Transrectal ultrasound-guided endoscopic drainage and vacuum therapy of pelvic abscesses: an alternative to (computed tomography-guided) percutaneous drainage
06 March 2013 (online)
A 43-year-old, otherwise healthy man had increasing abdominal pain in the lower abdomen without a fever. His leukocyte count was 20.0 × 109/L (normal range: 4 – 9 × 109/L) and the C-reactive protein level was 155.5 mg/L (normal < 5 mg/L). Abdominal computed tomography (CT) confirmed the suspected diagnosis of diverticulitis and revealed a large pelvic abscess ([Fig. 1]). The intended CT-guided drainage  carried a high risk of injury to the iliac vessels in a translumbar approach and of damaging the sciatic nerve for access through the obturator foramen. The overlying small bowel forbade a ventral approach. The patient underwent transrectal endosonography ([Fig. 2]) for localization of the abscess. Using an endoscopic cystoenterostomy device (Cystotome, Cook Medical, Winston-Salem, North Carolina, USA), originally developed for transgastric puncturing of pancreatic pseudocysts, the abscess was punctured under ultrasonographic guidance. After the puncture site was emptied of pus and dilated with a standard balloon ([Fig. 3]), the abscess cavity was flushed and a vacuum therapy sponge (Endo-SPONGE, B. Braun, Melsungen, Germany) was inserted into it ([Fig. 4]). The patient received antibiotics and parenteral feed for the first week. No ostomy was placed. The vacuum therapy sponge was changed endoscopically on every third day until day 17, when the patient was discharged. Laparoscopic sigmoid resection was performed 1 month later without complications.
The abscess should be punctured as far orally as possible because the sigmoid resection must include the fistula created by the puncture. Otherwise, the resection line will unnecessarily be pushed further aborally. Transrectal one-time abscess puncture , and temporary transrectal drain placement are feasible options . However, in case of complicated diverticulitis, transrectal ultrasound-guided endoscopic drainage followed by vacuum sponge therapy similar to that for an anastomotic leak in the same region   is a safe alternative in the hands of an experienced endoscopist and might spare the patient an ostomy.
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