Treatment of pelvic abscesses: value of one-step sonographically guided transrectal needle aspiration and lavage

Successful treatment of rectal cancer with pelvic abscess using transrectal drainage followed by laparoscopic radical resection: a case report

The incidence of rectal cancer with a pelvic abscess is rare; hence, treatment strategies are difficult because both malignant and infectious inflammation need to be addressed. Here, we report the case of a 53-year-old man diagnosed with rectal cancer accompanied by a pelvic abscess. We performed transrectal drainage of the abscess, and a transanal rectal drainage tube was inserted into the abscess cavity. His symptoms rapidly improved, and computed tomography showed that the pelvic abscess had disappeared. Six weeks after drainage, radical laparoscopic Hartmann’s procedure with resection of the rectal cancer and incision drainage scar was performed. After adjuvant chemotherapy, laparoscopic stoma closure was performed a year after the operation. The patient showed no evidence of cancer recurrence 1.5 years after radical surgery. Transrectal drainage followed by laparoscopic radical resection can be a less invasive and effective treatment for rectal cancer accompanied by a pelvic abscess.

TRUS-guided drainage of the ectopic ureter entering the prostatic urethra and TRUS-guided transurethral neo-orifice formation using holmium laser

A fifty-nine year-old male was hospitalized for exacerbation of chronic pancreatitis. As a gigantic cyst of the pancreatic tail was identified, it was fused with the jejunal loop. Due to persistent fever and severe symptoms in the storage and voiding phases, the patient was referred to a urologist. Because transrectal ultrasound examination revealed a fluid collection resembling the left seminal vesicle filled with purulent material, a transrectal puncture procedure was performed. The analysis of computed tomography scans led to the diagnosis of duplicated collecting system of the left kidney with the enormous ureter of the upper moiety that entered the prostate gland. In order to permanently decompress the hydronephrosed upper moiety of the left kidney, the patient was deemed eligible for endoscopic treatment. A transurethral incision through the bladder wall and the adjacent segment of the ectopic ureter was made with holmium laser under transrectal ultrasonography guidance, thus creating a neo-orifice of this ureter.

One step endoscopic ultrasound guided management of pelvic abscesses: a case series

BACKGROUND

Endoscopic management of pelvic abscesses not amenable to percutaneous drainage has been described. The technique employs endoscopic ultrasound (EUS)-guided placement of stents or drains, which may require multiple procedures, is cumbersome and uncomfortable for the patient. We describe the successful management of these abscesses in a single step involving EUS-guided lavage and instillation of antibiotics.

METHODS

Six consecutive patients with seven symptomatic pelvic abscesses not amenable to percutaneous drainage were referred for EUS-guided drainage. The abscesses were aspirated with a 19-gauge needle under EUS guidance and serially lavaged with an equal aspirate to instillation volume of sterile saline until cleared of pus. The residual cavity was then instilled with gentamicin 40 mg/ml. Patients were followed clinically and radiographically with repeat computed tomography or magnetic resonance imaging.

RESULTS

All patients had rapid resolution of symptoms. The abscesses disappeared completely in four patients. One patient with recurrent diverticulitis and abscess had marked decrease in abscess size and inflammation to permit planned sigmoid resection. One patient with Crohn's disease had clinical improvement and marked decrease in abscess size, permitting outpatient management of Crohn's disease.

CONCLUSIONS

EUS-guided lavage and instillation of antibiotics is a simple, one-step approach in the management of pelvic abscesses and may obviate the need for prolonged drain management and repeat procedures in select cases.

Intra-Abdominal Abscesses: Emphasis on Image-Guided Diagnosis and Therapy

Infection of the peritoneal cavity can be divided into acute peritonitis and chronic abscess formation. While acute peritonitis is easier to diagnose and treatment is often straightforward, the diagnosis of an intra-abdominal abscess can be subtle and treatment can involve multiple diagnostic and therapeutic modalities. The advent of high-quality computed tomography and ultrasonography has revolutionized the care of these patients, and has allowed for the definitive management of these infections without open operation. We review the current techniques for the diagnosis, localization, and treatment of these serious infections, discuss important factors influencing the decision between percutaneous and operative approaches, and examine several other controversies In this challenging area.

Endoscopic Ultrasound-Guided Treatment beyond Drainage: Hemostasis, Anastomosis, and Others

Since the introduction of endoscopic ultrasound (EUS) in the 1990s, it has evolved from a primarily diagnostic modality into an instrument that can be used in various therapeutic interventions. EUS-guided fine-needle injection was initially described for celiac plexus neurolysis. By using the fundamentals of this method, drainage techniques emerged for the biliary and pancreatic ducts, fluid collections, and abscesses. More recently, EUS has been used for ablative techniques and injection therapies for patients with for gastrointestinal malignancies. As the search for minimally invasive techniques continued, EUS-guided hemostasis methods have also been described. The technical advances in EUS-guided therapies may appear to be limitless; however, in many instances, these procedures have been described only in small case series. More data are required to determine the efficacy and safety of these techniques, and new accessories will be needed to facilitate their implementation into practice.

ACR Appropriateness Criteria® right lower quadrant pain--suspected appendicitis

The diagnostic imaging of patients presenting with right lower quadrant pain and suspected appendicitis may be organized according to age and gender and to the presence or absence of "classic" signs and symptoms of acute appendicitis. Among adult patients presenting with clinical signs of acute appendicitis, the sensitivity and specificity of CT are greater than those of ultrasound, with improved performance when CT is performed with intravenous contrast. The use of rectal contrast has been associated with decreased time in the emergency department. Computed tomography has also been shown to reduce cost and negative appendectomy rates. Both CT and ultrasound are also effective in the identification of causes of right lower quadrant pain unrelated to appendicitis. Among pediatric patients, the sensitivity and specificity of graded-compression ultrasound can approach those of CT, without the use of ionizing radiation. Performing MRI after inconclusive ultrasound in pregnant patients has been associated with sensitivity and specificity of 80% to 86% and 97% to 99%, respectively. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Transurethral drainage of prostatic abscess: points of technique

Background

The incidence of prostatic abscess (PA) has markedly declined with the widespread use of antibiotics and the decreasing incidence of urethral gonococcal infections.

Objectives

To evaluate different treatment methods for prostatic abscess and to describe technical points that will improve the outcome of transurethral (TUR) drainage of prostatic abscess.

Patients and Methods

We performed a retrospective study of a series of 11 patients diagnosed with prostatic abscess, who were admitted and treated in Farwaniya Hospital, Kuwait, between February 2008 and November 2010. Drainage was indicated when antibiotic therapy did not cause clinical improvement and after prostatic abscess was confirmed by TRUS (Transrectal ultrasonography) and/or CT computed Tomographyscan. TUR drainage was indicated in 7 cases, ultrasound-guided transrectal drainage was performed in 2 cases, and ultrasound-guided perineal drainage was performed in 2 cases.

Results

All patients that underwent TUR-drainage had successful outcomes, without the need of secondary treatment or further surgery.

Conclusions

TUR drainage of a prostatic abscess increases the likelihood of a successful outcome and lowers the incidence of treatment failure or repeated surgery. Less invasive treatment, with perineal or transrectal aspiration, may be preferred as a primary treatment in relatively young patients with localized abscess cavities.

EUS-guided drainage and stent placement for postoperative intra-abdominal and pelvic fluid collections in oncological surgery

OBJECTIVES

The objective of this study was to evaluate the role and benefits of endoscopic ultrasonography (EUS) in the management of postoperative intra-abdominal fluid collections after attempted curative surgery for abdominal cancer.

METHODS

The authors retrospectively analysed the Endobase from 1 July 2007 to 30 January 2011 for patients with a postoperative intra-abdominal fluid collection who had undergone EUS-guided drainage and the placement of a stent. The data analysed included the demographics, type of surgery and clinical indications of each patient as well as their clinical and radiological findings.

RESULTS

Six patients (three men and three women; mean age, 61.8 years [range, 38-78 years]) with intra-abdominal and pelvic fluid collections after abdominal surgery for cancer had undergone EUS-guided internal drainage. All procedures had been performed using linear EUS guidance and 8-Fr stent drainage catheters ('one step device', Giovannini, NWOA system Needle-Wire, Cook). The collection types included perigastric abscess (n = 3), perigastric hematoma and rectal hematoma (n = 1), perirectal biloma (n = 1), and perirectal abscess (n = 1). Patients had undergone the following types of surgery: lower-anterior rectal resection (n = 2), Whipple's duodenopancreatectomy type (n = 1), total gastrectomy (n = 1), splenectomy (n = 1), and distal pancreatectomy (n = 1). The number of stents inserted for each collection was one (five patients) and two (one patient).

CONCLUSIONS

EUS-guided drainage and stenting provide another option for the management of postoperative collections. It allows access to areas that are difficult to reach with the CT-guided approach and it can be performed accurately, efficiently and safely. In addition to this, the internal nature of the drainage offers patients more comfort.

Ultrasound-guided drainage of deep pelvic abscesses: experience with 33 cases

The aim of this study was to demonstrate and evaluate the ultrasound-guided drainage of deep pelvic abscesses in which transabdominal percutaneous access could not be performed because of overlying structures. A retrospective analysis of 32 consecutive patients with 33 deep pelvic abscesses was performed. The underlying causes of the abscesses included postsurgical fluid collection or surgical complications in 18 of the 32 patients, and 11 of these patients underwent recent rectal cancer surgery. The locations of the abscesses, which had a median diameter of 6 cm (range 2-10 cm), were as follows: perirectal (n=13), presacral (n=9), pouch of Douglas (n=7), internal genitals (n=2) and between the bowel loops (n=2). The abscesses were all drained using ultrasound (US) guidance with a transrectal (n=18), transvaginal (n=11), transperineal ( n=2) or transgluteal (n=2) approach. Of the larger abscesses (median diameter 7 cm), 19 were treated with catheter drainage and 18 of these cases resulted in favorable clinical outcomes. Of the smaller abscesses (median diameter 4 cm), 14 were treated with needle drainage. In two of these cases, follow-up US showed that a repeat puncture and drainage was necessary. All needle drainages resulted in favorable clinical outcomes. Sixteen of the 29 transrectal or transvaginal drainage procedures were performed without any anesthesia (10 were performed with a needle and six were performed with a catheter). Apart from minor discomfort during the drainage procedure and the subsequent in-dwelling catheter period, there were no serious complications related to the drainage procedures. We conclude that ultrasound-guided transrectal, transvaginal, transperineal and transgluteal drainage of deep pelvic abscesses are safe and effective treatment approaches. Based on our findings, needle drainage will be our most common first-line treatment approach because of the simplicity of the procedure, improved patient comfort and reduced costs. Catheter drainage will be reserved for large multiloculated abscesses.

[Transrectal drainage of pediatric pouch of Douglas abscesses under suprapubic US guidance: technique and results]

Pelvic abscesses are not always amenable to percutaneous drainage. Transrectal drainage of pouch of Douglas abscesses, performed blindly by surgeons for many years, is not familiar to radiologists. The purpose of this article is to describe our technique for the drainage of pouch of Douglas abscesses under suprapubic US guidance and report our results in a series of 7 pediatric patients with deep pelvic abscess not amenable to percutaneous drainage after failure of antibiotics. The procedure was performed under general anesthesia. All procedures were successful and without complication. The drainage catheter was well tolerated in all cases with short post-drainage hospital stay. After failure of medical management, this technique can be used irrespective of patient age or sex using US transducers and drainage catheters routiney available in any radiology department.

The management of pelvic abscess

The optimum treatment for pelvic abscess would be an approach that is safe, efficacious, cost-effective, minimally invasive, and which affects the woman's fertility potential as little as possible. In women of reproductive age tubo-ovarian abscess is one of the most common types of pelvic abscess. Tubo-ovarian abscesses are classically treated with broad-spectrum antibiotics. Frequently this approach fails and surgical intervention becomes necessary in about 25% of all cases. Surgical procedures include laparotomy or laparoscopy with drainage of abscess, unilateral or bilateral salpingo-ophorectomy, and hysterectomy. However, surgery for tubo-ovarian abscess is often technically difficult and associated with complications. An alternative approach is the use of imaging-guided drainage of abscess in combination with antibiotics. Combined data from several studies indicate that ultrasound-guided transvaginal drainage with concomitant antibiotics is especially safe and efficacious. This chapter discusses the management of pelvic abscess with a special focus on transvaginal ultrasound-guided drainage of tubo-ovarian abscess.

Endoscopic transcolonic catheter-free pelvic abscess drainage

Natural orifice transluminal endoscopic surgery is a novel therapeutic method in development that uses different routes of surgical approach. The use of various methods, instruments and accessories during this procedure are currently being investigated. A case of appendicitis-related intra-abdominal abscess that was resolved by a transcolonic endoscopic approach using a wide-channel colonoscope with the help of precut and standard sphincterotome without radiological percutaneous drainage is presented.

Transvaginal drainage of pelvic fluid collections: results, expectations, and experience

OBJECTIVE

The purpose of this study was to review our 13-year experience with sonographically guided transvaginal drainage procedures in terms of type of transvaginal procedure, that is, aspiration or catheter drainage, complication rate, and long-term success.

MATERIALS AND METHODS

A search of an interventional radiology database identified 85 transvaginal drainage procedures on 67 patients. Pertinent medical records and images were reviewed. Clinical success was defined as no need for surgery.

RESULTS

The mean follow-up period was 36.6 months (range, 7 days-132 months). Forty-five aspiration and 40 catheter drainage procedures were performed on 67 patients. Indications for the procedures included postoperative fluid collection (n = 25), tuboovarian abscess unresponsive to medical therapy (n = 17), symptomatic ovarian cyst (n = 17), and miscellaneous causes (n = 8). Clinical success was achieved in 50 of 67 cases (75%), including all cases of 25 postoperative fluid collection, 12 of 17 tuboovarian abscesses (71%), and seven of 17 ovarian cysts (41%). No complications were found in patients who underwent aspiration alone. The following minor complications occurred in patients who underwent catheter drainage: two cases of bladder transgression, one case of infection, and one case of catheter-related pain. Premature dislodgment of the catheter was an issue for four of 40 patients (10%).

CONCLUSION

Postoperative fluid collections can be managed with a high rate of success by means of transvaginal aspiration or catheter drainage. Transvaginal catheter drainage is an alternative to surgery in the management of tuboovarian abscesses unresponsive to medical management. Aspiration alone is sufficient to drain ovarian cysts and provide symptomatic relief. Most cysts recur, however, ultimately necessitating surgery. Aspiration is safe, but catheter drainage is associated with a 10% rate of minor complications.

A technique for MRI-guided transrectal deep pelvic abscess drainage

OBJECTIVE

The purpose of this article is to introduce a technique for transrectal drainage of deep pelvic abscesses performed under interactive MRI guidance.

CONCLUSION

A new method for triorthogonal image plane MRI guidance was developed and used to interactively monitor the puncture needle on continuously updated sets of adjustable three-plane images. The merits and limitations of the technique are highlighted and the patient population that is likely to benefit from this approach is suggested.

Ultrasound-guided interventional radiology in critical care

Ultrasound-guided intervention is becoming an increasingly popular and valuable tool in the critical care setting. In general, image-guided procedures can expedite wait times and increase the accuracy, safety, and efficacy of many procedures commonly performed within intensive care units. In the intensive care unit setting, ultrasound has particular advantages over other imaging modalities such as computed tomography and fluoroscopy, including real-time visualization, portability permitting bedside procedures, and reduced exposure to nephrotoxic contrast agents. We review the technical and procedural aspects of a number of ultrasound-guided interventions appropriate for critical care patients. These include central venous catheter deployment, thoracentesis, paracentesis, and drainage of a wide variety of abscesses, and percutaneous nephrostomy, percutaneous cholecystectomy, and inferior vena cava filter placement. Although we believe ultrasound is significantly underutilized in critical care today, we anticipate that with the improvement of ultrasound technology and the innovation of new ultrasound-guided procedures, the role of ultrasound in the intensive care unit will continue to expand, with bedside ultrasound-guided interventions increasingly becoming the norm.

Endocavitary Three-dimensional Ultrasonographic Assistance for Transvaginal or Transrectal Drainage of Pelvic Fluid Collections

PURPOSE

Determine the feasibility of using three-dimensional ultrasonography (3D US) to assist in planning and performing endocavitary drainage of deep pelvic fluid collections.

MATERIALS AND METHODS

Retrospective review of images and medical records of 16 patients in whom endocavitary 3D US was used during transvaginal or transrectal drainage of 17 deep fluid collections. 3D US was assessed regarding its ability to display the relevant structures, whether new information was provided compared with pelvic computed tomography (CT) and conventional two-dimensional US (2D US) displays, and whether this information altered drainage techniques.

RESULTS

Targeted fluid collections were visualized in all patients. 3D US added information in 11 of 16 patients (69%) that, in turn, resulted in adjustment of interventional technique in eight of 16 patients (50%). Specific features of 3D US that provided new information included the simultaneous display of three orthogonal US images, display of reconstructed US image plane orientations not possible with 2D US, and the ability to interactively scroll images through complex structures to assess for communication between the loculations. An attached needle guide was used in 15 of 16 patients to improve the precision of needle placement.

CONCLUSION

Endocavitary 3D US is feasible for assistance in transvaginal and transrectal drainage procedures, usually adds new information, frequently alters interventional technique, and permits precise access needle placement.

Transrectal and Transvaginal Sonographic Intervention of Infected Pelvic Fluid Collections

Infected pelvic fluid collections are relatively common particularly after abdominal or pelvic surgery or in patients suffering from benign intestinal disease such as diverticulitis, appendicitis, or Crohn's disease. Historically the treatment of pelvic abscess has been either laparotomy with lavage or blind surgical incision and drainage through the rectal or vaginal wall. More recently, computed tomography and ultrasound-guided percutaneous drainage has become the procedure of choice, when feasible, for the treatment of pelvic abscess. However, many deep pelvic collections are not amenable to percutaneous technique. Transrectal or transvaginal ultrasound-guided abscess drainage is a safe and effective method used in the treatment of deep pelvic abscesses. The purpose of this article is to review the techniques, patient selection, pre- and post-procedural care, and monitoring aspects of transrectal or transvaginal ultrasound-guided drainage.

The utility of a drainage needle for percutaneous abscess drainage

OBJECTIVE

In this article, I describe a percutaneous drainage needle that consists of six side holes in its cannula. The needle is specially designed for effective evacuation of complex abscess collections consisting of internal solid components, including floating debris, that tend to block the needle aperture during aspiration. The characteristic features of the needle and its performance in both in vitro and in vivo environments are described.

MATERIALS AND METHODS

An in vitro experiment was performed with the use of a model of a fluid collection containing floating sheets of gelatin sponge to mimic a complex body collection consisting of floating fibrinous strands. Five radiologists were asked to perform aspiration from two collections of normal saline and 5% methylcellulose of two different volumes using an ordinary aspiration needle and the drainage needle. The needle was evaluated in a prospective in vivo study of 30 postoperative abdominal collections in 29 consecutive patients that were drained by a single radiologist. Complete evacuation was attempted initially with a conventional aspiration needle. When there was sonographic evidence of residual fluid collection, a repeat aspiration using a drainage needle was performed during the same session.

RESULTS

In the in vitro experiment, the median percentage of fluid aspirated with the conventional needle from the 10- and 15-mL collections of saline was 10% and 15% and from the 10 mL and 15 mL of methylcellulose solution was 20% and 26.67%, respectively, whereas the drainage needle was able to remove 100% of fluid in all attempts. In the in vivo study, the conventional needle was able to remove all drainable fluid from the 12 simple collections. For the 18 complex collections, the drainage needle was always able to remove some residual fluid from the collection after aspiration with the conventional needle. The median percentage of fluid volume aspirated with the conventional needle was 55.6%, whereas that aspirated with both the conventional and drainage needles was 95.5%, with a significant difference by Wilcoxon's signed rank test (p < 0.001).

CONCLUSION

This drainage needle was effective in evacuating fluid from complex abdominal collections that could not be drained with conventional end-hole needles.

[Image guided drainage of pelvic fluid collections: results in 42 patients]

PURPOSE

To review the etiology, location, and morphology of pelvic collection as well as the technique and results of image guided drainage.

MATERIALS AND METHODS

From June 1996 to August 2002, we performed image guided drainage of pelvic fluid collections in 21 males and 21 females. In patients where a direct contact between the collection and the endocavitary probe was present, the drainage was performed either by transrectal or transvaginal approach using 10F, 12F, 14F or 16F catheters according to the viscosity of the fluid. When the patients were no longer septic, when drainage had stopped, the drains were removed at day 5. When a fistula was present, the drain was left in place until the fistula healed.

RESULTS

The most common location of pelvic collections was the cul-desac (43%). A total of 81% of pelvic abscesses were digestive in origin, either from the colon or appendix. Transrectal or transvaginal drainage was possible in 83% of cases. Mean follow-up was 41 months. No drainage related complication was recorded. In two patients with collections of clear fluid, a simple aspiration was performed without insertion of a drain. In the 40 other patients, a drainage catheter was inserted. Twenty-nine patients were cured after 15 days of drainage. Two patients had recurrent collections. Image guided drainage failed in five patients, and all underwent successful surgical management.

CONCLUSION

Image guided drainage of pelvic collections is a safe and effective procedure. Failures were due to initially undiagnosed pathology requiring surgical treatment.

Prostatic abscess: transrectal color Doppler ultrasonic diagnosis and minimally invasive therapeutic management

The purpose of this study was to analyze the transrectal ultrasound (US), or TRUS, and color Doppler ultrasonography (CDU) findings and therapeutic strategies with TRUS-guided procedures in 13 patients with prostatic abscess. Over a period of 6 years, 18 prostatic abscesses were diagnosed in 13 patients (mean age: 59 years). Diagnostic workup included TRUS, analysis of midstream urine, and analysis and culture of abscess fluid for leukocytes and pathogens. These patients were treated either conservatively (for abscess cavities < 1 cm in diameter), or by aspiration or draining procedures (cavities > or = 1 cm). The transrectal CDU findings were correlated to the treatment effects. The predisposing factors were also reviewed. In the 13 patients, the most common clinical symptom and sign were urinary frequency (77%) and pus cell in the midstream urine (92%). Predisposing factors were found in 11 men, with diabetes in 5 of them. In 10 patients, the definitive preinterventional diagnosis was based on the TRUS findings. TRUS with probe palpation demonstrated tiny floating echogenic speckles in the abscess cavity in 4 patients. CDU demonstrated increased color-flow signals at the margin and surrounding tissue of the abscess pockets. Abscesses with poorly defined boundaries had more prominent surrounding color-flow signals and achieved, with relative difficulty, a satisfactory aspiration procedure. Aspiration was done for all 11 abscesses between 1 and 3 cm. A total of 4 larger abscesses (> 3.0 cm) were treated with aspiration or drainage using a 5-French pigtail catheter. No surgical drainage was performed. Transrectal CDU may help in the evaluation of maturity of an abscess pocket. US-guided aspiration with an 18-gauge needle or drainage with a 5-French pigtail catheter significantly shortened the hospital stay.

Computed Tomography-guided Drainage of Intra-abdominal Infections

Image-guided percutaneous abscess drainage has become a standard method of treatment of most abdominal abscesses. In most cases, it should be considered the treatment of choice, but there are selected areas and circumstances that require specific approaches and methods. Typical abscesses within solid parenchyma organs or those in the peritoneal spaces can be reliably detected and efficiently drained. Abscesses that are multiple or long and circuitous require careful placement of catheters. Management of the drainage catheters includes irrigation with fluid to minimize accumulations of material that may impair egress of fluid. In selected cases, fibrinolytic agents have proved effective in shortening the drainage times and shortening hospital stays. Some controversial areas such as splenic abscesses, pancreatic abscesses, echinococcal abscesses, and fungal abscesses should only be attempted with careful selection and meticulous technique. Successful treatment is most likely with candid consultation among the various clinical services.

Emergent ultrasound interventions

The interventionist can perform many emergent procedures with ultrasound guidance, because of its real-time, multiplanar imaging capability and portability. With the use of color Doppler, additional important information, such as aberrant vessels, can be ascertained to help plan needle trajectory. Ultrasound is also useful for nonemergent procedures, such as biopsies. All interventionists are encouraged to be facile with the use of ultrasound.

Transgluteal approach for percutaneous drainage of deep pelvic abscesses: 154 cases

PURPOSE

To assess the effectiveness of a computed tomographic (CT) image-guided transgluteal approach for percutaneous drainage of deep pelvic abscesses as an alternative to surgical drainage.

MATERIALS AND METHODS

The medical records of 140 patients who underwent percutaneous CT-guided transgluteal drainage of 154 deep pelvic abscesses were reviewed to determine the origins, location, and size of the abscesses; volume of initial aspirate; organisms identified in fluid culture; duration of catheter drainage; incidence of catheter-related pain and procedure-related complications; and short- and long-term outcomes. The resultant data were analyzed with a Fisher exact test for difference in the incidence of postprocedural catheter-site pain between transpiriformis and infrapiriformis approaches.

RESULTS

The origins of the pelvic abscesses included postoperative fluid collection (n = 115), perforating appendicitis (n = 6), diverticulitis (n = 16), tubo-ovarian inflammation (n = 5), Crohn disease (n = 10), and internal bowel fistula due to irradiation (n = 2). The abscesses were 4-12 cm in diameter. The volume of the aspirate was 5-310 mL. Laboratory cultures of the aspirate grew mixed flora, but the organism most frequently isolated was Escherichia coli. Catheters were removed after a mean of 8 days. In 134 (96%) of 140 patients, there was complete resolution of the abscess following transgluteal drainage, without subsequent surgery. In six of 140 (4%) patients, incomplete resolution necessitated subsequent surgery for postoperative fluid collection (n = 3), diverticulitis (n = 2), or perforating appendicitis (n = 1). Complications of transgluteal drainage were rare and included hemorrhage in three (2%) of the 140 patients. There was no procedure-related mortality. A transpiriformis approach was significantly more likely to be associated with postprocedural pain (P <.001) than was an infrapiriformis approach.

CONCLUSION

Percutaneous CT-guided transgluteal drainage is a safe and effective alternative to surgery for deep pelvic abscesses. Major complications are rare.

Multiloculated prostate abscess: treatment with transrectal ultrasound guided transrectal needle aspiration and lavage with the saline and antibiotic

Prostatic abscess is a rare but nevertheless serious disease. It should be diagnosed at an early stage by the combination of clinical examination and transrectal ultrasound, and drained. We treated a 79-year-old case with multiple prostate abscesses (PAs) by using lavage of the saline and antibiotic (cefoxitin) after transrectal ultrasound-guided transrectal puncture and aspiration. We are presenting the transrectal ultrasound images of pre- and postmedication, where we achieved complete success and no relapse was seen in follow-up of 1 year.

Ultrasound of the acute female pelvis

Ultrasound is the most valuable imaging modality in evaluating the premenopausal female presenting with acute pelvic pain. The appropriate interpretation of the ultrasound study requires correlation with the patient's clinical history and laboratory values. This is especially true of the serum beta-hCG, where ultrasound relies on this test to make the diagnosis of ectopic pregnancy. When the serum test for pregnancy is negative and the patient has an adnexal mass this could be secondary to a complicated ovarian cyst (hemorrhage, rupture), ovarian torsion or pelvic inflammatory disease. The ultrasound image can usually make the diagnosis in conjunction with the clinical papameters, however, this is most difficult in patients with ovarian torsion.

Ultrasound-guided endocavitary drainage of pelvic abscesses: technique, results and complications

AIM

To evaluate the experience in our institution with ultrasound-guided transrectal and transvaginal (endocavitary) drainage of pelvic abscesses.

MATERIALS AND METHODS

Eighteen patients (four male, 14 female; mean age 55 years, range 30-78 years) presenting with pelvic abscesses were referred to our institution for therapeutic drainage over a 4 year period. Patients received broad-spectrum antibiotics prior to drainage, which was performed by either the transvaginal or transrectal route under ultrasound guidance. Patients were given sedo-analgesia in the form of midazolam and fentanyl and local anaesthesia was also employed. Eight French catheters were inserted into the abscess cavities, and patients were subsequently monitored on a daily basis by a member of the interventional radiology team until such time as it was deemed appropriate to remove the catheter.

RESULTS

Eighteen catheters were placed in 17 patients, and transvaginal aspiration alone was performed in one patient. Drainage was successful in 16 of 17 patients, but a transgluteal approach was ultimately required in the remaining patient to enable passage of a larger catheter into an infected haematoma. The mean duration of drainage was 5 days, mean time to defervesce 2 days. Spontaneous catheter dislodgement occurred in four patients associated with straining, but this did not have any adverse effect in three of the four patients.

CONCLUSION

Endocavitary drainage is an effective method of treatment for pelvic abscesses. Spontaneous catheter dislodgement does not affect patient outcome.

Single-step transvaginal aspiration and drainage for suspected pelvic abscesses refractory to antibiotic therapy

OBJECTIVE

For treatment of suspected pelvic abscesses, the use of the trocar technique avoids many of the technical challenges of the Seldinger method. The purpose of this study was to evaluate the effectiveness and safety of sonographically guided transvaginal aspiration or drainage with the trocar technique in suspected pelvic abscesses that were refractory to antibiotic treatment.

METHODS

We retrospectively reviewed 22 patients with suspected pelvic abscesses refractory to antibiotic therapy who underwent single-step transvaginal pelvic aspiration or drainage between 1995 and 2000.

RESULTS

Transvaginal aspiration or drainage was successful in 19 (86%) of the 22 patients. Of the 3 patients in whom aspiration or drainage failed, all ultimately went on to have surgery despite undergoing repeated drainage procedures. Drainage catheters were placed in 15 (68%) of the 22 patients and left in place an average of 3.7 days. Aspiration alone resulted in a 100% success rate, whereas drainage with catheter placement resulted in an 80% success rate. No complications, including bleeding, bowel perforation, and death, were reported in any of the procedures.

CONCLUSIONS

Transvaginal ultrasonographically guided aspiration or catheter placement with the trocar technique is a safe and effective treatment for suspected pelvic abscesses refractory to antibiotic therapy.

Transvaginal Interventional Procedures: Aspiration, Biopsy, and Catheter Drainage

Transvaginal ultrasonographically (US) guided procedures are simple and safe and often represent the only means of access to pelvic disease. Aspiration of cystic pelvic masses and core biopsy of solid pelvic masses can be easily performed by using the transvaginal route, an endoluminal US transducer, and a needle guide. Because of concerns about false-negative diagnosis and potential tumor seeding with biopsy of primary ovarian cystic lesions, the indications for transvaginal aspiration and biopsy of ovarian and adnexal lesions are predominantly therapeutic. Similarly, using an endoluminal probe with modification of the guide, one can also perform safe and effective trocar catheter drainage of pelvic abscesses via the transvaginal route. The transvaginal route is ideally suited to pelvic abscess drainage because of the proximity of the vaginal fornices to most pelvic fluid collections. The transvaginal route has the disadvantage of being semisterile; because of the risk of superinfecting previously noninfected pelvic pathologic conditions, the transvaginal approach should be used only for solid lesions or cystic lesions that can be completely aspirated. Familiarity with the transvaginal route of access is crucial for adequate treatment of many gynecologic and nongynecologic pelvic pathologic conditions.

Real-time intraoperative ultrasound guidance: the transrectal approach

OBJECTIVE

To assess the role of real-time transrectal ultrasound guidance in complicated gynecologic procedures.

DESIGN

In 1998-99, real-time guidance with transrectal ultrasound was utilized in our department to assist the gynecologic surgeon in two procedures: completing the evacuation of the uterine cavity after identification of uterine wall perforation during first trimester termination of pregnancy, and drainage of infected vaginal vault hematoma following hysterectomy.

RESULTS

The technique was applied for 11 patients, six abortions and five infected hematomas. All the procedures were completed without any further complications and the patients were discharged on the following day. Follow-up was uneventful.

CONCLUSIONS

On-line intraoperative transrectal ultrasound can effectively provide real-time assistance to the gynecologic surgeon during complicated pelvic procedures.

Transrectal ultrasonographically guided drainage of gynecologic pelvic abscesses

OBJECTIVE

This study assessed the feasibility of ultrasonographically guided transrectal aspiration of gynecologic pelvic abscesses to treat patients for whom intravenous antibiotic therapies failed and whose abscesses were not optimally amenable to colpotomy drainage or transabdominal or transvaginal ultrasonographically guided aspiration.

STUDY DESIGN

This was a retrospective review of the first 15 women with pelvic abscesses that resulted from salpingitis or complications of gynecologic surgery who underwent transrectal pelvic abscess drainage after failure of antibiotic therapy.

RESULTS

Purulent material was aspirated from the abscesses in 14 of the 15 women. All 14 women with aspirated material were successfully treated with real-time ultrasonographically guided transrectal drainage; only 4 of the 14 had indwelling catheter placement.

CONCLUSION

Ultrasonographically guided transrectal drainage of gynecologic pelvic abscesses is a safe and effective treatment of pelvic abscesses for women who do not have an adequate response to antibiotic therapy.

Is the stat Gram stain helpful during percutaneous image-guided fluid drainage?

RATIONALE AND OBJECTIVES

The purpose of this study was to use logistic regression to analyze both Gram stain results and other clinical information to create a decision rule capable of predicting which abdominal or pelvic fluid collections would later prove to be infected and therefore require catheter drainage.

MATERIALS AND METHODS

The authors retrospectively collected Gram stain results and clinical data (postoperative status and antibiotic use) regarding 124 abdominal or pelvic fluid drainage procedures performed between 1991 and 1996. They then analyzed these data by using logistic regression to create an equation that predicted the presence of fluid infection. Finally, they validated this equation by applying it to 39 abdominal or pelvic fluid drainage procedures performed in 1997.

RESULTS

The resulting equation predicted that a fluid collection was likely to be infected if any of the following were present: Gram stain positive for bacteria, Gram stain showing moderate or many white blood cells, and purulent fluid at visual inspection. For the initial data set, the sensitivity of the decision rule was 91%, the specificity was 54%, and the overall accuracy was 77%. For the 1997 data set, the sensitivity of the decision rule was 88%, the specificity was 50%, and the accuracy was 77%.

CONCLUSION

When combined with clinical information, Gram stain results are sensitive but nonspecific in the detection of abdominal or pelvic fluid infection. Use of the decision rule could prevent unnecessary catheter placement in a minority of patients with abdominal or pelvic fluid collections.

Bedside diagnostic ultrasound and therapeutic ultrasound-guided procedures in the intensive care setting

The availability, portability, safety, and other features of ultrasound have ushered this relatively new imaging modality into the everyday clinical practice of multiple disciplines. Features unique to ultrasound lend this imaging modality the opportunity for extensive use in the ICU. A review of its uses in this capacity includes bedside diagnosis of common disorders seen in the ICU setting, such as DVT, cholecystitis, and abscess. Bedside sonography also can aid in the treatment of such disorders, including DGC of pseudoaneurysms, fluid aspirations, and abscess drainages. This article is a review and could not possibly cover all bedside uses of ultrasound or provide in-depth information of specific uses described in this article. Hopefully, this article will spark an interest and prove as a starting point on a rewarding learning adventure.

Transrectal versus transvaginal abscess drainage: survey of patient tolerance and effect on activities of daily living

PURPOSE

To evaluate patient perception of pain related to transrectal and transvaginal drainage and the catheter's effect on activities of daily living.

MATERIALS AND METHODS

From July 1993 to August 1997, 22 male and 40 female patients (mean age, 41 years; age range, 4-80 years) underwent transrectal or transvaginal aspiration or drainage. Fifty-seven drainages were performed. In a follow-up survey, patients were asked to score pain experienced during the procedure and afterward on a scale of 1-10 and to rate the effect of the catheter on their activities of daily living.

RESULTS

Twenty-two patients participated in the telephone survey. For those able to recall the insertion procedure, the mean pain score was 3.2 for transrectal and 5.9 for transvaginal drainage. Mean indwelling catheter pain was 1.6 for transrectal and 4.8 for transvaginal drainage. Pain after removal was 1.4 for transrectal and 2.3 for transvaginal drainage. Only one patient with a transrectal catheter reported severe limitation (bowel movement), with no reports of any serious effect on urinating, bathing, sitting, or walking. Transvaginally placed catheters caused marked limitation in all categories and were more painful than transrectal catheters (P < .05).

CONCLUSION

Of the transrectal and transvaginal approaches, transrectal is better tolerated.

Sonographically guided intralesional antibiotic injection for treatment of a recalcitrant pelvic abscess: a case report

A pelvic abscess occurred in an infertile woman with an endocervical gonococcal infection after hysterosalpingographical examination. The pelvic abscess was not cured despite rigorous antimicrobial chemotherapy until two intra-abscess ceftriaxone injections were administered. This shows that antibiotics administered systemically may not reach therapeutic concentration in an abscess and an intra-abscess antibiotic injection may help to cure it.

Transrectal and transvaginal abscess drainage

The TR and TV approaches to deep pelvic abscesses have been made safe and easy by improvements in endoluminal US technology. Most procedures take well under an hour, and standard intravenous sedation is usually sufficient for patient comfort. The simplest and safest technique employs a combination of endoluminal US, with biopsy guides for precision needle advancement, and fluoroscopy for dilating the tract and placing a drainage catheter. Patient acceptance of TR and TV catheters is high, and resolution can typically be expected within 3-5 days. In the majority of cases, catheter treatment, combined with antibiotic therapy, is curative.