The inaccessible or undrainable abscess: how to drain it

CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment

The celiac plexus is the largest visceral plexus and is located deep in the retroperitoneum, over the anterolateral surface of the aorta and around the origin of the celiac trunk. It serves as a relay center for nociceptive impulses that originate from the upper abdominal viscera, from the stomach to the proximal transverse colon. Celiac plexus neurolysis, with agents such as ethanol, is an effective means of diminishing pain that arises from these structures. Percutaneous imaging-guided celiac plexus neurolysis has been established as an invaluable therapeutic option in the management of intractable abdominal pain in patients with upper abdominal malignancy. The use of multidetector computed tomography (CT) for imaging guidance has superseded other modalities and allows direct visualization of the spread of the neurolytic agent in the antecrural space. Accurate depiction of the retroperitoneal anatomy and the position of the needle tip helps avoid crucial anatomic structures such as the pancreas, aorta, celiac artery, and superior mesenteric artery. Proper patient education, meticulous preprocedure planning, use of optimal multidetector CT techniques, adjunctive CT maneuvers, and postprocedure care are integral to successful celiac plexus neurolysis. Celiac plexus neurolysis does not completely abolish pain; rather, it diminishes pain, helping to reduce opioid requirements and their related side effects and improving survival in patients with upper abdominal malignancy.

[CT-guided biopsies and drainage]

Following the implementation of computed tomography (CT) or ultrasound-guided biopsy of solid tumors and the puncture and drainage of liquid processes, the number of surgical open biopsies and curative operations for abscess drainage has declined. Such CT-guided interventions are performed in nearly every organ. Instead of aspiration biopsies, more and more core biopsies are being performed to allow histopathological evaluation and thus allowing targeted therapy.This article is intended to give a general overview of techniques, materials, indications and contraindications. Ultrasound-guided biopsies as well as large bore vacuum biopsies of the breast are not included in this review.

Ultrasound-guided drainage of deep pelvic abscesses: experience with 33 cases

The aim of this study was to demonstrate and evaluate the ultrasound-guided drainage of deep pelvic abscesses in which transabdominal percutaneous access could not be performed because of overlying structures. A retrospective analysis of 32 consecutive patients with 33 deep pelvic abscesses was performed. The underlying causes of the abscesses included postsurgical fluid collection or surgical complications in 18 of the 32 patients, and 11 of these patients underwent recent rectal cancer surgery. The locations of the abscesses, which had a median diameter of 6 cm (range 2-10 cm), were as follows: perirectal (n=13), presacral (n=9), pouch of Douglas (n=7), internal genitals (n=2) and between the bowel loops (n=2). The abscesses were all drained using ultrasound (US) guidance with a transrectal (n=18), transvaginal (n=11), transperineal ( n=2) or transgluteal (n=2) approach. Of the larger abscesses (median diameter 7 cm), 19 were treated with catheter drainage and 18 of these cases resulted in favorable clinical outcomes. Of the smaller abscesses (median diameter 4 cm), 14 were treated with needle drainage. In two of these cases, follow-up US showed that a repeat puncture and drainage was necessary. All needle drainages resulted in favorable clinical outcomes. Sixteen of the 29 transrectal or transvaginal drainage procedures were performed without any anesthesia (10 were performed with a needle and six were performed with a catheter). Apart from minor discomfort during the drainage procedure and the subsequent in-dwelling catheter period, there were no serious complications related to the drainage procedures. We conclude that ultrasound-guided transrectal, transvaginal, transperineal and transgluteal drainage of deep pelvic abscesses are safe and effective treatment approaches. Based on our findings, needle drainage will be our most common first-line treatment approach because of the simplicity of the procedure, improved patient comfort and reduced costs. Catheter drainage will be reserved for large multiloculated abscesses.

Nonsurgical treatment of pyomyoma in the postpartum period

BACKGROUND

Only 13 cases of pyomyoma related to pregnancy have been described since 1945. Treatment consists of hysterectomy, which exposes critically ill patients to operative risks and induces infertility.

CASES

Three cases of pyomyoma in the postpartum period are described. Treatment using computed tomography-guided drainage was realized successfully in two cases.

CONCLUSION

Therapy via drainage and lavage of pyomyoma is a viable option to preserve patient fertility. In the absence of a proper response to this treatment, total abdominal hysterectomy is the treatment of choice.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome

OBJECTIVE

The purposes of this study were to retrospectively investigate the effectiveness and safety of CT-guided percutaneous drainage in the treatment of patients with acute appendicitis complicated by perforation and to identify CT findings and procedure-related factors predictive of clinical and procedure outcome.

MATERIALS AND METHODS

From March 2005 through December 2008, 41 consecutively registered patients (24 men, 17 women; age range, 18-75 years) underwent CT-guided percutaneous drainage for the management of acute appendicitis complicated by perforation and abscess. Three board-certified radiologists independently reviewed preprocedure CT images. Patients were assigned to one of three risk categories on the basis of the CT findings. Success and failure of percutaneous drainage were defined on a per-patient (i.e., clinical outcome) and per-procedure (i.e., technical outcome) basis. Immediate, periprocedure, and delayed complications were recorded. The association between candidate predictive variables, including demographic characteristics, preprocedure CT findings, and procedure-related factors and clinical or technical outcome was assessed with logistic regression models.

RESULTS

Fifty-two CT-guided procedures were performed on 41 patients. Percutaneous drainage had clinical and technical success rates of 90% (37 of 41 patients, 47 of 52 procedures) with no procedure-related complications. In seven patients (19%) clinical success required repeated drainage procedures. A large, poorly defined periappendiceal abscess and an extraluminal appendicolith on preprocedure CT images were independent predictors of clinical failure of percutaneous drainage.

CONCLUSION

CT-guided percutaneous drainage is both effective and safe in the treatment of patients with acute appendicitis complicated by perforation and abscess. The clinical and technical success rates are high.

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Transanorectal interventions

Over the past few decades, advances in modern imaging technology have enabled less invasive approaches to diagnose and treat disease. In the field of image-guided techniques, this has seen the common adaptation of needle biopsy and catheter drainage into clinical practice. In this article we review the most common applications of transanorectal techniques. As nearly all these techniques are performed under ultrasound guidance in dayto-day practice, the review focuses almost exclusively on ultrasound-enabled techniques.

Endoscopic transcolonic catheter-free pelvic abscess drainage

Natural orifice transluminal endoscopic surgery is a novel therapeutic method in development that uses different routes of surgical approach. The use of various methods, instruments and accessories during this procedure are currently being investigated. A case of appendicitis-related intra-abdominal abscess that was resolved by a transcolonic endoscopic approach using a wide-channel colonoscope with the help of precut and standard sphincterotome without radiological percutaneous drainage is presented.

Imaging and interventional techniques in acute left-sided diverticulitis

Computed tomography is the most accurate and readily available imaging study in the diagnosis of acute, left-sided diverticulitis. It not only detects the presence of an abscess and guides percutaneous drainage of these abscesses, it may also guide subsequent surgical treatment based upon a modification of the Hinchey classification.

Celiac Plexus Block: A New Technique Using the Left Lateral Approach

We describe a new celiac plexus block approach in a patient with cholangiocarcinoma who was referred to the Pain Clinic due to uncontrollable abdominal pain. The patient was initially programmed for a neurolytic celiac plexus block using the anterior approach with helical computerized tomography (CT) guidance. The CT scan revealed interposition of the transverse colon in the anterior approach territory, which made the anterior approach technique difficult, and also difficulty to practice the posterior approach without injuring the kidneys. We decided to attempt a left lateral atypical approach because the CT revealed the possibility of using a left lateral window to arrive to the celiac area. The left lateral access allowed us to carry out the neurolytic block using 50% alcohol without injuring any viscera. The patient tolerated the technique and was discharged without pain. No complications regarding either the punction or the block were observed.

Computed tomography-guided percutaneous abscess drainage in coloproctology: review of the literature

BACKGROUND

Percutaneous abscess drainage (PAD) of the lower abdomen and pelvis has been reported to reduce morbidity and mortality, shorten hospital stay and cut costs compared to a surgical approach. However, the wide differences in outcome reported by different authors indicate the need for an overview and further evaluations. This review evaluates each point of the procedure to explain the possible causes for such discrepancies in results.

METHODS

We performed a PubMed search of outcomes for percutaneous abscesses drainage, focusing on deep pelvic collections, which represent the most difficult task, searching among papers published from 1981 to 2006.

RESULTS

Ninety-nine papers were selected. Most authors emphasized that the most important steps of the care process are: (a) patient selection; (b) indications and contraindications; (c) choice of the best access route; (d) procedure performance; and (e) outcome (success and complication rates).

CONCLUSIONS

PAD is a safe and effective alternative to surgery for draining deep infected fluid collections, with a higher success rate, lower complication rate and shorter hospital stay compared to surgical drainage. Meticulous technique and careful access planning seem to be the two most important factors affecting the outcome.

EUS-guided drainage of pelvic abscess (with video)

BACKGROUND

Although pelvic abscesses have traditionally been drained by surgery or under radiologic guidance, a small subset of patients who are not candidates for these interventions require an alternate mode of drainage.

OBJECTIVE

Evaluate the efficacy of EUS for drainage of pelvic abscesses that could not be drained under US or CT guidance.

DESIGN

Prospective case series.

SETTING

Tertiary referral center.

PATIENTS

Four patients underwent EUS-guided drainage of pelvic abscesses that were not amenable for drainage by US and/or CT guidance.

INTERVENTIONS

A 10F drainage catheter was deployed in the abscess cavity under EUS guidance in all patients. The catheters were flushed periodically until resolution of the abscess was confirmed by CT imaging.

MAIN OUTCOME MEASUREMENTS

Resolution of a pelvic abscess on follow-up CT and improvement in clinical symptoms.

RESULTS

A drainage catheter was successfully placed in all 4 patients. The mean size of the abscess was 68 x 72 mm. There were no procedure-related complications. One patient died of worsening congestive heart failure 48 hours after the procedure. The abscesses resolved in the remaining 3 patients within a mean duration of 6 days, with complete symptom relief.

LIMITATIONS

A small number of patients and short duration of follow-up.

CONCLUSIONS

EUS-guided placement of drainage catheter is a minimally invasive technique for draining pelvic abscesses that are within the reach of the echoendoscope.

Minimization of needle deflection in robot-assisted percutaneous therapy

BACKGROUND

Needle deflection and tissue deformation are two problems encountered during needle insertion into soft, non-homogeneous tissue. They affect the accuracy of needle placement, which in turn affects the effectiveness of needle-based therapies and biopsies.

METHODS

In this study, a needle is inserted using a robot with two degrees of freedom. The needle is modelled as a flexible beam with clamped support at one end, and its deflection is estimated using online force/moment measurements at the needle base. To compensate for the needle deflection, the needle is axially rotated through 180 degrees . The needle deflection estimation data is used to find the insertion depths at which needle rotations are to be performed.

RESULTS

A bevelled-tip needle was inserted into animal tissue. The needle deflection at the target was reduced by about 90%. It was observed that minimization of needle deflection reduced tissue deformation. The proposed method reduced needle deflection more than when needle insertion was performed with constant rotation.

CONCLUSIONS

Estimating needle tip position using online force/moment measurement improves the accuracy of robot-assisted percutaneous procedures when imaging feedback is not available.

Imaging and invasive techniques for diagnosis and treatment of surgical infections

BACKGROUND

Advances in imaging techniques have caused a radical change in the radiologic approach to the diagnosis and treatment of surgical infections.

METHOD

Review of the pertinent English-language literature.

RESULTS

Ultrasonography (US) is a useful modality for the initial evaluation of intra-abdominal infection, whereas computed tomography (CT) often represents the modality of choice for definitive identification of the cause and extent of the infection. Both US and CT can be used to guide diagnostic fluid aspiration or drainage catheter placement. Fluoroscopy may be useful for diagnostic and interventional procedures in the biliary and urinary tracts, whereas magnetic resonance imaging plays a leading role in evaluating bone and soft tissue structures and the pancreatobiliary tree.

CONCLUSION

The choice of imaging study must be individualized to the particular circumstances of the clinical situation, particularly whether image-guided therapy may be required in addition to diagnosis. Computed tomography is the most versatile for most clinical circumstances.

Needle insertion into soft tissue: a survey

Needle insertion in soft tissue has attracted considerable attention in recent years due to its application in minimally invasive percutaneous procedures such as biopsies and brachytherapy. This paper presents a survey of the current state of research on needle insertion in soft tissue. It examines the topic from several aspects, e.g. modeling needle insertion forces, modeling tissue deformation and needle deflection during insertion, robot-assisted needle insertion, and the effect of different trajectories on tissue deformation. All studies show that the axial force of a needle during insertion in soft tissue is the summation of different forces distributed along the needle shaft such as stiffness force, frictional force and cutting force. Some studies have modeled these forces. The force data in some procedures is used for identifying tissue layers as the needle is inserted or for path planning. Needle deflection and tissue deformation are major problems for accurate needle insertion and attempts have been made to model them. Using current models several insertion techniques have been developed which are briefly reviewed in this paper.

Review article: intestinal failure

Intestinal failure is a specific disease entity resulting from intestinal resection or disease-associated malabsorption and characterized by the inability to maintain protein-energy, fluid, electrolyte or micronutrient balance. We performed a MEDLINE search (1966-2006) to identify relevant articles, using keywords intestinal failure, parenteral or enteral nutrition, intestinal fistula and short bowel syndrome. Causes of intestinal failure are varied, with self-limiting or 'Type 1' intestinal failure occurring relatively commonly following abdominal surgery, necessitating short-term fluid or nutritional support. The rarer, 'Type 2' intestinal failure, is associated with septic, metabolic and complex nutritional complications, usually following surgical resection in patients with Crohn's or mesenteric vascular disease. A multidisciplinary approach to the management of patients with Type 2 intestinal failure is crucial: resolution of sepsis is required before adequate nutritional repletion can be achieved, and it is important to optimize nutritional status, not only through enteral or parenteral supplementation, but also by addressing complications of short bowel syndrome, before considering definitive surgical reconstruction. A structured approach to the management of Type 2 intestinal failure should reduce the likelihood of these complex patients developing 'Type 3' intestinal failure, which is characterized by the need for long-term parenteral nutrition.

Percutaneous Drainage of Postoperative Abdominal Abscess with Limited Accessibility: Preexisting Surgical Drains as Alternative Access Route

PURPOSE

To retrospectively assess the effectiveness and safety of postoperative percutaneous drainage of abdominal abscesses with limited accessibility by using a preexisting surgical drain as an access route.

MATERIALS AND METHODS

The study was approved by the institutional review board, and informed consent was not required. The authors reviewed the medical records of 92 patients (62 male, 30 female; median age, 59 years; age range, 3-79 years) with postoperative abdominal abscesses in whom percutaneous drainage was performed by using surgical drains as an access. Factors evaluated included the location and size of the lesion; time between surgery and the drainage procedure; distance between the lesion and surgical drain; presence of fistula; duration of drainage; type of surgical drain; size, type, and length of drainage catheter; and complications. Technical success was defined as adequate placement of a new drainage catheter into the target abscess. Midterm success was defined as avoidance of surgery or additional percutaneous drainage during the 6 months of follow-up. Univariate analysis and multiple logistic regression analysis were performed to determine factors that affected the technical or midterm success of the procedure.

RESULTS

Of 92 postoperative abscesses for which the technique was attempted, 56 (61%) had a subphrenic location and 36 (39%) had a peripancreatic location. Technical success was achieved in 87 of the 92 patients (95%). Technical success was not significantly associated with any of the factors tested. Midterm success was achieved in 75 of the 87 patients (86%) in whom technical success was achieved. Midterm failure showed a statistically significant relationship with the presence of fistula (P = .04). No procedure-related complications were identified.

CONCLUSION

Percutaneous drainage by using the surgical drain as an access route is an effective and safe alternative for draining postoperative abdominal abscesses that are less accessible with direct puncture..

Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage

PURPOSE

There is no definite consensus on the management of intra-abdominal abscesses in adults. This retrospective study evaluated the use of antibiotic therapy and percutaneous image-guided drainage in adult patients with intra-abdominal abscesses.

METHODS

A retrospective chart review of 114 patients with intra-abdominal abscesses was conducted. Data collected included patient demographics, presenting symptoms, radiographic interpretation, vital signs, antibiotic coverage, laboratory values, and details of the hospital course. Bivariate statistical tests were performed using the Wilcoxon rank-sum test, chi-squared test, or Fisher's exact test, where appropriate.

RESULTS

Sixty-seven of 114 patients (59 percent) had intra-abdominal abscesses resulting from appendicitis, diverticulitis in 30 patients (26 percent), postoperative in 13 patients (11 percent), and undetermined in 4 patients (4 percent). Three patients (3 percent; 95 percent confidence interval, 1-8 percent) failed conservative management and underwent urgent operation. Sixty-one (54 percent; 95 percent confidence interval, 44-63 percent) patients improved with intravenous antibiotic therapy alone. Fifty patients (44 percent; 95 percent confidence interval, 35-54 percent) underwent image-guided percutaneous drainage after 48 to 72 hours of antibiotic therapy. Patients who improved on antibiotics alone had average abscess diameter of 4 cm, whereas patients who underwent percutaneous drainage had average diameter of 6.5 cm (P<0.0001). Maximal temperature at time of admission was 100.8 degrees F for antibiotic group and 101.2 degrees F for percutaneous drainage group (P=0.0067).

CONCLUSIONS

The majority of the patients with intra-abdominal abscesses improved with antibiotic therapy alone. Those patients with an abscess diameter>6.5 cm and temperature at admission>101.2 degrees F have higher likelihood of failing conservative therapy with antibiotics alone and requiring percutaneous drainage.

Transrectal and Transvaginal Sonographic Intervention of Infected Pelvic Fluid Collections

Infected pelvic fluid collections are relatively common particularly after abdominal or pelvic surgery or in patients suffering from benign intestinal disease such as diverticulitis, appendicitis, or Crohn's disease. Historically the treatment of pelvic abscess has been either laparotomy with lavage or blind surgical incision and drainage through the rectal or vaginal wall. More recently, computed tomography and ultrasound-guided percutaneous drainage has become the procedure of choice, when feasible, for the treatment of pelvic abscess. However, many deep pelvic collections are not amenable to percutaneous technique. Transrectal or transvaginal ultrasound-guided abscess drainage is a safe and effective method used in the treatment of deep pelvic abscesses. The purpose of this article is to review the techniques, patient selection, pre- and post-procedural care, and monitoring aspects of transrectal or transvaginal ultrasound-guided drainage.