Modified Retroperitoneal Access for Percutaneous Intervention after Pancreaticoduodenectomy
A 61 year-old man developed a non-remitting fever, 7 days after pancreaticoduodenectomy. CT showed an abscess in surgical bed of the pancreaticouodenectomy (excised pancreatic head) ("*", ). Based on the CT findings, direct anterior approach was considered suboptimal with overlying bowel loop, liver and post-surgical drains and phlegmon. A retroperitoneal approach through the anterior pararenal space was elected (white line, ). With the patient in the left lateral decubitus position, under CT fluoroscopic guidance, a two-part 18 G Trocar needle (Cook Medical, Bloomington, IN, USA) () was inserted into the anterior pararenal space, between the ascending colon and the right kidney. To increase the margin of safety in the planned trajectory that is extremely narrow (white line, ), hydrodissection using 20 mL of diluted contrast (2% by volume; 1 mL of Omnipaque 350 in 50 mL of saline) was performed by continuous injection through the outer cannula of the Trocar needle (with stylet removed), during a small incremental advancement. The "salinoma" created displaces of the colon from the right kidney, creating a safe corridor for a needle passage (). On reaching the abscess cavity, a 0.035 inch Rosen guidewire (Cook Medical, Bloomington, IN, USA) was inserted and the track dilated, using a 10 Fr Coons dilator (Cook Medical, Bloomington, IN, USA). A 10 Fr Navarre drainage catheter was inserted (Bard Peripheral Vascular, Tempe, AZ, USA), yielding a 20 mL of frank pus. The drainage catheter was removed 5 days later on the resolution of the abscess () and patient had an uneventful recovery period.