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Pediatric Imaging |
1 From the Department of Radiology, Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104 (A.M.C., K.M.B, R.D.K., R.B.T.); and Department of Radiology, Children’s Hospital of Pittsburgh, Pa (C.R.F.). Received November 10, 2003; revision requested February 3, 2004; revision received May 20; accepted June 15. Address correspondence to K.M.B. (e-mail: baskin@email.chop.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Institutional review board approval and informed consent for interventional procedures were obtained. From September 1995 to December 2002, 140 abdominopelvic fluid collections were drained at two institutions. Retrospective analysis of a prospectively gathered procedural database revealed that a transgluteal approach was used to drain 53 of these 140 collections (38%) in 51 patients (29 female, 22 male; mean age, 11.2 years; age range, 0.2–19 years). All patients received antibiotics before the procedure. A retrospective analysis was conducted of the patients’ medical records and diagnostic imaging and interventional procedure findings, including the reason for referral; location, volume, and character of collections; method and equipment used for evacuation; duration of therapy; evidence of complications; results of microbiologic examination of specimens; and success rates.
RESULTS: Transgluteal drainage was performed with computed tomographic (CT) guidance in 45 of the 53 collections (85%), with fluoroscopic guidance in three (6%), and with a combination of both modalities in five (9%). A drainage catheter was successfully placed in 49 collections; four small collections were aspirated without drain placement. Infected fluid was obtained from 41 collections, and serosanguineous fluid was obtained from 12 collections. The mean volume aspirated was 80 mL (2–600 mL). A positive culture was obtained at 28 of the 53 procedures. The mean duration of catheter placement was 4 days (range, 2–14 days). There were no major complications.
CONCLUSION: The transgluteal approach to the drainage of abdominopelvic fluid collections with imaging guidance is safe and effective.
© RSNA, 2005
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Percutaneous drainage of deep pelvic abscesses has been performed by means of the transgluteal route (16,17). To our knowledge, this approach has only been reported in the treatment of a small group of children by Gervais et al (18). Despite the successful use of the transgluteal approach in that study, this procedure continues to carry the stigma of being a more complicated or painful alternative. The purpose of our study was to evaluate a transgluteal approach for draining pelvic fluid collections in pediatric patients.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Procedure
All children referred for pelvic drainage were treated with broad-spectrum antibiotics (ampicillin, gentamicin sulfate, and metronidazole) before the drainage procedure. If an intravenous contrast material–enhanced computed tomographic (CT) scan had not been obtained as part of the diagnostic work-up, one was obtained. Previously obtained images and medical history were reviewed before the interventional procedure to confirm the diagnosis, to assess for risk factors related to sedation, and to plan the safest drainage route.
The procedure was usually performed with deep sedation of the patient (52 patients [98%]); only one procedure was completed with general anesthesia. The pediatric interventional nurse, under the supervision of the attending interventionalist, intravenously administered a combination of 1–3 µg/kg fentanyl citrate (Sublimaze; Janssen, Piscataway, NJ), 2–8 mg/kg pentobarbital sodium (Nembutal; Abbott Laboratories, North Chicago, Ill), and 0.1–0.3 mg/kg midazolam hydrochloride (Versed; Hoffman-LaRoche, Nutley, NJ). For the purposes of sedation, all patients fasted for 6 hours before the procedure.
Imaging guidance was performed with CT (Fig 1) for 45 of the 53 collections (85%), fluoroscopy (Fig 2) for three (6%), and a combination of both modalities for five (9%). Once adequately sedated, the patient was placed in the prone position on the CT or fluoroscopy table. Rectal contrast material was not routinely administered. Six patients received intravenous contrast material before procedural imaging to help differentiate between the fluid collection and the urinary bladder.
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Local anesthesia in the overlying skin and along the prospective tract was achieved with 1% lidocaine buffered with sodium bicarbonate in an 8:2 mixture. A small skin incision was made with a number 10 scalpel blade, and a Kelly forceps (Codman, Raynham, Mass) was used to develop a short subcutaneous tract by means of blunt dissection. An 18-gauge sheathed access needle (Yueh; Cook) was advanced with CT visualization until the fluid collection was reached.
If necessary, a tandem technique (Fig 1b) was used in which a fine needle (eg, 22 gauge) was advanced and the correct trajectory verified. The sheathed needle was then advanced alongside the fine needle subtending the same angle at the skin surface.
When fluid was visualized in the needle, a guidewire was advanced and coiled within the fluid collection. Collections smaller than 3 cm in diameter were drained by means of aspiration only; wire or catheter insertion was not performed. If the collection was large enough to accept a formed pigtail (ie, larger than 3 cm), a small aliquot was collected for laboratory analysis before insertion of the guidewire. We preferentially used a stiff guidewire (ie, a Rosen or Amplatz stiff [Cook] or a stiff hydrophilic glide [Terumo; Boston Scientific Vascular/Meditech, Natick, Mass] guidewire) to facilitate easier tract dilation and to avoid guidewire kinking due to the depth of the collection and the firmness of the gluteal muscle tissue. The position of the guidewire in the collection was confirmed with CT if needed. The tract was then serially dilated to the required French size for catheter placement.
A self-retaining locking pigtail catheter was then inserted over the guidewire and a metal stiffener. The collections were evacuated as completely as possible. If necessary, the catheter was repositioned to improve drainage of the collection. A postprocedural CT scan was then obtained through the region of the drained collection. Fluid samples were retained for microbiologic analysis in all patients.
The catheter was sutured in place and secured to the skin with a Stat-Lock device (Venetec, San Diego, Calif) and covered with a dry sterile occlusive dressing. The catheter was then usually placed to suction by using a Hemovac suction device (Zimmer, Warsaw, Ind) or a Jackson Pratt bulb (Cardinal Health, McGraw Park, Ill), depending on the preference of the interventionalist. The interventional radiology team managed all catheters in consultation with the referring physicians. Although catheters were not routinely irrigated, they were checked for patency by means of irrigation when the output per 24 hours decreased substantially (usually to less than 10 mL per 24 hours).
If patency was confirmed and the patient experienced defervescence and improvement in his or her clinical condition, then catheter removal was considered. In the event of increased or feculent drainage, the catheter was injected with contrast material under fluoroscopic guidance to exclude the possibility of an enteric fistula. Repeat imaging with or without contrast material instillation through the drainage catheter was not otherwise routinely performed before drain removal.
Data Collection
A retrospective analysis was conducted of the medical records for each patient treated with the transgluteal approach; analysis was performed by all authors unless specifically noted. Diagnostic images and interventional findings were reviewed from the picture archiving and communication system database when available or by reviewing hard-copy files for patients treated before archiving began. Reason for referral, duration of therapy, and evidence of delayed complications (eg, decrease in hematocrit level, signs or symptoms of shock, pertinent changes in neurologic status, nursing reports of catheter-related pain, or increase in pain medications) were evaluated from medical progress notes and procedural dictations (A.M.C, C.R.F.). The location of the collection was evaluated from preprocedural cross-sectional images. The method of fluid collection (aspiration or catheter drainage), volume and character of fluid evacuated, equipment used, and any immediate complications were noted in the prospectively gathered procedural database maintained by healthcare staff in the interventional suites. The nature of the collection (infected or sterile) was evaluated with visual inspection (for frank pus) by the operating interventionalist (A.M.C., R.D.K., C.R.F., R.B.T.). In addition, microbiology reports were reviewed when available (A.M.C., K.M.B.). Success rates were evaluated according to published quality assurance guidelines (19) by reviewing progress notes, discharge summaries, and postprocedural images where available (A.M.C., K.M.B., C.R.F.).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Location
All collections included in this study were accessed by means of a percutaneous transgluteal route. Most collections accessed with this method were located in the pouch of Douglas (n = 44). Other collections accessed with this approach were located at the level of the sigmoid colon (n = 6) or the right pararectal space (n = 2). One fluid collection extended posteriorly from the symphysis pubis to the rectum; the bulk of this collection was located posteriorly in the pelvis.
Aspiration versus Catheter Drainage
Of the 53 fluid collections identified in the 51 patients, four met the criteria for aspiration only (ie, smaller than 3 cm in diameter). A diagnosis was achieved in all four of these collections (100% success). A drainage catheter was successfully placed in the remaining 49 collections. Of these, 42 collections were considered to be infected because frank pus was aspirated, the fluid obtained was culture-positive, or both. Successful (curative) drainage was achieved in 41 of the 42 infected collections (98%). One patient with neutropenia and a polymicrobial collection (Escherichia coli, Klebsiella species, Proteus species, and Enterococcus species) treated with apparent success after 7 days of catheter drainage underwent aspiration of a second small (5 mL) collection culture-positive for Bacterioides fragilis 38 days after catheter removal. Although likely a previously untreated collection, a treatment failure could not be excluded.
Small-caliber (8.5-F) catheters were adequate for drainage of most collections (32 of 49 collections). Larger catheters were used in select cases at the discretion of the interventionalist, including 10.2-F (14 collections), 12-F (two collections), and 14-F (one collection) catheters. All were locking pigtail catheters.
The mean duration of catheter placement was 4 days (range, 2–14 days). Other than the polymicrobial collection noted earlier, there was no evidence of incomplete drainage or reaccumulation of the fluid collections following removal of the primary drainage catheter.
One case was complicated by malposition of a drainage catheter in the rectum. This was immediately recognized and corrected by removing the catheter. A new catheter was correctly positioned in the pathologic fluid collection. There were no sequelae. No other minor complications and no major complications were associated with either initial insertion of the catheter or treatment of the collections by means of transcatheter drainage. In particular, there was no evidence of abnormal bleeding or other injury to pelvic nerves, vessels, or organs.
Fluid Retrieved
The mean volume aspirated to evacuate each collection was 80 mL (range, 2–600 mL). Purulent fluid was obtained in 41 collections, and serosanguineous fluid was obtained in 12. A positive culture was obtained from 28 of the 53 collections (including one apparently serosanguineous collection), and a negative culture was obtained from 16. In nine of the 53 collections, no result was available for retrospective review. Of the 28 positive cultures, E coli was the most common isolate (n = 21). Staphylococcus aureus (n = 2), B fragilis (n = 2), Enterococcus species (n = 1), and Pseudomonas aeruginosa (n = 1) were also identified. One culture was positive for multiple organisms (Klebsiella, Enterobacter, Serratia, and Citrobacter species).
Pain
Objective postprocedural pain assessment was obtained for all 13 catheter drainage procedures performed in one center by reviewing the pain medication charts and the nursing assessments. Within the first 24 hours after catheter insertion, there was no change in pain medications in seven of the 13 patients, an increase in pain medication in three patients, cessation of pain medication in two patients, and a decrease in pain medication in one patient.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Pelvic fluid collections have been treated with a variety of access routes depending on the location of the collection and its anatomic relationships, including transabdominal (5,20–22), transrectal (23–25), transvaginal (26), transperineal (27,28), transurethral (29), and transgluteal (16,18,30,31) approaches. Developmental issues (anatomic and body image) and catheter-care issues virtually preclude the use of the transvaginal, transurethral, and transperineal routes in the pediatric population. All other routes are routinely employed, although operator and institutional preferences often limit the choices in a given case.
In our series, patients with a pelvic collection treated by means of a transgluteal approach experienced successful diagnostic fluid aspiration 100% of the time and successful drainage 98% of the time, without any major complications (19). In particular, none of our patients experienced episodes of bleeding or nerve injury, as has been reported elsewhere (16,32). In our experience, this route allows aspiration and drainage of fluid collections throughout the pelvic cavity and associated soft tissues posteriorly and is not limited to collections in the pouch of Douglas.
Technically, the transgluteal approach is straightforward. Cross-sectional imaging (CT or ultrasonography [US]) is recommended in most cases, although large collections in the pouch of Douglas may often be accessed with fluoroscopic guidance alone. Procedural modifications reported in the literature and in common use (33,34), such as a tandem needle approach, aspiration without drainage of small collections, gantry angulation, and creation of a saline "window" in the perirectal space, increase the range of fluid collections that can be safely approached with this route. CT is our imaging modality of choice for guiding the transgluteal approach because US penetration of the gluteal soft tissues and bony pelvis is often insufficient for visualizing the pathologic collection.
The use of a stiff guidewire is of substantial technical benefit, especially during tract dilation and catheter delivery, for avoiding kinking or coiling in the firm gluteal tissues. However, the operator must take care to fix the stiff guidewire firmly at the skin entry point. Failure to do so may allow tension in the coiled guidewire to spring back, thus potentially losing purchase in the cavity and tract.
Pain related to transgluteal catheter placement has been a concern among practitioners (35). Although we did not prospectively study pain related to this procedure, in retrospect we found that pain was not adequately controlled in three of 13 (23%) children treated in one of the two centers. Although this is a relatively large proportion compared with results in adults described in the literature, the small sample size and incomplete information from the remaining patients leaves this an open question. In our experience, the challenges in pain management for this procedure are relatively easily addressed and should not limit the use of this technique in children.
The trend toward better pain management in this procedure in particular and in interventional procedures in general probably relates to the more aggressive use of intraprocedural local anesthetic and more proactive use of analgesics early in the course of treatment, as suggested by Gervais et al (18). We also agree with Harisinghani and colleagues (31) that avoiding transpiriformis catheter placement by using a more caudal access route is more likely to avoid the sacral plexus as well as vessels at risk in the greater sciatic foramen. We have not found it necessary to follow the more extreme infragluteal, paracoccygeal approach described by Longo et al (36) and, in fact, have not, to date, had to make specific allowances for the sciatic foramen in planning these procedures.
As a result of our experience, several advantages of the transgluteal route were noted. As is the case with abscess drainage in the pediatric population in general, the procedure can almost always be accomplished by using intravenous sedation with analgesia and local anesthesia. With the high rate of success and low rate of complications, a percutaneous transgluteal route should be considered during the initial approach to diagnosis and treatment of pelvic fluid collections. Open surgery should be reserved for those very few cases in which no safe route is available, when a legitimate trial of transcatheter drainage has failed, or if there is another indication for surgery in the same anatomic space.
It is of interest that a positive culture was obtained from more than half of the purulent collections despite the fact that all patients were treated with broad-spectrum antibiotics before the procedure. This underscores the importance of obtaining cultures from all abnormal pelvic fluid collections. The absence of results in nine of the 53 cases should focus our attention on our clinical responsibility to properly handle, transfer, and follow up the samples obtained, without merely relying on the referring service to perform this function. In recognition of this oversight, we have now altered our practice.
Our study is limited because of its retrospective nature, lack of comparison to relevant alternative treatment groups (eg, US-guided or blind [surgical] transrectal drainage), and incomplete follow-up data with regard to catheter-related pain.
To our knowledge, to date there has been no prospective study in which the transrectal and transgluteal approaches to the drainage of pelvic fluid collections have been evaluated. In fact, both approaches appear to be equally safe and successful in general, and both should be in the armamentarium of the pediatric interventionalist. The nature and location of the collection, the experience and preference of the interventionalist, and the preferences of the patient and family can safely guide the final choice.
To the best of our knowledge, ours is the largest series of pelvic abscess drainage with the transgluteal route reported in children. On the basis of our experience, we recommend imaging-guided transgluteal drainage as a safe alternative for effective treatment of pelvic collections in the pediatric population. Even when patients have received antibiotics before transcatheter drainage, cultures of fluid samples can still have a high yield. Pain management remains an important issue to address prospectively for this procedure.
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FOOTNOTES |
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Author contributions: Guarantor of integrity of entire study, A.M.C.; study concepts, A.M.C., K.M.B., R.B.T.; study design, all authors; literature research, A.M.C., K.M.B.; clinical studies, all authors; data acquisition, A.M.C., C.R.F.; data analysis/interpretation, A.M.C., K.M.B., R.B.T.; statistical analysis, A.M.C., K.M.B., R.B.T.; manuscript preparation and editing, A.M.C., K.M.B., R.B.T.; manuscript definition of intellectual content, revision/review, and final version approval, all authors
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  S. H. Lee, C. Tomlinson, M. Temple, J. Amaral, and B. L. Connolly Imaging-Guided Percutaneous Needle Aspiration or Catheter Drainage of Neonatal Liver Abscesses: 14-Year Experience Am. J. Roentgenol., March 1, 2008; 190(3): 616 - 622. [Abstract] [Full Text] [PDF]
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