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Transgluteal Approach for Draining Pelvic Fluid Collections in Pediatric Patients¹

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).

View larger version (107K): [in a new window]   Figure 1a. Prone transverse CT scans in a 15-year-old female patient with a pelvic abscess in the pouch of Douglas after perforating appendicitis. (a) Purulent fluid was aspirated through the transgluteal sheathed access needle (Yueh; Cook, Bloomington, Ill). The stylet was removed from the needle (short arrow) and a guidewire (long arrow) advanced into the collection. Layering gastrointestinal contrast material (*) remains evident in dependent portions of rectum and bowel loops. (b) Scan obtained after the tract was dilated to 9 F and an 8.5-F locking pigtail drainage catheter advanced into the collection over a metal stiffener. The stiffener and guidewire were removed and the catheter (arrow) was locked and fixed to the skin. The cavity was aspirated and the catheter left to gravity drainage. Layering gastrointestinal contrast material (*) remains evident in dependent portions of rectum and bowel loops.

View larger version (106K): [in a new window]   Figure 1b. Prone transverse CT scans in a 15-year-old female patient with a pelvic abscess in the pouch of Douglas after perforating appendicitis. (a) Purulent fluid was aspirated through the transgluteal sheathed access needle (Yueh; Cook, Bloomington, Ill). The stylet was removed from the needle (short arrow) and a guidewire (long arrow) advanced into the collection. Layering gastrointestinal contrast material (*) remains evident in dependent portions of rectum and bowel loops. (b) Scan obtained after the tract was dilated to 9 F and an 8.5-F locking pigtail drainage catheter advanced into the collection over a metal stiffener. The stiffener and guidewire were removed and the catheter (arrow) was locked and fixed to the skin. The cavity was aspirated and the catheter left to gravity drainage. Layering gastrointestinal contrast material (*) remains evident in dependent portions of rectum and bowel loops.

View larger version (105K): [in a new window]   Figure 2a. Images in a 6-year-old girl who had successfully undergone drainage of multiple abdominopelvic abscesses after perforating appendicitis. (a) CT scan obtained through the pelvis with the patient in a supine position after rectal and intravenous administration of contrast material shows a newly diagnosed low-attenuation fluid collection within an enhancing thick-walled abscess cavity (arrows) in the pouch of Douglas. Contrast material (*) is also seen in the dependent portion of the urinary bladder anterolateral to the abscess. (b) Fluoroscopic image obtained with the patient prone shows the guidewire being advanced with a transgluteal approach into the pelvic fluid collection through a Yueh needle, which was then removed. The needle evident on this image was used for initial access in a tandem-needle technique. Aspiration of grossly purulent fluid helped confirm the location within the abscess cavity. Dilute contrast material from a previous imaging study remains evident in the right ureter and urinary bladder. (c) Fluoroscopic image obtained with the patient prone. The tract was dilated to 9 F and an 8.5-F locking pigtail catheter (arrow) was inserted over the guidewire, which was then withdrawn. Approximately 60 mL of frankly purulent fluid was aspirated. A small amount of contrast material (*) was injected through the catheter to help confirm location within the abscess cavity. Dilute contrast material from a previous imaging study remains evident in the ureters and urinary bladder. The pigtail was locked and the catheter secured to the skin and left to gravity drainage. (d) Follow-up supine CT scan obtained through the pelvis after rectal (*) and intravenous administration of contrast material. The scan was obtained several days after drain insertion and demonstrates the drainage catheter (arrows) in a satisfactory position and interval decompression of the abscess cavity. The drain was removed shortly after this study was obtained, without recurrence of the fluid collection.

View larger version (153K): [in a new window]   Figure 2b. Images in a 6-year-old girl who had successfully undergone drainage of multiple abdominopelvic abscesses after perforating appendicitis. (a) CT scan obtained through the pelvis with the patient in a supine position after rectal and intravenous administration of contrast material shows a newly diagnosed low-attenuation fluid collection within an enhancing thick-walled abscess cavity (arrows) in the pouch of Douglas. Contrast material (*) is also seen in the dependent portion of the urinary bladder anterolateral to the abscess. (b) Fluoroscopic image obtained with the patient prone shows the guidewire being advanced with a transgluteal approach into the pelvic fluid collection through a Yueh needle, which was then removed. The needle evident on this image was used for initial access in a tandem-needle technique. Aspiration of grossly purulent fluid helped confirm the location within the abscess cavity. Dilute contrast material from a previous imaging study remains evident in the right ureter and urinary bladder. (c) Fluoroscopic image obtained with the patient prone. The tract was dilated to 9 F and an 8.5-F locking pigtail catheter (arrow) was inserted over the guidewire, which was then withdrawn. Approximately 60 mL of frankly purulent fluid was aspirated. A small amount of contrast material (*) was injected through the catheter to help confirm location within the abscess cavity. Dilute contrast material from a previous imaging study remains evident in the ureters and urinary bladder. The pigtail was locked and the catheter secured to the skin and left to gravity drainage. (d) Follow-up supine CT scan obtained through the pelvis after rectal (*) and intravenous administration of contrast material. The scan was obtained several days after drain insertion and demonstrates the drainage catheter (arrows) in a satisfactory position and interval decompression of the abscess cavity. The drain was removed shortly after this study was obtained, without recurrence of the fluid collection.

View larger version (144K): [in a new window]   Figure 2c. Images in a 6-year-old girl who had successfully undergone drainage of multiple abdominopelvic abscesses after perforating appendicitis. (a) CT scan obtained through the pelvis with the patient in a supine position after rectal and intravenous administration of contrast material shows a newly diagnosed low-attenuation fluid collection within an enhancing thick-walled abscess cavity (arrows) in the pouch of Douglas. Contrast material (*) is also seen in the dependent portion of the urinary bladder anterolateral to the abscess. (b) Fluoroscopic image obtained with the patient prone shows the guidewire being advanced with a transgluteal approach into the pelvic fluid collection through a Yueh needle, which was then removed. The needle evident on this image was used for initial access in a tandem-needle technique. Aspiration of grossly purulent fluid helped confirm the location within the abscess cavity. Dilute contrast material from a previous imaging study remains evident in the right ureter and urinary bladder. (c) Fluoroscopic image obtained with the patient prone. The tract was dilated to 9 F and an 8.5-F locking pigtail catheter (arrow) was inserted over the guidewire, which was then withdrawn. Approximately 60 mL of frankly purulent fluid was aspirated. A small amount of contrast material (*) was injected through the catheter to help confirm location within the abscess cavity. Dilute contrast material from a previous imaging study remains evident in the ureters and urinary bladder. The pigtail was locked and the catheter secured to the skin and left to gravity drainage. (d) Follow-up supine CT scan obtained through the pelvis after rectal (*) and intravenous administration of contrast material. The scan was obtained several days after drain insertion and demonstrates the drainage catheter (arrows) in a satisfactory position and interval decompression of the abscess cavity. The drain was removed shortly after this study was obtained, without recurrence of the fluid collection.

View larger version (90K): [in a new window]   Figure 2d. Images in a 6-year-old girl who had successfully undergone drainage of multiple abdominopelvic abscesses after perforating appendicitis. (a) CT scan obtained through the pelvis with the patient in a supine position after rectal and intravenous administration of contrast material shows a newly diagnosed low-attenuation fluid collection within an enhancing thick-walled abscess cavity (arrows) in the pouch of Douglas. Contrast material (*) is also seen in the dependent portion of the urinary bladder anterolateral to the abscess. (b) Fluoroscopic image obtained with the patient prone shows the guidewire being advanced with a transgluteal approach into the pelvic fluid collection through a Yueh needle, which was then removed. The needle evident on this image was used for initial access in a tandem-needle technique. Aspiration of grossly purulent fluid helped confirm the location within the abscess cavity. Dilute contrast material from a previous imaging study remains evident in the right ureter and urinary bladder. (c) Fluoroscopic image obtained with the patient prone. The tract was dilated to 9 F and an 8.5-F locking pigtail catheter (arrow) was inserted over the guidewire, which was then withdrawn. Approximately 60 mL of frankly purulent fluid was aspirated. A small amount of contrast material (*) was injected through the catheter to help confirm location within the abscess cavity. Dilute contrast material from a previous imaging study remains evident in the ureters and urinary bladder. The pigtail was locked and the catheter secured to the skin and left to gravity drainage. (d) Follow-up supine CT scan obtained through the pelvis after rectal (*) and intravenous administration of contrast material. The scan was obtained several days after drain insertion and demonstrates the drainage catheter (arrows) in a satisfactory position and interval decompression of the abscess cavity. The drain was removed shortly after this study was obtained, without recurrence of the fluid collection.