Fan, KMJ

Foo, CC

Liu, ZH

Endoscopy

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Title Transperineal endoscopic drainage of a presacral andparaspinal abscessAuthor(s) Foo, CC; Liu, ZH; Fan, KMJCitation Endoscopy, 2016, v. 48 n. suppl. 01, p. E361-E362Issued Date 2016URL http://hdl.handle.net/10722/237698RightsEndoscopy. Copyright © Georg Thieme Verlag.; This work islicensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Transperineal endoscopic drainage of a presacraland paraspinal abscessImage-guided percutaneous catheterdrainage (PCD) has largely replaced opendrainage for deep body-cavity abscessesin the era of interventional radiology [1];however, presacral abscesses are often noteasily accessible.A healthy 36-year-old man fell from aheight of 3 meters while working in aconstruction yard. His buttock landed on asteel rod resulting in penetrating traumato the perineum. The rod, which was 2cmin diameter and used for reinforcingconcrete, entered his body to a depth of atleast of 30cm. Despite this, the patientremained stable and was able to removethe rod himself before seeking medicalhelp.On arrival at the hospital, examinationrevealed a 2-cm perineal laceration withair gushing out from it 4cm from theanus in the three o’clock position. Digitalexamination of the rectum showed a rec-tal wall defect. A computed tomography(CT) scan of the abdomen and pelvisshowed a comminuted fracture of thevertebral bodies of L5 to S2, paravertebraland pelvic hematomas, and a pneu-moperitoneum. A laparotomy was per-formed. Apart from the rectal perforation,there was a 3-cm perforation of the sig-moid colon, whichwas repaired primarily.The rectal perforation, being extraperito-neal, was left untouched. A diversion sig-moid colostomy was fashioned.On postoperative day 10, the patient wasnoted to have a swinging fever and a leu-kocytosis. Reassessment CT and amagnet-ic resonance imaging (MRI) scan showed apresacral abscess, measuring 10.2×7.0×4.6cm in size, with paraspinal extensionof 12.4×3.9×2.6cm (●" Fig.1a). Rectalcontrast injection showed extravasationof contrast but the perforation was notcommunicating with the abscess cavity.Drainage of the presacral abscess was per-formed on postoperative day 14. The peri-neal wound, which was by then 2cm, wasdigitally dilated. A 12-mm laparoscopicport was inserted and carbon dioxide wasinsufflated. A track was created by bluntdissectionusing a10-mm30° laparoscope.As the scope probed into the abscess cav-ity, there was giving way and drainage offrank pus occurred. A gastroscope (Olym-pus, Japan) was used to aspirate pus andto perform irrigation (●" Fig.2). A 28-Frchest drainwas then insertedover aguide-wire (●" Fig.3;●" Video1).A further reassessment scan showedmarked interval reduction in the size ofthe collection (●" Fig.1b). Culture of thepus yielded Escherichia coli and Entero-bacter cloacae. Irrigation with 100mL ofsaline was performed twice a day via thedrain. A repeat endoscopic drainage wasperformed 2 weeks later and the patientremained afebrile after the second endo-scopic drainage.To perform PCD, which can be trans-abdominal, transperineal, or transgluteal,one needs to find a straight path thatdoes not traverse anatomical structuressuch as the sacrum, rectum, and smallbowel [2]. Transrectal drainage with en-dorectal ultrasound guidance is anotheroption that can be used, especially whenthe collection is related to recent rectalsurgery [3]. These are non-invasive inter-ventions, but they are limited to the place-ment of relatively small drainage cathe-ters, usually 8–10Fr.In this case, endoscopic drainage not onlyallowed drainage of pus but also delocula-tion and removal of solid residuals. Inser-tion of a large-bore drainage catheter waspossible, with use of the track created,permitting repeated endoscopic lavageand debridement. This is the first case inthe literature to report the endoscopicdrainage of a presacral abscess. A similartechnique has been described in the man-agement of necrotizing pancreatitis [4,5].Endoscopy_UCTN_Code_TTT_1AT_2AFCompeting interests: NoneFig.1 Imaging 10 days after the penetrating perineal injury showing: a,b on magnetic resonanceimaging (MRI), a presacral abscess with paraspinal extension; c,d on a contrast enhanced computedtomography (CT) scan after the drainage procedure, a reduction in the size of the abscess and thedrainage catheter in situ.Cases and Techniques Library (CTL) E361Foo Chi Chung et al. Endoscopic drainage of presacral abscess… Endoscopy 2016; 48: E361–E362Downloaded by: The University of Hong Kong. Copyrighted material.Chi Chung Foo1,2, Zhong Hui Liu2,Joe King Man Fan1,21 Division of Colorectal Surgery, Depart-ment of Surgery, The University of HongKong, Hong Kong, China2 Department of Surgery, The Universityof Hong Kong – Shenzhen Hospital,Shenzhen, ChinaReferences1 Lorenz JM, Al-Refaie WB, Cash BD et al. ACRappropriateness criteria radiologic manage-ment of infected fluid collections. J Am CollRadiol 2015; 12: 791–7992 Trambert JJ. Percutaneous interventions inthe presacral space: CT-guided precoccygealapproach – early experience. Radiology1999; 213: 901–9043 Puri R, Choudhary NS, Kotecha H et al. Endo-scopic ultrasound-guided pelvic and pro-static abscess drainage: experience in 30 pa-tients. Ind J Gastroenterol 2014; 33: 410–4134 Becker V, Huber W, Meining A et al. Infectednecrosis in severe pancreatitis – combinednonsurgical multi-drainage with directedtransabdominal high-volume lavage in criti-cally ill patients. Pancreatology 2009; 9:280–2865 Yamamoto N, Isayama H, Takahara N et al.Percutaneous direct-endoscopic necrosec-tomy for walled-off pancreatic necrosis. En-doscopy 2013; 45 (Suppl. 02): E44–E45BibliographyDOI http://dx.doi.org/10.1055/s-0042-118597Endoscopy 2016; 48: E361–E362© Georg Thieme Verlag KGStuttgart · New YorkISSN 0013-726XCorresponding authorJoe K. M. Fan, MBBSDepartment of SurgeryQueen Mary Hospital102 Pokfulam RoadHong KongFax: +852-28728425drjoefan@hku.hkFig.2 Transperinealendoscopic drainageof the presacral andparaspinal abscess.The photo at the topright-hand cornershows an endoscopicview of the abscesscavity.Fig.3 Three-dimensional reconstruction of the post-drainage computed tomography (CT) scanshowing the position of the drainage catheter (red arrows). Note the rectum is vaguely seen becauseof the presence of rectal contrast.Video 1Transperineal endoscopic drainage of the pre-sacral and paraspinal abscess.Foo Chi Chung et al. Endoscopic drainage of presacral abscess… Endoscopy 2016; 48: E361–E362Cases and Techniques Library (CTL)E362Downloaded by: The University of Hong Kong. Copyrighted material.

Transperineal endoscopic drainage of a presacral and paraspinal abscess

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