DOI:10.2214/AJR.07.3830
AJR 2008; 191:1540-1544
© American Roentgen Ray Society
Sonographically Guided Transvaginal or Transrectal Pelvic Abscess Drainage Using the Trocar Method with a New Drainage Guide Attachment
John P. McGahan1 and
Charlyne Wu
1 Both authors: Department of Radiology, University of California, Davis Medical
Center, 4860 Y St., Ste. 3100, Sacramento, CA 95817.
Received February 13, 2008;
accepted after revision May 23, 2008.
J. P. McGahan has one patent agreement through the University of California
(U.S. patent no. 6.095,981) and a second patent pending through the University
of California (U.S. patent pending). Through the Regents of the University of
California, he has entered into a potential agreement with Civco Medical
Solutions regarding the patents on this product.
Address correspondence to J. P. McGahan
(john.mcgahan{at}ucdmc.ucdavis.edu).
Abstract
OBJECTIVE. In this article, we describe a drainage guide attachment
that allows trocar catheter placement for abscess drainage using the
transvaginal or endorectal route under sonographic control. This drainage
guide attachment has a central groove for catheter placement and a removable
cover. Thus, the cover may be removed after catheter placement to allow the
catheter to stay in place while the rest of the drainage guide attachment and
the ultrasound probe are removed from the patient.
CONCLUSION. Our findings indicate that a new sonography drainage
guide attachment can be used for endorectal or endovaginal trocar catheter
drainage of pelvic abscesses.
Keywords: catheter placement • drainage guide attachment • pelvic abscess • sonographic guidance • trocar method
Introduction
Over the past decade, percutaneous imaging-guided drainage of pelvic
abscesses has been shown to be an effective alternative to surgical techniques
[1]. Various approaches have
been advocated for drainage of these abscesses, including the transabdominal
route, transgluteal route [2],
endorectal route [3,
4], and transvaginal route
[5,
6]. CT or sonography has been
used to guide transabdominal and transgluteal abscess drainage. Endorectal or
transvaginal abscess drainage is usually guided by sonography. However, there
is a technical limitation for all endoluminal transducers and guidance
systems: There is no open channel to disengage the catheter from the
transducer after puncture using the trocar technique.
Different endoluminal ultrasound probes have been modified to allow trocar
catheter placement. These modifications have included the use of a trocar
catheter that is placed through a peel-away sheath or trocar catheters that
are placed in a groove on the ultrasound probe and are fixed with rubber bands
[7–10].
However, none of these modifications uses a predesigned needle biopsy guide
attached to the ultrasound probe. In this article, we describe a drainage
guide attachment that allows trocar catheter placement for abscess drainage
using the transvaginal or endorectal route under sonographic control.
Materials and Methods
This project was approved by the human subjects committee institutional
review board of our institution. This study is a retrospective study of 17
procedures performed from August 2004 through September 2007 in which the
newly designed endoluminal drainage guide attachment was used in 16 patients.
Endorectal or transvaginal drainage of pelvic fluid collections
(Fig. 1) presumed to be
abscesses was attempted using this endoluminal guidance system.
View larger version (145K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1 —66-year-old woman (patient 3 in
Table 1) who had undergone
surgical resection for diverticulitis presenting with possible pelvic
abscesses for endovaginal drainage. Contrast-enhanced CT scan shows fluid
collection (A) posterior to uterus (U). B = bladder.
|
|
The study group consisted of 16 patients, five men and 11 women, ranging in
age from 20 years 0 months to 78 years 6 months, with a mean age of 44 years
(Table 1). All provided signed
informed consent for the procedure. All patients were febrile, had elevated
WBC counts, and were nonresponsive to antibiotic therapy. Most patients
received double or triple antibiotic treatment before drainage
(Table 1). The indication for
abscess drainage included sepsis in patients with suspected abscesses from
appendectomy, diverticulitis, tumor resection, surgery for trauma, tuboovarian
abscess, cholecystectomy, and cystolithotomy
(Table 1).
View this table:
[in this window]
[in a new window]
|
TABLE 1: Patients, Diagnosis, Catheter Route, and Culture Results of Fluid from
the Transrectal or Transvaginal Drain and Need for Further Surgery
|
|
Selection of transvaginal or endorectal sonographic guidance versus CT
guidance was made at the discretion of the physician operator. The endorectal
route was the preferred method of abscess drainage unless there was a
tuboovarian abscess, the patient had undergone prior rectosigmoid resection,
or the transvaginal route was in direct contact with the fluid collection
compared with the endorectal route.
When these procedures were performed, all patients received deep conscious
sedation with midazolam hydrochloride (Versed, Hoffinan La-Roche) and fentanyl
citrate. Catheters were placed using an endovaginal probe (dEV-8C4,
Siemens-Acuson) via either the endorectal route (n = 10) or the
transvaginal route (n = 7) (Table
1). The drainage guide attachment includes a central groove for
catheter placement and a removable cover that can be detached after catheter
place ment (Figs. 2A,
2B and
3A,
3B). This drainage guide
attachment is large enough to allow trocar placement of a 6.7-French catheter
(McGahan catheter, Cook Surgical) (n = 15) or a 7.0-French catheter
(Dawson Mueller catheter, Cook Surgical) (n = 2)
(Table 1).
View larger version (32K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —Drainage guide attachment. Cover (straight arrow) is
slid into groove covering catheter channel of drainage guide attachment
(curved arrow). Affixed two components of system are then attached to
endoluminal probe.
|
|
This drainage guide attachment is a metal guide that requires sterilization
between use. It was tested in a water phantom before use in patients to ensure
the lines of the software aligned with the catheter. The current model must be
sterilized between use, but a disposable model will be completed in the near
future. The disposable model will allow placement of 8-French, 10-French, and
possibly 12-French catheters.
When a catheter was being placed via the endovaginal or endorectal
technique, color flow Doppler sonography was used to avoid vessels in the
intervening path (Fig. 4A). The
trocar catheter was then placed in the fluid collection (Figs.
4B and
4C). The inner stylet of the
trocar catheter was removed after entering the fluid collection and fluid
aspiration of turbid or purulent fluid was performed. The catheter was pushed
from its stiffening cannula into the fluid collection and was then affixed
with tape to the patient's inner thigh.
View larger version (35K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A —66-year-old woman (patient 3 in
Table 1; same patient as shown
in Fig. 1) who had undergone
surgical resection for diverticulitis presenting with possible pelvic
abscesses for endovaginal drainage. Endovaginal sonogram to localize fluid
collection (A) and color used to avoid vessels (arrow) in path of
trocar catheter.
|
|
View larger version (86K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B —66-year-old woman (patient 3 in
Table 1; same patient as shown
in Fig. 1) who had undergone
surgical resection for diverticulitis presenting with possible pelvic
abscesses for endovaginal drainage. Trocar catheter (arrow) is placed
using endovaginal route.
|
|
View larger version (101K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C —66-year-old woman (patient 3 in
Table 1; same patient as shown
in Fig. 1) who had undergone
surgical resection for diverticulitis presenting with possible pelvic
abscesses for endovaginal drainage. Catheter is pushed from its stiffening
cannula and Cope loop (arrow) is formed. Cover of guide is removed,
then catheter is left in place and ultrasound guide and probe are removed.
|
|
Once the catheter was in the fluid collection, the cover of the drainage
guide attachment was removed by pulling the proximal O ring. Once this cover
had been removed, the catheter was removed from the central groove of the
drainage guide attachment (Fig.
2A,
2B). The ultrasound transducer
and drainage guide attachment were removed and the catheter was left in the
patient. The catheter was then attached to a Jackson-Pratt suction bulb (Bard,
Inc.) and was irrigated every 12 hours with normal saline. Patients were
continued on antibiotic therapy, with antibiotics adjusted on the basis of
culture results (Table 1). The
catheter was removed after patients had been afebrile for 24 hours, had a
normal WBC count, and had drainage of less than 10 mL/d, and a decrease in the
size of the abscess cavity was seen on CT or sonography. The patients were
then followed up clinically after catheter removal.
The medical records of each patient were retrospectively reviewed
electronically. Details about the clinical and medical history,
sonographically guided aspiration, catheter placement, aspirate culture, and
subsequent clinical course were noted. Treatment was con sidered unsuccessful
if the patient became symptomatic, an infected fluid collection persisted
despite treatment, or the patient required surgery.
Results
Seventeen procedures were performed in 16 patients
(Table 1). Placement of a
catheter under sonographic guidance using the trocar method with this new
drainage guide attachment was successful in all 17 procedures. In three
patients, additional abdominal abscesses were present and drained via the
transabdominal route. In one patient, the catheter had not completely drained
the fluid collection, as noted on CT, and a second endovaginal catheter was
placed (patient 13). This abscess eventually drained and the procedure was
considered successful (Table
1).
Ultimately, 15 of 16 patients (94%) or 15 of 17 procedures (88%) had a
successful therapeutic result in which surgical intervention or subsequent
drainage was not required. One patient with an infected hematoma (patient 4)
did not respond to catheter drainage for pelvic hematoma and required surgical
intervention. In patient 14, the abscess resolved but other abscesses required
draining and lysis of adhesions. Fifteen of 17 procedures resulted in clinical
improvement and all 16 patients were eventually discharged from the hospital.
There were no complications encountered in any of the patients. In patient 4,
the catheter was inadvertently removed and the hematoma was surgically
drained. All fluid collections had positive cultures, as listed in
Table 1.
Of the 17 procedures, 11 procedures had documented dates of catheter
removal. Dwell times ranged from 2 to 9 days, with an average dwell time of 4
days and median of 3 days. The remaining estimated dates of catheter removal,
which include an unsuccessful in and out drainage of a pelvic hematoma, were
from 1 to 33 days (Table
1).
Discussion
In a number of reports, investigators have described endorectal or
transvaginal sonographic guidance for drainage of deep pelvic abscess
[5–10].
When placing the catheter for the endorectal route, the Seldinger technique
can be used. With the guidewire exchange technique, almost any endocavitary
guidance attachment can be used. The needle is positioned in the fluid
collection, and the guide-wire is placed through the needle after the needle
stylet is removed. Thus, the needle, needle guide, and ultrasound probe are
removed while the guidewire is kept in place in the fluid collection. The rest
of the guidance for final positioning of the dilator and catheter is by
fluoroscopy or sonography. This technique allows placement of larger catheters
than the trocar technique but may take more time than trocar placement.
Catheter placement via the guidewire technique when using the endovaginal
route is considerably more difficult than the endorectal route
[7] because the guidewire
buckles when dilators or catheters are placed through the thicker vaginal
musculature, which is distant from the site of catheter manipulation external
to the patient [1,
6].
The trocar technique avoids the difficulty of guidewire buckling using the
transvaginal route [5,
7,
9,
10]. A number of techniques
for trocar placement of catheters for either endorectal or transvaginal
guidance of abscess drainage have been described. Almost all have involved the
use of a standard endoluminal ultrasound probe with modifications to the probe
using tools such as rubber bands to fix the catheter to the ultrasound probe
[8,
9,
11]. Once the catheter is in
position, the ultrasound probe is removed and the rubber bands are cut to
leave the catheter in place and separate from the ultrasound probe
[7]. This is the system we used
previously. Others have instead affixed a peel-away sheet to the ultrasound
probe with rubber bands and then placed the trocar catheter through the
peel-away sheet [10]. Once the
catheter is in the abscess cavity, the ultrasound probe is removed as the
sheath of the peel-away sheet is peeled back.
To date, no reusable or disposable drainage guide attachment has been
designed that can be fixed to an endoluminal ultrasound probe for catheter
placement. We described a newly designed drainage guide attachment that can be
fixed to the endoluminal probe. This drainage guide attachment has a central
groove for catheter placement and a removable cover. Thus, the cover may be
removed after catheter placement to allow the catheter to stay in place while
the rest of the drainage guide attachment and the ultrasound probe are removed
from the patient (Figs. 3A and
3B). A catheter was
successfully placed in all 17 procedures without complications.
In conclusion, our findings indicate that a new sonography drainage guide
attachment can be used for endorectal or endovaginal trocar catheter drainage
of pelvic abscesses.
References
- Casola G, vanSonnenberg E, D'Agostino HB, Harker CP, Varney RR,
Smith D. Percutaneous drainage of tubo-ovarian abscesses.
Radiology 1992;182
: 399–402[Abstract/Free Full Text]
- Butch RJ, Mueller PR, Ferrucci JT Jr, et al. Drainage of pelvic
abscesses through the greater sciatic foramen.
Radiology 1986;158
: 487–491[Abstract/Free Full Text]
- Alexander AA, Eschelman DJ, Nazarian LN, Bonn J. Transrectal
sonographically guided drainage of deep pelvic abscesses.
AJR 1994; 162:1227
–1230; discussion
1231–1232[Abstract/Free Full Text]
- Kuligowska E, Keller E, Ferrucci JT. Treatment of pelvic abscesses:
value of one-step sonographically guided transrectal needle aspiration and
lavage. AJR 1995;164
: 201–206[Abstract/Free Full Text]
- McGahan JP, Brown B, Jones CD, Stein M. Pelvic abscesses:
transvaginal US-guided drainage with the trocar method.
Radiology 1996;200
: 579–581[Abstract/Free Full Text]
- vanSonnenberg E, D'Agostino HB, Casola G, Goodacre BW, Sanchez RB,
Taylor B. US-guided transvaginal drainage of pelvic abscesses and fluid
collections. Radiology 1991;181
: 53–56[Abstract/Free Full Text]
- Lee BC, McGahan JF, Bijan B. Single-step transvaginal aspiration
and drainage for suspected pelvic abscesses refractory to antibiotic therapy.
J Ultrasound Med 2002;21
: 731–738[Abstract/Free Full Text]
- Hovsepian DM, Steele JR, Skinner CS, Malden ES. Transrectal versus
transvaginal abscess drainage: survey of patient tolerance and effect on
activities of daily living. Radiology1999; 212:159
–163[Abstract/Free Full Text]
- Nielsen MB, Torp-Pedersen S. Sonographically guided transrectal or
transvaginal one-step catheter placement in deep pelvic and perirectal
abscesses. AJR 2004;183
:1035
–1036[Free Full Text]
- Varghese JC, O'Neill MJ, Gervais DA, Boland GW, Mueller PR.
Transvaginal catheter drainage of tuboovarian abscess using the trocar method:
technique and literature review. AJR2001; 177:139
–144[Free Full Text]
- Eschelman DJ, Sullivan KL. Use of a Colapinto needle in US-guided
transvaginal drainage of pelvic abscesses. Radiology1993; 186:893
–894[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
