Transanal endoscopic drainage of abdominopelvic sepsis.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an evolving experimental field exploring the technical feasibility and outcome of therapeutic interventions performed through the natural orifices of the body. The knowledge accumulating in NOTES is the result of animal experimentation and ongoing early clinical experience in humans. In this report we describe a patient treated with transanal endoscopic drainage of postoperative abdominopelvic sepsis.

INTRODUCTION

Natural Orifice Transluminal Endoscopic Surgery (NOTES) has recently generated significant interest amongst surgeons and gastroenterologists.[1-14] Pushing minimally invasive surgery a step forward, the concept of incisionless surgery is appealing to patients and physicians alike. Accessing the abdominal cavity and its organs via natural orifices, such as the mouth, anus, vagina, and urethra, may enable surgeons in the future to approach operations they traditionally performed in open and laparoscopic fashions. The potential benefits of such techniques include less physiologic stress and trauma; faster recovery; less pain; fewer complications, such as intestinal adhesions and hernia; better cosmesis; and decreased healthcare cost by decreasing the rate of hospitalization.[1-14] The technical feasibility of NOTES has been demonstrated in animal models. Several operations including cholecystectomy, splenectomy, appendectomy, gastrojejunostomy, and oophorectomy have been performed.[1,3-5,7,10-12] However, little data are available in humans.[13,14] The following case illustrates the application of NOTES in the treatment of abdominal sepsis.

CASE REPORT

A 61-year-old woman with ulcerative colitis refractory to medical therapy presented to our department following numerous admissions for anemia requiring blood transfusions. She had 12 to 15 bloody bowel movements daily. The patient was on 60 mg of prednisone and Coumadin. She had a history of deep venous thrombosis and pulmonary embolism status post placement of an inferior vena cava filter, cerebrovascular disease with left hemiplegia, and coronary artery disease. Because of her disabling symptoms, the patient elected to proceed with surgical intervention. She underwent an uneventful proctocolectomy with end ileostomy. On postoperative day 1, the patient developed phlegmasia cerulea dolens, and an MRI revealed thrombosis of her inferior vena cava and iliac veins. Her symptoms improved following intravenous heparin. On postoperative day 5, the patient developed acute abdominal hemorrhage. The heparin was discontinued and the patient was transfused. She remained stable until postoperative day 12 when she became septic. CT scan revealed an infected lower abdominal and pelvic hematoma (. Transanal drainage through the anal cuff was performed at the bedside with irrigation of the lower pelvis with a mushroom catheter, and antibiotic therapy was instituted. The patient remained septic and 2 days later underwent placement of a percutaneous drain by interventional radiology. The drain was ineffective due to the organized nature of the infected hematoma with multiple septations and phlegmonous reaction. No clinical improvement was noted. Re-exploration and drainage of the abdomen was entertained, but due to the frailty of the patient, a transanal endoscopic drainage was performed on postoperative day 17 in the endoscopy suite. The peritoneal cavity was accessed transanally with a flexible sigmoidoscope (60 cm). Room air under pressure was used to insufflate the abdominopelvic cavity for visualization. A large, multiseptated and organized intraperitoneal hematoma was encountered with the pigtail drain embedded in a fibrinous collection (. Following mechanical and hydrogen peroxide fragmentation, the hematoma was retrieved with suction, forceps, and baskets, and the pelvis and lower abdomen were cleared (. CT scan images were used to guide the depth of intervention to minimize any injury to small bowel. Two 19 French round Blake drains were introduced via the anal opening and guided into the abdomen with the use of an endoscopic snare.

Computed tomography image reveals a component of the abdominal hematoma (white arrow).

Endoscopic view of the hematoma with the embedded pigtail drain.

(A) Hydrogen peroxide fragmentation of hematoma via ERCP catheter. (B) Hematoma retrieval with Roth Basket.

The patient's clinical status rapidly improved, and her white count normalized within 2 days. Cultures grew Escherichia coli, Enterococcus faecium, and Morganella morganii. On postoperative day 30, all drains were removed and the patient was discharged.

DISCUSSION

The evolution of minimally invasive surgery over the last 2 decades has redefined the practice of surgery. Driven by technological advances and supporting clinical data, the implementation of these new techniques has been remarkable and has stimulated inquiry into future directions. NOTES has emerged as a serious sequel to the minimally invasive surgery revolution.[1] Future development within the field will result from continuous technological innovations and animal experimentation.[1-14] But ultimately, these burgeoning techniques need to be applied to human patients. Undoubtedly, most of the initial human data will come from case reports and short series attesting to the feasibility, safety, and limitations of NOTES. Rao and colleagues[13,14] from India have already demonstrated that appendectomy via a transgastric route is feasible in humans.

Although transanal drainage of pelvic sepsis (the bedside drainage we performed in our patient as initial intervention) is a known procedure in the surgical armamentarium, this report illustrates the utilization of flexible endoscopy to reach a higher location in the abdominopelvic cavity and to perform more extensive drainage of a loculated infected hematoma. Our case exemplifies an unusual application of NOTES. The patient had failed bedside transanal drainage, antibiotics, and subsequent percutaneous drainage. None of these interventions were successful due to the location, extent, and nature of the organized hematoma, and the overall debilitated state of the patient. Although commonly used, percutaneous drainage is not always successful at controlling abdominal sepsis.[15,16] In our case, re-exploratory laparotomy was the only remaining option to evacuate the patient's infected hematoma. Considering her clinical status, such an intervention would have carried significant morbidity. With the patient's full consent, a transanal endoscopic approach was used to successfully treat her condition. Obviously in this case, the rectum was surgically missing so access to the peritoneal cavity was unhindered, and it was not necessary to close the anorectal stump. Had the rectum been present, a transanal proctotomy would have been necessary to gain access to the abdomen. But this case illustrates that it is technically feasible to endoscopically tackle the postoperative abdomen, fragment, retrieve, and drain infected hematoma with current equipment. The equipment and endoscopic expertise to perform such a task in a routine, reliable, and safe fashion are currently limited but growing.[17,18] In addition, several endoluminal methods and devices are being developed to gain entry access into the peritoneal cavity through the digestive tract.[7]

CONCLUSION

NOTES is a field in its infancy, and whether it will gain widespread acceptance and application is yet to be determined. Although most advances in this field will be driven by animal experimentation, some may result from challenging situations such as our case that may provide opportunities to push the boundaries of our current surgical practices.