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Original report |
1 All authors: Department of Radiology, Abdominal Radiology Division, Massachusetts General Hospital, White 270, 32 Fruit St., Boston, MA 02114.
Received February 15, 2000;
accepted after revision April 11, 2000.
Address correspondence to D. A. Gervais.
Abstract
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CONCLUSION. Transgluteal catheters are well tolerated by children, and the transgluteal route is an effective approach to selected pelvic abscesses in children.
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We have successfully performed transgluteal abscess drainage in children without complication or significant pain from the catheter. We describe our experience using this approach to deep pelvic abscess drainage in children.
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CT guidance was used in all cases with patients placed in the prone or decubitus positions. Careful attention to the anatomic landmarks prevented injury to the neurovascular bundle. The sciatic nerve courses along the lateral inferior aspect of the greater sciatic foramen, and each abscess was drained from the most medial approach possible while sparing the rectum. In six patients, the trocar technique was used (Fig. 2A,2B). This technique entailed placing an 18- or 20-gauge spinal needle into the abscess with CT guidance and confirming the return of pus. The spinal needle was then used as a tandem guide to catheter placement. In one patient, the Seldinger technique was used with placement of an 18-gauge needle into the collection followed by placement of an Amplatz wire (Cook, Bloomington, IN). After dilatation, a catheter was placed. Self-retaining pigtail catheters ranging in size from 7- to 10-French were used. Catheter size was chosen by the attending radiologist. All abscesses were aspirated until return ceased, and catheters were then left to gravity drainage. Initial volume of pus aspirated ranged from 10 to 300 mL.
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Sedation and pain control were achieved with general anesthesia and endotracheal intubation in two patients. The other five patients were successfully treated without the need for endotracheal intubation. Three of these five patients were sedated by the anesthesiology team using propofol. The remaining two patients were given midazolam and fentanyl citrate by a radiology nurse. Pulse oximetry, heart rate and rhythm, and blood pressure were monitored in all patients. All patients were given triple IV antibiotics (ampicillin, gentamicin sulfate, and metronidazole) before and after drainage.
After the procedure, the patients were treated by the surgical and interventional radiology teams. All catheters were left to gravity drainage and were flushed with 5 to 10 mL of saline solution every 8 hr to maintain patency. Catheters were removed when the patient was afebrile and outputs diminished to less than 10 mL a day. Success of percutaneous drainage was determined by a combination of immediate imaging after drainage, defervescence, diminished leukocytosis, and improvement in general clinical condition. At the discretion of the attending surgeon, five patients underwent CT 2-5 days after the procedure.
All patients were prospectively examined for pain with careful evaluation of pain from the catheter versus pain related to the abscess. Pain was assessed by talking to the patients and parents. Care was taken to separate abdominal pain versus localized buttock or leg pain. Pain medication that was required before and after the procedure was recorded.
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The three patients who underwent appendectomy required no further procedures. Mean length of follow-up was 6 years (time range, 2-9 years). The four other patients underwent appendectomy. Two of these four patients underwent electively scheduled interval appendectomy 4-6 weeks after catheter removal. One patient with an underlying foreign body underwent appendectomy at 4 days. His appendectomy was performed sooner than usual because of concern for abscess recurrence in the presence of an ingested foreign body that caused the appendicitis. Finally, one of these four patients required urgent surgery 6 days after catheter removal for a mechanical small bowel obstruction due to adhesions. At surgery, no residual abscesses were found in any of the four patients who required appendectomy.
Pain was separated into that related to the abscess and that related to the abdominal catheter when present, or buttock and leg pain related to the transgluteal catheter. None of the seven patients had radiating leg pain or catheter-related pain severe enough to limit catheter tolerance. No patients had transgluteal catheter-related pain at rest, but three patients complained of catheter-related pain with motion. Two of these three patients had transgluteal catheter-related discomfort with ambulation only. In both, the pain responded to oral pain medication. The discomfort was transient for one patient who experienced it only on the first day after the procedure. The other patient experienced catheter-related discomfort with ambulation intermittently until day 4. The third patient had one episode of transient pain while getting on a bedpan immediately after the procedure but was without transgluteal catheter-related complaints afterward.
Two patients had pain with flushing of the transgluteal catheter. One patient did not tolerate flushes from the start, and they were discontinued on day 2. One patient experienced pain with flushes at day 4 when the cavity size was contracted. All three patients who had a separate right lower quadrant abscess drained via an anterior percutaneous approach required pain medication for specific complaints regarding the anterior catheter. The transgluteal catheters were well tolerated in these three patients.
Six of the seven children had abdominal pain on presentation. These six patients all required pain medication ranging from day 1-4 after the procedure. Pain control was achieved in all patients initially with parenteral and then with oral analgesics. No patient had increased need for pain medications after the procedure. All showed progressively less need for medication as drainage continued, thus correlating more closely, in general, with the presence of the abscess and its associated inflammation than with the presence of the catheter.
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The transgluteal approach offers a third option to the interventional radiologist. Many interventional radiologists have achieved proficiency with the transgluteal approach to pelvic abscess drainage and have the skills necessary for the safe performance of this procedure in children. Butch et al. [6] first described the transgluteal approach to deep pelvic abscess drainage in 1986. Although some greeted this approach with reluctance at the time [8], transgluteal abscess drainage has become a common approach to deep pelvic abscess. Butch et al. recommended a thorough knowledge of the anatomy of the greater sciatic foramen to minimize the possibility of neurovascular injury. The foramen is located inferior to the sacroiliac joint and is bounded inferiorly by the sacrospinous ligament. The piriform muscle, sacral plexus, and superior and inferior gluteal vessels course through the greater sciatic foramen along its cephalad aspect. The sacral plexus exists as the sciatic nerve along the lateral caudal aspect of the foramen. Butch et al. recommended a percutaneous route along the medial aspect of the greater sciatic foramen to avoid neurovascular structures. In that series, 20% of patients had catheter-related pain lasting more than 24 hr [6]. In a more recent report, Boland found only 2 (4%) of 52 patients had temporary leg pain with no patient experiencing permanent nerve irritation or injury (Boland GW et al., RSNA meeting, December 1993). Boland attributed improved tolerance of transgluteal catheters to the fact that preprocedural and intraprocedural pain treatment was superior to that used in 1985.
Three patients experienced initial transgluteal catheter-related pain either with ambulation (n = 2) or bedpan use (n = 1), but these complaints were transient for two patients and persisted intermittently for only one patient. These results are similar to our experience with adults. Furthermore, the three patients who had separate collections drained percutaneously all had documented pain related to the anterior catheter but not to the transgluteal catheter.
Our experience with the transgluteal approach to pelvic abscess drainage in children has shown that children can tolerate these catheters well and, at times, can tolerate them better than transabdominal catheters. The transgluteal approach gives the radiologist performing interventional procedures in children an additional means to achieve drainage of deep pelvic abscesses. Children should not be denied imaging-guided catheter drainage of pelvic abscesses for which anterior percutaneous or transrectal routes are not feasible. In these patients, the interventionalist can proceed with the transgluteal approach to pelvic abscess drainage. This approach may prevent further surgery in patients with abscesses after surgery and allow primary abscesses to be drained percutaneously, thus simplifying subsequent surgical procedures if these prove necessary. On the basis of this experience, we believe that transgluteal catheters can be well tolerated by children.
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