. The fluid aspirate was sterile in 3 patients and contained Escherichia coli in 1 patient. No procedure-related complications were encountered in any patient. One patient who underwent treatment for congestive heart failure died from cardiac decompensation 48 hours after the procedure. The other 3 patients experienced immediate symptom relief after abscess drainage. At follow-up CT, which was performed when the aspirate was clear, complete resolution of the abscess was noted in all 3 patients. The mean duration for abscess resolution was 6 days (range 4-8 days). All cases were managed as inpatients. The mobility of patients was not restricted in any manner because of placement of transrectal drainage catheters. A follow-up CT obtained in all patients at 3-month follow-up revealed no pelvic abscess recurrence.
RESULTS
DISCUSSION
Of the 6 patients referred for EUS-guided drainage of pelvic abscess, 2 were excluded: 1 patient had a large rectocele and another had a multiloculated fluid collection with immature walls. The remaining 4 patients (3 men; mean age, 54 years [range 48-56 years]) underwent EUSguided drainage of a pelvic abscess. In 3 patients, the abscess developed after low anterior resection for rectal cancer, and, in 1 patient, the abscess developed as a complication after resection for sigmoid diverticulitis. Location
This study demonstrated that EUS-guided drainage of pelvic abscess is technically feasible, with a good outcome in carefully selected patients. The technique permits the endoscopist to precisely locate the area of contact between the abscess and the digestive tract. This is important, particularly when the abscess does not cause any luminal compression. Although a high success rate has been reported for US- or CT-guided drainage of pelvic abscess,1,2 a small proportion of patients are not candidates
374 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 2 : 2007
www.giejournal.org
Varadarajulu & Drelichman
EUS-guided drainage of pelvic abscess
Figure 5. Fluoroscopic image, showing a drainage catheter in the pelvic abscess cavity.
Figure 6. Repeat CT of the pelvis at 1 week, showing marked reduction in size of the abscess cavity.
TABLE 1. Clinical features and outcomes of individual patients who underwent EUS-guided drainage of pelvic abscess
No.
Abscess location
Etiology
1
Perirectal
LAR
70 68
None
Resolution at day 4
2
Perirectal
LAR
62 82
None
Resolution at day 6
3
Perirectal
LAR
71 66
None
Resolution at day 8
68 72
None
Death at day 2y
4
Pericolonic* Diverticulitis
Abscess size (mm) Complications
Outcome
LAR, Low anterior resection for rectal cancer. *Location was perisigmoid, 25 cm above the dentate line. yFrom worsening heart failure.
for such procedures because of a lack of an adequate window for drainage. In a study of 12 patients with deep pelvic abscesses in whom EUS-guided transrectal stent (8.5F/10F) placement was attempted, Giovanninni et al5 reported a technical success rate of 75%, with resolution of the abscess in 8 of 12 patients. Stent placement failed in 3 patients, because the abscess was located O20 mm from the tip of the transducer. The mean duration of stent placement was 4.3 months (range 3-6 months). With the exception of 2 patients (largest abscess measured 85 83 mm), others had a pelvic abscess that was smaller than 60 mm. The outcome was unsuccessful in the patient with largest abscess, and he eventually required surgical drainage. In another report, EUS guidance was used to gain access to a diverticular abscess for placement of transmural stents as a bridge to surgery. The patient, however, had a submucosal bulge that was evident at endoscopy.6
Although not reported, transrectal stents can potentially clog easily, particularly with fecal matter or pus, and when left long term can cause perirectal pain or can migrate spontaneously. The current technique reported by us enables continued access to the abscess cavity for flushing and drainage of the infected fluid collection. This is particularly important when the abscess cavity is filled with thick fluid. Also, the chance of infecting a sterile abscess is remote with transrectal drain placement than with stent placement.7 As shown in the present series, unlike a stent, the drain can be removed in a shorter period of time, because continued therapy will potentially resolve the abscess faster. It is unambiguously stated in the radiology literature that percutaneous catheters are better suited for drainage of deep-seated abscesses.8 In this series, we adopted to ‘‘burrow’’ rather than ‘‘puncture’’ with a needle knife to establish a tract between the abscess and the rectum. Perforation has been reported as
www.giejournal.org
Volume 66, No. 2 : 2007 GASTROINTESTINAL ENDOSCOPY 375
EUS-guided drainage of pelvic abscess
a complication during EUS-guided drainage of pancreatic pseudocysts by using the needle-knife technique.8,9 It can sometimes be challenging to control the direction of the cut when using needle-knife catheters, leading to inadvertent perforation. Although this could be minimized by using an over-the-wire needle knife, the needle, when deployed, often points in a tangential angle because of its thin caliber, leading to an undesirable incision. We routinely dilate the wall of the pancreatic pseudocyst, after gaining access with a 19-gauge needle and passing a 0.035-inch guidewire, by using a 4.5F to 5F ERCP catheter and then by using a 10F ERCP inner guiding catheter. This facilitates subsequent passage of 6- to 8-mm biliary balloon dilators and through-the-scope balloons for further dilation of the pseudocyst wall. We have experienced no complications with this technique while managing patients with pancreatic pseudocysts. This is particularly relevant in the management of pelvic abscesses where the rectum, unlike the stomach, is immobile and permits easier access to the abscess cavity. In summary, a pelvic abscess is a serious postsurgical complication that hitherto was drained only by surgery or under radiologic guidance. When pelvic abscesses are within the reach of the echoendoscope, drainage catheters can be safely placed under EUS guidance with successful outcomes. Comparative studies with a larger number of patients will help to identify cases that benefit the most from this technique.
Varadarajulu & Drelichman
REFERENCES 1. Hovsepian DM. Transrectal and transvaginal abscess drainage. J Vasc Interv Radiol 1997;4:501-15. 2. Brusciano L, Maffettone V, Napolitano V, et al. Management of colorectal emergencies: percutaneous abscess drainage. Ann Ital Chir 2004;75: 593-7. 3. Benigno BB. Medical and surgical management of pelvic abscess. Clin Obstet Gynecol 1981;24:1187-97. 4. Nelson AL, Sinow RM, Oliak D. Transrectal ultrasonographically guided drainage of gynecologic pelvic abscesses. Am J Obstet Gynecol 2000;6: 1382-8. 5. Giovanninni M, Bories E, Moutardier V, et al. Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy 2003;35: 511-4. 6. Attwell AR, McIntyre RC, Antillon MR, et al. EUS-guided drainage of a diverticular abscess as an adjunct to surgical therapy. Gastrointest Endosc 2003;58:612-6. 7. Maher MM, Gervais DA, Kalra MK, et al. The inaccessible or undrainable abscess: how to drain it. Radiographics 2004;24:717-35. 8. Azar RR, Oh YS, Janec EM, et al. Wire-guided pancreatic pseudocyst drainage by using a modified needle knife and therapeutic echoendoscope. Gastrointest Endosc 2006;63:688-92. 9. Kahaleh M, Shami VM, Conaway MR, et al. Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage. Endoscopy 2006;38:355-9.
Received August 23, 2006. Accepted February 27, 2007.
DISCLOSURE
Current affiliations: Division of Gastroenterology-Hepatology (S.V.), Division of Gastrointestinal Surgery (E.R.D.), University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA.
The authors do not have any relevant disclosures to make.
Reprint requests: Shyam Varadarajulu, MD, Division of GastroenterologyHepatology, University of Alabama at Birmingham Medical Center, 410 LHRB, 1530 3rd Ave S, Birmingham, AL 35294.
376 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 2 : 2007
www.giejournal.org