Presacral perirenal pneumography

268

JOURNAL

OF

THE

PRESACRAL

FACULTY

PERIRENAL

OF

RADIOLOGISTS

PNEUMOGRAPHY

BY LAURENCE F. TINCKLER SURGICAL REGISTRAR, PROFESSORIALSURGICALUNIT, LIVERPOOLROYAL INFIRMARY,DEPARTMENTS OF SURGERY AND RADIOLOGY UNIVERSITYOF LIVERPOOL

DELINEATION of the outlines of the retroperitoneal organs, kidneys, and adrenal glands by radiography has always presented a difficult radiological problem. By means of direct soft-tissue contrast radiography the outline of the kidneys can be visualized either in part or the whole, but the adrenal glands can never be satisfactorily demonstrated with any degree of certainty. The anatomy of the renal pelves can be studied by intravenous pyelography, and displacement of the kidneys by extrinsic tumours can be demonstrated in this way. in order to provide some contrast to the renal outline, Carelli (1921) injected CO 2 into the perirenal tissues and so demonstrated the outline contrasted by the gas shadow, which gathered in the surrounding areolar tissue. In the majority of Cases he demonstrated satisfactorily the kidney and the adrenal gland, particularly in Addison's disease, Barina (195o) noted in the performance of pneumoperitoneum, where there had been accidental diffusion of the air, that the outlines of the posterior abdominal viscera were well shown. His work was followed up by Ruiz Rivas (I95O), who was the first to utilize retroperitoneal injection as a diagnostic procedure. He utilized the preSacral method and succeeded in outlining the posterior abdominal organs satisfactorily. Since that time numerous papers have appeared dealing with this method, which is rapidly becoming accepted as a safe diagnostic procedure, Air can be injected into the retroperitoneal tissues directly into each renal area by the introduction of a cannula below the twelfth rib and the injection of air or oxygen into the perirenal space. Injections 0f 200-250 C.C. SUffiCe, massage of the loin giving an adequate distribution of the air. The disadvantages of this technique are the necessity of using two punctures if both sides are to be visualized, and the difficulty of selecting the correct tissue plane. There is also the danger of introducing air into what is a fairly vascular area, particularly when a renal neoplasm is present. The second method is by the presacral approach, an account of which is given below. The technique was described by Blackwood (I95I), who published a series of 15 cases and called the method 'presacral perirenal pneumography'. The principle of this method is to produce an interstitial emphysema of the retroperitoneal tissues by the introduction of air into the space between the sacrum and rectum. A diffusion of the air occurs, partially by pressure of the insuffiation, but mainly by appropriate massage o f the patient. A single insufftation permits contrast visualization of the whole of the retroperitoneal area. Air embolism and sepsis are the most obvious complications of this procedure, but can be avoided by taking ordinary precautions. Perirenal pneumography has been c~rried out in a very large series of cases, and in the present series it was performed in 36 consecutive cases by the author without any untoward effect. : Perhaps its most valuable application is in the diagnosis Of adrenal turnouts. On direct radiography these may be suspected by downward displacement of the kidney, but the only satisfactory method to date, other than air insuffiation, has been by abdominal aortography.

METHOD Preparation of the patient is directed towards eliminating colon gas and faeces. An aperient is given the night before, fluids curtailed, and breakfast given on the morning of the insufftation. The peri-anal area is shaved and cleansed with soap and water. Although discomfort of the procedure is not intolerable, sedation with pethidine, ioo rag. given half an hour before, is beneficial. The armamentarium consists of a lumbar puncture needle with a two-way tap, a 2o-c.c. syringe, a 5-c.c. syringe, and needles for introducing local anaesthesia, 2 per cent procaine, and

PRESACRAL

PERIRENAL

PNEUMOGRAPHY

269

a finger-stall. An aseptic technique is observed and the irtsufttation conveniently carried out in the ward on the patient's bed. The genupectoral position may be used, but the lateral lying position with knees drawn up and buttocks on the edge of the bed has been preferred as being more comfortable for the patient. The tip of the coccyx is palpated and a skin wheal of local anesthetic raised mid-way between it and the anal region. Infiltration of the deeper tissues, including the ano-coccygeal raphe, with

Fig,

z 8 6 . - - P l a i n scout film of abdomen.

Fig. 2 8 7 . - - N o r r n a l control pneunaogram anteroposterior view, showing soft tissue shadows outlined by contrast m e d i u m . of air.

procaine is then carried out. A finger is now placed in the rectum to guide the point of the lumbar puncture needle, which is introduced with stylet through the skin wheal. The direction of the needle should betowards the pulp of the rectal fingerand passing just in front of the coccyx. Resistance is felt as the needle pierces the ano-coccygeal ligament and will cause discomfort to the patient if it is not adequately anaesthetized. When correctly placed the needle is directed upwards and backwards into the hollow of the sacrum to a depth of 2½-3 in. The tip can be distinctly palpated by the rectal finger through the thin posterior rectal wall, which should slide easily over it. :' Having placed the needle correctly, the rectal finger is withdrawn and the 2o-c.c/syringe connected after removing the stylet. The post-rectal space is relatively avascular, but a trial aspiration is carried out to ensure that the needle is not in a blood-vessel. Should blood be aspirated the needle is withdrawn ar~.d a fresh introduction made. Aspiration of blood was only encountered once in the author's series, but without resultant h~ematoma. 18

270

JOURNAL

OF

THE

FACULTY

OF

RADIOLOGISTS

Air is now insufllated, 2o c.c. at. a time. By manipulating the two-way tap of the lumbar puncture needle, air is alternately drawn into the syringe through the side part, then insufftated through the needle. There should be no resistance to the introduction of air. If there is, slight withdrawal of the needle will usually overcome the obstruction. Over a period of about five minutes 4oo-5oo c.c. of air are insufflated and the same amount introduced with the patient turned over in the opposite lateral lying position. To ensure that the needle is still correctly placed it is ,as well to carry out another rectal examination after the change of position. Diffusion of air retroperitoneally gives rise to a feeling of abdominal distension and an aching sensation in the flanks. Occasionally the arrival of air under the diaphragm is heralded by slight shoulder-tip pain. On completing the insufflation a wisp of cottonwool and collodion seal the puncture wound and the patient is seated upright in bed. An interval of half an hour suffices for complete diffusion of the air. Radiographs are then carried out in the supine and upright positions. Anteroposterior, lateral, and oblique views of the abdomen are taken and may at times be usefully combined with tomography and intravenous or retrograde pyelography. Further diffusion of air takes place into the mediastinum and neck where it gives rise to slight swelling and palpable crepitus six to twelve hours after insufflation. At this stage the patient may complain of a sore throat, but is reassured by a timely word of explanation , and the sensation passes off in a few hours. The air is completely absorbed in three to four days. Fig. z88:--Normal control pneumogram lateral view. Two patients underwent thoracolumbar sympathectomy four hours after perirenal pneumography. At operation the fatty tissue in the region of the kidney was found to have a frothy appearance consequent upon the artificially produced emphysema. After injection, the air at.first collects in the hollow of the sacrum, but rapidly spreads up the posterior abdominal wall retroperitoneally. The peritoneum of the posterior abdominal wall and the anterior vertebral and lateral abdominal muscles are separated by a layer of areolar tissue mainly composed of fat and fibrous tissue. This layer surrounds all the extraperitoneal viscera and extends down partially with the nerve-trunks and vessels. This tissue anteriorly is thin and extends only a little way up the anterior abdominal wall, but posteriorly it covers the whole of the posterior abdominal wall and extends up to the diaphragm. It is loosely attached to the contents and extends a short way into the mesentery" of the intraperitoneal organs. In the radiographs the air is seen outlining the psoas muscle, where it appears to collect in the space between the anterior part of the psoas and the lateral posterior abdominal wall. The kidneys themselves are well outlined by the gas and the adrenals can be distinguished Usually at their junction with the renal outline. The air travels up below the diaphragm and the medial aspect of the liver can be demonstrated. Some of the air will diffuse by means of the tissues around the great vessels into the thorax and will extend even farther up from the thorax into the base of the neck. This can

PRESACRAL

PERIRENAL

PNEUMOGRAPHY

A B Fig. z 8 9 . - - P n e u m o g r a m of Miss C. A, Anteroposterior view demonstrating a large right supra-renal tumour.

27I

B, Lateral view

outlining the supra-renal tttmour.

Fig. 29o.--Intravenons ileogram o f Mr. R., showing normal pyelographie appear anees in spite of the subsequent disclosure of a h y p e r n e p h r o m a of the right kidney,

Fig. 2 9 i . - - P n e u m o g r a m of Mr. R., part of the outline of a hypernephroma projecting f r o m the lateral aspect of the right kidney at the upper pole can be seen outlined b y air.

27z

JOURNAL

OF

THE

FACULTY

OF

RADIOLOGISTS

be seen in the radiographs of the thorax taken w i t h the patient standing~ T h e margins of the d i a p h r a g m and the crura can usually be seen and the spleen visfialized by the contrast of t h e air placed posteriorly b e h i n d it. T h e ease w i t h w h i c h the air permeates t h r o u g h the tissues and r o u n d the kidneys to outline ,them satisfactorily suggests that the fascial sheath of G e r o t a is n o t closed below the kidney. It has always been a m a t t e r of anatomical conjecture to k n o w if this fascial sheath does-fuse below the kidney (Mitchell, I95O ). A f t e r the injection; radiographs are taken supine and upright, w i t h the Potter Bucky d i a p h r a g m in anteroposterior, postero-anterior and lateral projections. T o m o g r a p h y will help to elucidate d o u b t f u l shadows in difficult cases by d e m o n str'ating the section and continuity of the shadows. E x a m i n a t i o n after a short interval, the patient having b e e n exercised in the m e a n time, will often displace the air sufficiently to clarify m a n y d o u b t f u l shadows. T h e t e c h n i q u e used is that for the average renal examination. Figs. 286-288 depict a normal control. T h e absence of soft-tissue shadows in the straight film is in m a r k e d contrast to the p n e u m o g r a m (Fig. 287) , in Which the kidney and suprarenal shadows can be seen as well as the liver, spleen, diaphragm, and its l u m b a r attachments. Illustrated examples of the practical application of presacral perirenal p n e u m o g r a p h y are as follows : -

~ ' - I P ~ ~ ~

t ' l/~lii~iii~ii~i~i~iiiiiiiiiiliitiii~ j t ~2~, ~ 2 ~ ,

Fig. 292.--Nephrectomy spezimen of Mr. R., s,howing a hypernephroma of the upper pole.

Miss C., a schoolgirl of 14 years, complained of growth of hair on the face first notmed twelve months previously. She had also had severe facial acne for two years. As well as displaying hirsutism, her body had features of male configuration, with an unusual degree of muscular development for a girl. The clitoris was enlarged and the breasts moderately develoPed only. Her menses were infrequent. Her bone age as demonstrated by X-ray examination of the epiphyses was that o f a p e r s o n o f 19 y e a r s .

The virilism was considered

to be due to a turnout either of the pituitary, suprarenal ..~ cortex, or ovaries. Presacral, perirenal pneumography demonstrated a tumour "of t h e right adFenal gland (Fig. 289), and this was removed at operation on Jan. ii, I95Z, by Professor Wells via a transthoracie approach. Three months after the operation her facial acne had entirely disappeared ; the hair texture was much finer and she required less frequent depilation. Mr. R., aged 43 years. This patient was first investigated for a low-grade continuous pyrexia and a general feeling of ill-health. Various diagnoses, including rheumatic fever and brucellosis, were considered, but there was no response to treatment. He subsequently developed an enlarged gland in the right supraclavicular group and a biopsy disclosed the presence of hypernephroma tissue. Pyelography did not demonstrate any distortion in the ealiceal pattern of either kidney (Fig. 290). Presacral perirenal pneumography, however, revealed the outline of a rounded swelling,protruding from the lateral aspect of the upper pole of the right kidney (Fig. 291)Right nephrectomy was carried out on 'March 7, 1952, by Professor Wells, and the operation specimen is illustrated in Fig. 292The lateral projection, shown in Fig. 293, illustrates a solitary cyst at the lower pole of the right kidney which was palpable on clinical examination. Fig. z94 shows a tumour involving the upper pole of t h e right kidney. Nephrectomy was subsequently carried out and a hypernephroma found.

PRESACRAL

PERIRENAL

PNEUMOGRAPHY

273

The youngest case in the series was a little girl, aged 8. Apart from reducing the amount of air insufI]ated to 2oo c.c. on each side, the technique used was the same as that for adult patients. There are one or two diagnostic points which appear to stand out. In simple lesions of the kidney associated with renal enlargement the kidney outline is clearly seen in its entirety, but in the case of malignant lesions such as retroperitoneal lymphosarcoma, etc., one will find that the shadow which would normally be present is obliterated, owing to infiltration of the soft tissues.

Fig. 293.--Lateral view of pneumogram demonstrating a solitary cyst df the lower pole of the right kidney,

Fig. 294.--A pneumographic example of a hypernephroma involving the upper pole of the right lddney.

Simple cysts of the kidney, congenital c~¢stic disease, and hypernephromata will all show characteristic outlines, while inflammatory lesions involving the capsules of the kidney, as in the case of malignancy, will obliterate the associated air space. Liver and splenic enlargement can be demonstrated by contrast. The main advantages of this method of examination are, first, that it is simple and appears to be reasonably safe ; and secondly, the injection is not painful and one puncture only is necessary to demonstrate both sides. Its use may be extended to demonstrate uterine and ovarian lesions, although the use of the method for this purpose has not yet been fully explored. Although it is not a diagnostic method of routine application, perirenal pneumography can be recommended as a useful and innocuous procedure in selected cases. Probably its most useful sphere of application is in the demonstration of suprarenal shadows. Tumours of the suprarenal can be localized and distinguished from simple hyperplasia Of the glands. With the development of partial adrenalectomy for the treatment of hypertension and the adrenogenital syndrome, it is reassuring to be able to demonstrate the presence of a suprarenal gland on both sides by a simple method.

274

JOURNAL

OF

THE

FACULTY

OF

RADIOLOGISTS

SUMMARY I. The history of retroperitoneal pneumography is briefly reviewed. 2. The principle and technique of presacral perirenal pneumography based on the author's experience of 3 6 cases is described. 3. Case examples are quoted illustrating the additional information given by the method not covered by more commonly applied techniques. I have pleasure in recording m y gratitude to Professor C. A. Wells and Dr. P. H. Whitaker for their help and encouragement, and also to Mr. Lee, of the Photographic Department, for the excellent reproduction of the radiographs. REFERENCES BAmNA,L. (I95o), Pr. todd., 58. BLACKWOOD,J. (I95I), Brit. J. Surg., 39, III, CARELLI,H. H., and SORDELLIE(I92I), Rev. Asoc. todd. argent., 34MITCHELL, G. A. G. (I95O), Brit. J. Surg., 37, 257. RtVAS, R. (I95O), ~lrner. J. Radiol., 64, 5-