Drainage of a para-aortic abscess by transrectal endoscopic retroperitoneoscopy (with video)

BRIEF REPORTS

Drainage of a para-aortic abscess by transrectal endoscopic retroperitoneoscopy (with video) Gianfranco Donatelli, MD, Silvana Perretta, MD, Pierre Allemann, MD, Jacopo D’Agostino, MD, Parag Dhumane, MD, Federico Costantino, MD, Bernard Dallemagne, MD, Michel Doffoel, MD, Jacques Marescaux, MD, FRCS, FACS Strasbourg, France

Retroperitoneoscopy and the transperitoneal approach are well-established for retroperitoneal procedures. Natural orifice transluminal endoscopic surgery (NOTES) is a rapidly evolving mode of surgical access to body cavities. NOTES has been well-demonstrated in animal models and in (sporadic) human cases for various surgeries.1 In this report, we describe the first human case of transrectal endoscopic retroperitoneoscopy for drainage of a paraaortic periprosthetic abscess.

CASE REPORT A 58-year-old man was transferred to the intensive care unit of our hospital with a diagnosis of septic shock after open repair of an abdominal aortic aneurysm by using an aortobifemoral prosthesis without reimplantation of the inferior mesenteric artery. He responded well to aggressive antibiotic therapy. A lower GI endoscopy done for bloody diarrhea on postoperative day 12 showed full-thickness necrosis of the sigmoid and left colon. The patient was taken back to the operating room, and a colonic resection with terminal colostomy was performed, leaving a small, rectal stump. After some clinical improvement initially, the patient was readmitted to the intensive care unit for hemorrhagic shock on the 10th postoperative day (of the second surgery) because of an infected retroperitoneal hematoma detected on CT scanning (Figs. 1 and 2). Third-generation antibiotic therapy and percutaneous radiological drainage of the abscess were attempted without success. The endoscopic intervention was subsequently planned because of continued sepsis with mucus discharge per anum and widening of the retroperitoneal collection with suspected communication with the rectal stump on CT scanning. With the patient in the lithotomy position and under conscious sedation, we performed digital anal exploration and drained a large amount of pus and old blood that had collected in the anus. Endoscopy revealed complete dehiscence of the rectal stump, leading to a closed cavity (Video 1, available online at www. giejournal.org). After suctioning about 300 mL of bloodstained, purulent fluid, we advanced the endoscope further into the retroperitoneum to finish exploration and drainage of the abscess cavity. The retroperitoneoscopy performed in 1162 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 5 : 2011

Figure 1. Retroperitoneal para-aortic abscess.

this para-aortic space clearly visualized the aorta with its prosthesis, the left kidney, and the psoas muscle. The cavity was thoroughly washed with 500 mL of sterile (37°C) saline solution, and a silicon drain, pulled endoscopically, was left in the cavity 40 cm from the anal verge. A low insufflation rate was maintained throughout exploration without leakage of gas into the peritoneal cavity. The drain was removed after 1 week, and the rectal stump was stapled by laparoscopic access. The patient improved and was discharged after a month.

DISCUSSION Retroperitoneal access has been used for a long time for vascular, kidney, lymph node, and adrenal gland surgeries and drainage of postpancreatitis infected necrosis to avoid contamination of the peritoneal cavity.2 Recently, natural orifices have been used to access various abdominal organs. The transvaginal NOTES retroperitoneoscopic approach has www.giejournal.org

Brief Reports

tion and difficulty in securing rectotomy site closure needs to be done. In conclusion, the human retroperitoneal space is a virtually tangible space approachable via the infraperitoneal rectum. This can become an alternative in humans to the well-established transvaginal NOTES access. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Abbreviation: NOTES, natural orifice transluminal endoscopic surgery.

REFERENCES

Figure 2. Para-aortic abscess, perirenal extension.

been described for kidney resection, lymphadenectomy, and adrenal gland resection in animal models.3,4 A hybrid transvaginal retroperitoneoscopic nephrectomy in a human was recently reported.5 Here, we report the first case of transrectal drainage of a retroperitoneal para-aortic abscess after failure of percutaneous drainage. With advantages like avoidance of general anaesthesia in critically ill patients and relative ease of access in patients with previous abdominal surgery, the transrectal retroperitoneoscopic route can be of value, especially in such difficult clinical settings. EUS guidance can be of help in localizing the abscess if the draining point of the abscess is not visualized during endoscopy. A risk-benefit analysis of this type of access in the context of risk of infec-

1. Swanström L. Natural orifices transluminal endoscopic surgery. Endoscopy 2009;41:82-5. 2. Connor S, Ghaneh P, Raraty M, et al. Minimally invasive retroperitoneal pancreatic necrosectomy. Dig Surgery 2003;20:270-7. 3. Perretta S, Allemann P, Asakuma M, et al. Feasibility of right and left transvaginal retroperitoneal nephrectomy: from the porcine to the cadaver model. J Endourol 2009;23:1887-92. 4. Perretta S, Allemann P, Asakuma M, et al. Adrenalectomy using natural orifice translumenal endoscopic surgery (NOTES): a transvaginal retroperitoneal approach. Surg Endosc 2009;23:1390. 5. Zorron R, Goncalves L, Leal D, et al. Transvaginal hybrid natural orifice transluminal endoscopic surgery retroperitoneoscopy, the first human case report. J Endourol 2010;24:233-7. Institut de Recherche contre les Cancers de l’Appareil Digestif/European Institute of TeleSuregry (IRCAD/EITS), Department of Gastrointestinal and Endocrine Surgery (G.D., S.P., P.A., J.D., P.D., F.C., B.D., J.M.), Department of Hepatogastroenterology (M.D.), University of Strasbourg, Strasbourg, France. Reprint requests: Dr Gianfranco Donatelli, University of Strasbourg, Department of Gastrointestinal and Endocrine Surgery, 1 Place de l’Hopital, Strasbourg, FR 67091. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.10.054

Radiofrequency ablation-associated necrosis of the hepatic duct confluence: re-establishing biliary continuity with percutaneous cholangiographic-peroral cholangioscopic rendezvous (with videos) Arne Schneider, MD, Jochen Türck, MD, Thomas Helmberger, MD, Ralf Schmid, MD, Wolfgang Schepp, MD Munich, Germany

Radiofrequency ablation (RFA) is a technique widely used for the treatment of hepatic metastases and primary hepatic tumors. Direct thermal injury to the biliary ducts is very rare.1 We report a combined endoscopic approach to reestablish biliary drainage after accidental thermal destruction of the main hepatic branches during RFA. www.giejournal.org

CASE REPORT A 50-year-old woman with painless jaundice was seen at our clinic. She had a history of breast cancer, primarily diagnosed and resected 9 years ago. After several courses of chemotherapy and RFA for hepatic metastases, the patient Volume 74, No. 5 : 2011 GASTROINTESTINAL ENDOSCOPY 1163