AJR 2004; 183:1035-1036
© American Roentgen Ray Society
Sonographically Guided Transrectal or Transvaginal One-Step Catheter Placement in Deep Pelvic and Perirectal Abscesses
Michael Bachmann Nielsen1 and
Søren Torp-Pedersen2
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
For sonographically guided transrectal one-step catheter placement, the use
of a puncture channel that cannot be opened to free the catheter is a
technical limitation in most biopsy attachments for endorectal and endovaginal
transducers. Therefore, the one-step (trocar) technique cannot be used with
these attachments. The only exception we have been able to find is the
reusable puncture guide UA 1256 for B-K Medical's intracavity transducer 8657.
This guide is designed for catheters up to 5 French. We describe two
techniques for transvaginal or transrectal catheter placement for abscess
drainage using the one-step technique and the puncture line on the monitor.
The puncture line indicates the path of a needle inserted through the puncture
attachment and facilitates transducer positioning.
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.
Materials and Methods
In the first technique, we use a straight end-fire endoprobe (EC 7, Acuson)
and a 7-French string-lock pigtail catheter. We cover the endoprobe with a
sterile condom before placing the assembled catheter along the side of the
endoprobe (where the biopsy attachment would have been). The catheter is then
attached to the probe with two sterile rubber bands (Figs.
1A and
1B).
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Fig. 1B. —Procedure for catheter guidance with rubber bands. Photograph
shows side view of fully assembled system, with catheter mounted on side of
transducer (where puncture guide is usually mounted). Image illustrates
importance of retracting free tip of stylet during insertion of probe into
rectum or vagina.
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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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Fig. 2A. —Procedure for catheter guidance with modified puncture guide
and rubber bands. Photograph shows endoprobe (EC 7, Acuson) mounted with
reusable puncture guide (Amedic). At top of image, disposable rubber tube
normally used with this puncture guide is seen. Two rubber bands and 7-French
one-step catheter are same as in Figures
1A and
1B.
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Fig. 2B. —Procedure for catheter guidance with modified puncture guide
and rubber bands. Photograph shows side view of fully assembled system. Condom
covers reusable puncture guide. Catheter and two rubber bands are outside
condom. Groove of puncture guide is deep enough to allow tip of stylet to be
outside catheter during insertion of probe into rectum or vagina.
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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.
Discussion
The focus of this article is to describe the sonographically guided
placement of a transrectal or transvaginal catheter when that is desirable.
Sonographically guided transrectal or transvaginal needle aspiration and
lavage of pelvic abscesses is a safe and efficient treatment when there are no
problems with the puncture attachment
[1]. Our method should be
applied when catheter drainage is preferable to needle aspiration.
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.
References
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Transvaginal ultrasound-guided aspiration of pelvic abscesses.
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- Sperling DC, Needleman L, Eschelman DJ, Hovesepian DM, Lev-Toaff
AS. Deep pelvic abscesses: transperineal US-guided drainage.
Radiology1998; 208:111
-115[Abstract/Free Full Text]
- Truong S, Willis S, Jansen M, Neuerburg J, Schumpelick V.
Endosonographisch gesteurte percutane paracoccygale Drainage tiefer pelviner
Abscesse nach Rectumresektion. Chirurg1997; 68:633
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abscesses in children using a combined transrectal sonographic and
fluoroscopic guidance. Pediatr Radiol1996; 26:874
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Introduction
Materials and Methods
