EFFECTIVE ENDOSCOPIC ULTRASOUND-GUIDED TRANSRECTAL DRAINAGE OF A PERIANAL ABSCESS

Drenagem trans-retal endoscópica efetiva de abscesso perianal por ultra-som orientado

Keywords:
Drainage; endoscopy; ultrasonography; abscess.

Approximately 90% of all idiopathic perianal abscesses occur due to infection of the cryptoglobular glands^1,2. The purpose of drainage is to decompress the abscess cavity in order to prevent progressive inflammation, which could result in potentially life-threatening complications³.

A 31-year-old Japanese man was admitted to our hospital with severe anal pain and high fever. Computed tomography identified a perianal abscess and fluid collections near the right buttock (Figure 1). A surgical incision was made from the right buttock; however, drainage was poor because the fistula cavity was deep and long, and the symptoms worsened. We planned an endoscopic ultrasound (EUS)-guided perianal abscess drainage via the rectum. The drainage was performed using a convex EUS scope (GF-UCT260; Olympus Corp., Tokyo, Japan). The abscess was punctured with a 19-gauge needle (EZ Shot 3 Plus^®; Olympus Corp.) via the rectum at 75 mm from the anal verge. Fluid was aspirated to confirm that the puncture location was suitable, and the purulent material was collected (Figure 2a ). A 0.025-inch guidewire was inserted through the needle and coiled in the abscess cavity (Figure 2b). The puncture tract was dilated with a 6 mm balloon dilator (REN^®; Kaneka Medical Co., Tokyo, Japan). Thereafter, a double-pigtail plastic stent (DPPS; 7-Fr, 4 cm long) (Through & Pass^®; Gadelius Medical K.K., Tokyo, Japan) was passed through the dilated tract and into the abscess (Figures 2c, 2d, and 3); a large amount of purulent drainage started to flow into the colon soon after. This procedure was performed without any complications. On day 25 after drainage, the patient felt uncomfortable due to the migration of the DPPS towards the anus; computed tomography revealed a marked reduction in the abscess. We hypothesized that as the abscess space decreased, the DPPS moved to the anal side (Figure 4). We carefully pulled the DPPS using grasping forceps under endoscopic guidance (^E-VIDEO). We plan to perform an anal fistula surgery later, because it significantly reduces recurrences, persistent abscesses/fistulas, or the need for a repeat surgery⁴.

FIGURE 1
A 31-year-old Japanese man was admitted to our hospital with severe anal pain and high fever.

FIGURE 2
Procedure for EUS-guided perianal abscess drainage via the rectum.

FIGURE 3
The plastic stent is a 7-Fr, 4 cm long double-pigtail plastic stent (Through & Pass^®; Gadelius Medical K.K., Tokyo, Japan).

FIGURE 4
The patient felt uncomfortable due to the migration of the double-pigtail plastic stent (DPPS) towards the anus. Abdominal computed tomography reveals a marked reduction in the abscess, and the DPPS is noted to have moved to the anal side (arrow) at 25 days after the drainage.

EUS-guided perianal abscess drainage is more effective and safer than surgical or percutaneous drainage, because it has a minimal risk of injury to the nearby blood vessels and of material leakage at the puncture site⁵. Because the drainage tube can be placed inside the rectum, it is a useful method for long-term drainage and has a reduced risk of complications.

REFERENCES

• ¹
  Eisenhammer S. The internal anal sphincter and the anorectal abscess. Surg Gynecol Obstet. 1956;103:501-6.
• ²
  Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976;63:1-12.
• ³
  Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier’s gangrene: an analysis of 80 patients and a novel scoring system. Tech Coloproctol. 2010;14:217-23.
• ⁴
  Malik AI, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010;CD006827.
• ⁵
  Poincloux L, Caillol F, Allimant C, Bories E, Pesenti C, Mulliez A, et al. Long-term outcome of endoscopic ultrasound-guided pelvic abscess drainage: a two-center series. Endoscopy. 2017;49:484-90.

• E-VIDEO: https://youtu.be/GsZRSGGbjHE

• Disclosure of funding: no funding received

Publication Dates

• Publication in this collection
  06 July 2022
• Date of issue
  Apr-Jun 2022

History

• Received
  30 Aug 2021
• Accepted
  26 Nov 2021