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Interventional Radiology |
1 Department of Radiology, Section of Ultrasound X4123, Rigshospitalet,
University of Copenhagen, Blegdamsvej 9, Copenhagen DK 2100, Denmark.
2 Department of Rheumatology, Parker Institute, Frederiksberg Hospital,
University of Copenhagen, Copenhagen, Denmark.
Received June 23, 2003;
accepted after revision May 12, 2004.
Address correspondence to M. B. Nielsen.
Introduction
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The techniques are known and have been described in lectures given by us and others. The techniques are, however, not widely known because to our knowledge they have never been described in the literature.
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During insertion into the vagina or rectum, we ensure the stylet of the needle is retracted to avoid damage to the wall. Only when the endoprobe with the catheter is in the desired puncture position is the stylet fully advanced. To obtain the desired position, we activate the electronic puncture line, which indicates the path of the needle inserted through the puncture attachment.
With the puncture line on the monitor leading into the pararectal or vaginal abscess, the catheter is advanced and seen on sonography as it follows the puncture line (because the catheter is mounted where the biopsy attachment would have been). When the catheter is satisfactorily positioned in the abscess, the stylet is partly retracted and the loop of the catheter is drawn and locked. Before the stylet is completely removed, the endoprobe is retracted. This can be done quite easily because the catheter is attached to the catheter with only the two rubber bands.
We then treat the abscess as any other abdominal abscess with emptying, flushing with saline four to six times per day, and follow-up scanning after 2 days. Follow-up scans are obtained transrectally or transvaginally without risk of dislodging the catheter. The catheter is usually removed after 5–7 days.
In the second technique, we use a modified puncture guide. The Amedic intracavitary needle guide system (Amedic) consists of a reusable device with a groove into which a disposable plastic tube is placed. The reusable part is mounted on the side of the transducer under a condom, and the disposable part is mounted outside (Figs. 2A and 2B). When we use this system for catheter placement, the catheter is simply placed in the groove and held in position with two sterile rubber bands (Figs. 2A and 2B). The disposable tube is not used. The groove is deep enough that the tip of the stylet does not come into contact with the wall of the vagina or rectum. Consequently, we do not retract the stylet during the type of insertion already mentioned. We do, however, take care that the catheter is not advanced to the extent that the tip of the stylet is free of the groove.
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We have performed the procedure in more than 50 patients with ease. The procedure is performed without any anesthesia and is usually completed in less than 10 min. We regard the procedure as a slight modification of conventional percutaneous abdominal catheter placement. The major differences are the absence of local anesthesia and skin incision because we have neither the custom nor the need to anesthetize in these puncture sites and because a skin incision is neither feasible nor necessary. We have not encountered complications such as bleeding or fistula formation. Because the sonography unit is mobile, we also perform the procedure in the ICU. We use this technique routinely in deep pelvic or perirectal abscesses if the cavity is larger than 4 cm. For smaller abscesses, we prefer puncture drainage; that is, we empty and flush the abscess with a 1.2-mm needle using a conventional puncture attachment with a channel. The catheter procedure is well tolerated by the patients, and in some cases we have also used it in outpatients after they received instruction on how to flush the catheter with saline.
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Few reports explore sonographically guided treatment of perirectal or deep pelvic abscesses, usually describing transvaginal drainage [2] or percutaneous drainage [3]. In some cases, the percutaneous drainage is guided by transrectal sonography [4] or performed in combination with fluoroscopy [5, 6]. To our knowledge, sonographically guided one-step placement of a transrectal or transvaginal catheter for abscess drainage has not been described previously.
The procedure is simple, quick, and well tolerated by patients and may be performed without anesthesia, and we use it routinely.
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