Jacobi ring catheter treatment of Bartholin’s abscesses
Jacobi ring catheter treatment of Bartholin’s abscesses
To the Editor,
The treatment of Bartholin’s abscesses can be challeng- ing. A painful drainage procedure is usually required and a device is often placed in a sensitive area for several weeks to facilitate prolonged drainage of the gland. Recurrences are common. In many emergency departments (EDs), including ours, the process of incision and drainage of the abscess followed by placement of a Word catheter has been adopted as the standard approach to care of these abscesses. The Word catheter is a commercially available device that consists of a latex catheter with an inflatable balloon at its tip, which holds the catheter in place as the abscess continues to drain. Placement of the Word catheter is sometimes difficult. If the incision is too small, it is difficult to insert the catheter. If the incision is too long, the catheters often fall out before scheduled removal. In addition, patients often complain of pain if the Word catheter is overinflated. We investigated the use of a rubber ring catheter (the Jacobi ring) in the treatment of Bartholin’s abscesses. The ring catheter was made from a 7-cm length of an 8-French T tube threaded with a 20-cm length of 2-0 silk suture (Fig. 1). The catheter enters and exits the abscess through 2 separate incisions, forming a closed rubber ring when the suture ends are tied (Fig. 2). We compared the efficacy of the ring catheter
with that the Word catheter in a controlled trial.
The study was conducted at an urban teaching hospital over a 5-year period. Adult patients presenting to the ED with Bartholin’s abscesses were eligible for the study. Informed consent was obtained from all study patients. Patients who agreed to participate were randomized to treatment with either the ring catheter or a Word catheter. Patients who declined to participate were treated with a Word catheter. Randomization was performed using a random number table; the sequence was maintained on a list that was kept in a separate location and concealed until allocation. Administration of analgesia and treatment of the abscess were done by emergency medicine physicians. Incision and drainage of the abscess were performed with adjunctive and/ or local anesthesia at the discretion of the treating physician. Adjunctive anesthesia consisted of conscious sedation with the use of intravenous midazolam and fentanyl. A ring catheter or a Word catheter was placed by the physician after the abscess was drained. Patients returned for follow-up at 3 weeks, when the catheters were removed. The recurrence rate at 6 months was determined by telephone follow-up.
Physicians rated the ease of catheter placement as very easy, easy, difficult, or very difficult at the initial visit. At the follow-up visit, patients were asked if they were very satisfied, satisfied, unsatisfied, or very unsatisfied. Success- ful placement of the catheter, Abscess resolution, and
Presented in abstract form at the 2004 SAEM annual meeting.
Fig. 1 The Jacobi ring.
recurrence were recorded at the initial presentation, during the 3-week return visit, and at 6 months, respectively.
The primary outcomes of the study were successful placement of the catheter and resolution of the abscess. Secondary outcomes included ease of insertion, patient satisfaction, and recurrence at 6 months. Data were entered and analyzed using EpiInfo 6 (CDC, Atlanta, Ga). Compar- isons of catheter placement success, abscess resolution, and recurrence between the 2 groups were done using the Fisher exact test. Comparisons of ease of insertion and patient satisfaction were done using v2 analysis. The study was approved by our institutional review board.
Thirty-eight patients were enrolled in the study, 25 were randomized to the ring catheter and 13 to the Word catheter. All patients had successful placement of the catheter and resolution of the abscess after 3 weeks. No patient had a recurrence at 6 months. Hence, there were no significant clinical or statistical differences regarding catheter place- ment success, abscess resolution, or recurrence. The ease of insertion was similar for the 2 devices (Table 1; P = .08). Patient satisfaction was higher in patients treated with the ring catheter (Table 2, P b .05).
All catheters remained in place during the 3-week treatment period. Of interest, 2 patients had recurrence of the Bartholin’s abscess during the study period. Both recurrences occurred 1 year after the initial presentation. One patient was initially treated with the ring catheter and the second patient with a Word catheter.
The ring catheter appears to be effective in the treatment of Bartholin’s abscesses. In addition, patients appear to be more satisfied with the ring catheter than with the Word catheter. The ring catheter was judged as easy or very easy to insert in 24 of 25 cases, although most of our providers had little to no experience inserting the device.
Because catheter placement is somewhat provider dependent, our study may not be generalizable because of our institutional experience with both catheters. Our ED has a relatively large volume of patients with Bartholin’s abscesses, and we were experienced in using the Word
Fig. 2 Placement of a Jacobi ring. (1) An incision is made into the mucosal surface of the Bartholin’s abscess. Adhesions are lysed and the abscess is allowed to drain. (2) A hemostat is passed into the abscess cavity. (3) The hemostat is tunneled into the abscess cavity and a second incision is made. (4) The hemostat is used to grasp one end of the Jacobi ring. (5) The Jacobi ring is pulled through the abscess cavity with care that the suture is not pulled out of the catheter. (6) The 2 ends of the suture are tied, forming the closed ring.
catheter as our Treatment modality of choice. This may explain the low complication rate with the Word catheter in our study (ie, none of the catheters were dislodged prematurely). We also developed the ring catheter and gained experience with its use before initiating this study. The learning curve for the use of either catheter therefore may affect the performance of the catheters at sites where neither catheter is commonly used.
The true complication rate of Word catheters is likely higher than that identified in this study. Patients who declined to participate in the study were treated with Word catheters, which was previously our standard therapeutic approach to these abscesses. Although we did not record data for patients who declined to participate in the study, during the study period, no fewer than 3 of these patients presented with spontaneous displacement of the Word catheter before scheduled removal.
There are several limitations to our study. First, the trial could not be performed in a blinded fashion; thus, the ease
Table 1 Ease of device insertion
Ring
Very easy
Easy Difficult Very difficult
P = .08 (v2 analysis).
13
11
1
0
Word
8
2
3
0
Table 2 Patient satisfaction with device
Ring
Very satisfied
Satisfied Unsatisfied Very unsatisfied
P = .0032 (v2 analysis).
21
3
1
0
Word
3
10
0
0
of placement, as reported by the treating physicians, is subject to provider bias. Similarly, the patients may be biased in their reported satisfaction, although few would have preconceived notions about either of the devices. Second, anesthesia was not standardized in the study. Some patients received adjunctive anesthesia whereas others received local anesthesia only. We chose to allow the providers to use conscious sedation as needed to reflect our current practice and to avoid unnecessary application of this potentially risky modality. We doubt that the anesthesia selection had a major impact on patient satisfaction because these data were collected 3 weeks after the procedure. Third, our randomization table favored allocation to the ring catheter. The sample size of the 2 groups differed and, overall, was relatively small. Finally, the 6-month follow- up period may not be sufficient to reflect long-term outcome, particularly in light of the 2 recurrences that occurred at 1 year.
Paul Gennis MD Siu Fai Li MD Jennifer Provataris MD
Samina Shahabuddin MD Alison Schachtel MD Evelyn Lee MD
Department of Emergency Medicine
Jacobi Medical Center Albert Einstein College of Medicine
Bronx, NY 10461, USA
E-mail address: [email protected]
Paul Bobby MD
Department of Obstetrics and Gynecology
Jacobi Medical Center Albert Einstein College of Medicine
Bronx, NY 10461, USA
doi:10.1016/j.ajem.2005.02.033
Treatment of severe hypertriglyceridemia in nonDiabetic patients with insulin
To the Editor,
In nondiabetic individuals, insulin may be an effective and safe treatment of severe hypertriglyceridemia (serum