Computed tomography-guided percutaneous abscess drainage in intestinal disease: factors associated with outcome

Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review

BACKGROUND

The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof.

METHOD

Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan-guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30-90 days of index admission. Data were stratified by three arbitrary time intervals: 1986-2000, 2000-2010, and after 2010. The primary outcome was calculated for those groups and compared.

RESULTS

Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000-2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%).

CONCLUSION

This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.

Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review

PURPOSE

This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly, the paper aimed to compare different treatment options.

METHODS

PubMed, EMBASE and the Cochrane Library were searched. Two authors screened the records independently, initially on title and abstract and subsequently on full-text basis. Articles describing patients treated acutely for Hinchey Ib and II were included. Results were presented by treatment, classified as non-operative (percutaneous abscess drainage (PAD), antibiotics, or unspecified non-operative strategy), PAD, antibiotics, or acute surgery. The outcomes of interest were treatment failure, short-term mortality, and recurrence.

RESULTS

Of 1723 articles, 42 studies were included, describing 8766 patients with Hinchey Ib-II diverticulitis. Observational studies were the only available evidence. Treatment generally failed for 20% of patients, regardless of non-operative treatment choice. Abscesses with diameters less than 3 cm were sufficiently treated with antibiotics alone, possibly as outpatient treatment. Of patients treated non-operatively, 25% experienced a recurrent episode during long-term follow-up. When comparing PAD to antibiotic treatment, it appeared that PAD lead to recurrence less often (15.9% vs. 22.2%). Patients undergoing acute surgery had increased risk of death (12.1% vs. 1.1%) compared to patients treated non-operatively. Of patients undergoing PAD, 2.5% experienced procedure-related complications and 15.5% needed adjustment or replacement of the drain.

CONCLUSIONS

Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.

Preoperative Percutaneous Drainage of Spontaneous Intra-Abdominal Abscess in Patients With Crohn's Disease: A Meta-Analysis

GOALS

We aimed to compare clinical outcomes between percutaneous drainage (PD) with or without further elective surgery and initial surgery for patients with Crohn's disease (CD)-related spontaneous intra-abdominal abscess.

BACKGROUND

Intra-abdominal abscess is common in patients with CD leading to significant morbidity. The role of PD before abdominal surgery in patients with CD remains controversial.

STUDY

We performed a meta-analysis comparing PD and surgery as the initial approach to CD-related spontaneous intra-abdominal abscess. Overall complication and recurrent abscess were assessed. Subgroup analyses on initial PD were performed including preoperative PD and PD alone.

RESULTS

A total of 9 studies including 513 patients with CD-related spontaneous intra-abdominal abscesses were included. The overall complication rate was significantly higher in patients undergoing initial surgery compared with those undergoing initial PD [odds ratio (OR)=0.58; 95% confidence interval (CI), 0.35-0.96; P=0.03]. In a subgroup analysis, preoperative PD was associated with a significant reduction in overall complication (OR=0.44; 95% CI, 0.23-0.83; P=0.01) as compared with initial surgery. The risk for recurrent abscess was higher in patients who underwent PD alone than those who underwent initial surgery (OR=2.16; 95% CI, 1.03-4.54; P=0.04). No significance difference in postoperative recurrent abscess was found between preoperative PD group and initial surgery group.

CONCLUSION

Although abdominal surgery appeared to be inevitable in the majority of the patients with CD who develop intra-abdominal abscess, preoperative PD may decrease overall complication after surgery.

Impact of Surgical Infection Society/Infectious Disease Society of America-recommended antibiotics on postoperative intra-abdominal abscess with image-guided percutaneous abscess drainage following gastrointestinal surgery

PURPOSE

The aims of this study were to reveal how using the antibiotics recommended by the 2010 Surgical Infection Society (SIS) and Infectious Disease Society of America (IDSA) guidelines can affect the therapeutic outcomes.

METHODS

We reviewed the cases of 53 patients with a postoperative intra-abdominal abscess without anastomotic leakage after gastrointestinal surgery who underwent image-guided percutaneous abscess drainage (PAD) and concomitant antibiotic therapy. The type of antibiotic initially administered was determined based on the surgeon's judgment. A persistent abscess was defined as one or more PAD procedures resulting in complete resolution after 21 or more days. The recommended antibiotics were defined according to 2010 SIS/IDSA guidelines.

RESULTS

All 53 patients had complete resolution without the need for surgery. The results of a multivariable analysis revealed that a C-reactive protein level ≥12 mg/dL and non-recommended antibiotics were significant risk factors for a persistent abscess (P = 0.042 and 0.013, respectively). With regard to a fever lasting more than 48 h, there was a significant difference between the recommended (45.1%) and non-recommended (72.7 %) antibiotic groups (P = 0.046).

CONCLUSIONS

Using the recommended antibiotics may shorten the time to defervescence and reduce the risk of a persistent abscess in patients undergoing PAD for a postoperative abscess after gastrointestinal surgery.

Percutaneous Drainage of a Diverticular Abscess Should be Limited to Two Attempts for a Resilient Diverticular Abscess

Management of a resilient diverticular abscess poses a big challenge. Currently there are no guidelines for the number of percutaneous drainages to be performed in resilient diverticular abscesses before attempting surgery. All patients (n = 117) who presented with a computed tomography scan-proven diverticular abscess from July 2008 to June 2011 were studied. They were divided into four groups based on the number of percutaneous drainages they underwent for their diverticular abscess: six patients underwent three or more drainages, nine patients underwent two drainages, 27 patients had one drainage, and 75 patients had no drainage. Readjustment, flushing, and upgrading size of the drain were not considered as separate drainage procedures. The size of abscess cavity was significantly higher for the patients who had three or more drainages (mean 8 cm, P < 0.001). A Hartmann's procedure was performed in the majority of patients in the three or more drainage group (83%) but in decreasing frequency as the number of drainages performed dropped: two drainage group (44%), one drainage group (15%), and no drainage group (19%). There was a significantly higher preoperative hospital stay for drainage and antibiotics in the patients from the three or more drainage group ( P < 0.001). Patients with a resilient diverticular abscess are very likely to undergo a Hartmann's procedure after two attempted drainages. By performing additional percutaneous drainages in an attempt to avoid ostomy, patients are at an increased risk of sepsis and peritonitis with prolonged antibiotics and increased healthcare costs. We recommend limiting percutaneous drainage procedures to two attempts to cool down a resilient diverticular abscess before definitive surgery.

Risk factors for failure of percutaneous drainage and need for reoperation following symptomatic gastrointestinal anastomotic leak

BACKGROUND

Few studies have evaluated the role of computed tomography-guided percutaneous drainage (PD) in the management of gastrointestinal (GI) anastomotic leaks.

METHODS

Ten-year review of an interventional radiology database identified patients with symptomatic GI anastomotic leaks. Clinical, laboratory, radiographic, and operative characteristics following a technically successful PD which then failed and required reoperation for anastomotic leak were compared with those successfully treated with PD.

RESULTS

Sixty-one patients met study inclusion criteria. Fifty patients (82%) successfully underwent therapeutic PD of a perianastomotic fluid collection, with median follow-up of 16 months. Eleven patients (18%), at a median interval of 16 days, required reoperation following PD. A forward logistic regression showed cardiopulmonary disease (P = .03) and cancer surgery (P = .01) to be factors independently associated with the need for reoperation. The level of the anastomosis, initial fecal diversion/stoma, fluid collection size, and microbiology of aspirate did not predict failure of PD.

CONCLUSIONS

Cardiopulmonary disease and cancer surgery appear to be independent predictors for failure of PD and need for reoperation following a symptomatic GI anastomotic leak.

Factors influencing the outcome of image-guided percutaneous drainage of intra-abdominal abscess after gastrointestinal surgery

PURPOSE

To improve the selection of patients for percutaneous abscess drainage (PAD) to treat postoperative intra-abdominal abscess after gastrointestinal surgery, we investigated the factors predictive of outcome.

METHODS

Of 143 consecutive patients with symptomatic postoperative intra-abdominal abscess after a gastrointestinal tract resection, 104 who underwent image-guided PAD as the initial treatment were reviewed. We assessed the possible associations between successful PAD and patient-, abscess-, surgical-, and drainage-related variables, and investigated the success rates of PAD for patients with vs. those without the factors related to successful outcome.

RESULTS

Based on monitoring for 1 year after PAD, the success rate of this procedure was 85.6% (89/104). Multivariate analysis revealed that the interval between surgery and the onset of abscess (p = 0.0234) and a single abscess (p = 0.0038) were independently associated with a successful outcome. Single late-onset abscess resolved completely within 10 weeks in 91.4% of these patients.

CONCLUSIONS

Despite new strategies aimed at preventing surgical site infection, PAD remains an important factor in the postoperative management of gastrointestinal surgery in Japan. Initial recognition of the day of onset and the number of abscesses are important prognostic factors.

The clinical impact of preoperative percutaneous drainage of abdominopelvic abscesses in patients with Crohn's disease

PURPOSE

Although image-guided percutaneous drainage is increasingly being used to treat Crohn's disease-related abdominopelvic abscesses, surgery is seldom avoided. The aim of this study was to compare outcomes following the treatment of intra-abdominal Crohn's abscesses with percutaneous drainage followed by surgery to those after surgery alone.

METHODS

We retrospectively reviewed the charts of patients treated for Crohn's-related abdominopelvic abscesses at Mount Sinai Medical Center between April 2001 and June 2010. Patients who underwent drainage followed by surgery were compared to those who underwent surgery alone. Differences in operative and postoperative outcomes were compared.

RESULTS

Seventy patients with Crohn's disease-related abdominopelvic abscesses were identified, 38 (54%) of whom underwent drainage before surgery. Percutaneous drainage was technically successful in 92% of patients and clinically successful in 74% of patients. No differences in rate of septic complications (p = 0.14) or need for stoma creation (p = 0.78) were found. Patients who underwent percutaneous drainage had greater overall hospital lengths of stay (mean 15.8 versus 12.2 days, p = 0.007); 8.6% of patients had long-term postponement of surgery after percutaneous drainage.

CONCLUSIONS

In our series, the treatment of Crohn's abscesses with percutaneous drainage prior to surgery did not decrease the rate of postoperative septic complications.

A comprehensive review of inflammatory bowel disease focusing on surgical management

The two main diseases of inflammatory bowel disease are Crohn's disease and ulcerative colitis. The pathogenesis of inflammatory disease is that abnormal intestinal inflammations occur in genetically susceptible individuals according to various environmental factors. The consequent process results in inflammatory bowel disease. Medical treatment consists of the induction of remission in the acute phase of the disease and the maintenance of remission. Patients with Crohn's disease finally need surgical treatment in 70% of the cases. The main surgical options for Crohn's disease are divided into two surgical procedures. The first is strictureplasty, which can prevent short bowel syndrome. The second is resection of the involved intestinal segment. Simultaneous medico-surgical treatment can be a good treatment strategy. Ulcerative colitis is a diffuse nonspecific inflammatory disease that involves the colon and the rectum. Patients with ulcerative colitis need surgical treatment in 30% of the cases despite proper medical treatment. The reasons for surgical treatment are various, from life-threatening complications to growth retardation. The total proctocolectomy (TPC) with an ileal pouch anal anastomosis (IPAA) is the most common procedure for the surgical treatment of ulcerative colitis. Medical treatment for ulcerative colitis after a TPC with an IPAA is usually not necessary.

Crohn's disease: a surgeon's perspective

Crohn's disease (CD) is known for wide anatomic distribution, different presentations, life-threatening complications, and multiple modalities of management. Its multiple implications are still unaddressed. Since all the patients do not show a good response to medical modalities of treatment, a significant percentage of these patients are referred to the surgeon for the palliation of complications or for the ultimate curative treatment. Since most surgeons come across such patients only rarely, it is sometimes difficult for them to choose the appropriate procedure at the time of need. Moreover, the various surgical modalities available for the different presentations and complications of the disease have not been adequately discussed. The aim of this review is to offer insight and a detailed account of the management of CD from a surgical perspective. This review offers an overview of the various surgical options available, their utility in context, and an approach to various scenarios of complicated CD.

Diagnosis of gastrointestinal anastomotic dehiscence after hospital discharge: Impact on patient management and outcome

BACKGROUND

Anastomotic leaks are inevitable complications of gastrointestinal surgery. Early hospital discharge protocols have increased concern regarding outpatient presentation with anastomotic leaks.

METHODS

One hundred anastomotic leaks in 5,387 intestinal operations performed at a single institution from 2002 to 2007 were identified from a prospectively maintained database. Statistical analysis was conducted by the unpaired t test, Chi-square test, and analysis of variance.

RESULTS

Overall anastomotic leak with a rate of 2.6% for colonic and 0.53% for small bowel anastomoses. Mean time to anastomotic leak diagnosis was 7 days after operation. Twenty-six patients presented after discharge, with mean time to diagnosis 12 days versus 6 days for inpatients (P<.05). Patients presenting after hospital discharge were younger, had lesser American Society of Anesthesiologists (ASA) scores, and were more likely to have colon cancer and less likely to have Crohn's disease. Ninety-two patients required operative management, of whom 81 (90%) underwent diversion. No difference in management, intensive care unit (ICU) requirement, duration of stay, or mortality between inpatient versus outpatient diagnosis was demonstrated. Follow-up at mean of 36 months demonstrated no difference in readmission, reoperation, or mortality rate between outpatient and inpatient diagnosis. Restoration of gastrointestinal continuity was achieved in 61-67% in the outpatient and 59% in the inpatient group (P=NS).

CONCLUSION

Outpatient presentation delays diagnosis but does not alter management or clinical outcome, or decrease the probability of ostomy reversal. Prolonging hospital stay to capture patients who develop anastomotic leak seems to be unwarranted. For patients requiring operative management, we recommend diversion as the safest option with a subsequent 61% reversal rate.

Management of Hinchey II diverticulitis

Colonic diverticulosis can either be asymptomatic or present with complications resulting in significant morbidity and mortality. A key presentation of complicated disease is abscess formation (Hinchey type II). The natural course of this is unclear and therefore treatments range from conservative approach with antibiotics and percutaneous guided drainage (PCD) to surgery. There is no clear consensus on the exact management strategy. A Medline based literature search specifically looking at studies dealing with Hinchey type II diverticulitis and its management was carried out. For comparison, five-year retrospective data of diverticular abscesses from our institution was collected and the outcome analysed. Various studies have looked into this aspect of the disease, elaborating on the significance of the size and location of the abscesses, the role of PCD, recurrence rates and the controversies regarding the need for elective surgery. Conservative treatment with antibiotics alone is effective in a majority of cases with a role for PCD in large safely accessible abscesses. Variable recurrence rates have been reported in literature and elective surgery should be planned for selected groups of patients.

Percutaneous drainage and ileocolectomy for spontaneous intraabdominal abscess in Crohn's disease

BACKGROUND

Historical studies have shown that percutaneous drainage alone for intraabdominal abscess secondary to Crohn's disease is successful in avoiding surgery in only approximately 50% of patients. Failure, however, can require urgent surgery and is then associated with increased morbidity, extended hospital stays, and increased risk for stoma creation. Because of this, our current protocol is initial percutaneous drainage of the abscess, 5-7 days of broad spectrum IV antibiotics with simultaneous high-dose steroids and hyperalimentation, followed by planned one stage resection with primary anastomosis. The aim of the present study was to evaluate the success of this protocol with regard to length of stay, complications associated with the protocol, and its ability to avoid stoma creation.

METHODS

A retrospective chart review was performed for all Crohn's disease patients with intraabdominal abscess who underwent the above protocol from 1992 to the present.

RESULTS

Nineteen patients (11 male) were identified. Sixteen underwent ileocolectomy with primary anastomosis while only three patients required an upstream diverting ileostomy in addition to resection due to incompletely drained abscesses. The mean length of hospital stay was 13.9 +/- 0.6 days including 6.4 +/- 0.4 postoperative days. Four patients had post-op complications that did not require surgery (two self-limited anastomotic bleeds, one wound infection, and one pelvic abscess treated with a percutaneous drain). One patient needed reoperation for a small bowel obstruction.

CONCLUSIONS

Crohn's disease patients with intraabdominal abscess can safely undergo planned resection with primary anastomosis if initially treated with successful percutaneous drainage and aggressive antibiotic and steroid management. Such a protocol provides a standard of care against which nonsurgical management can be compared and judged.

Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study

PURPOSE

CT-scan-guided percutaneous abscess drainage of Hinchey Stage II diverticulitis is considered the best initial approach to treat conservatively the abscess and to subsequently perform an elective sigmoidectomy. However, drainage is not always technically feasible, may expose the patient to additional morbidity, and has not been critically evaluated in this indication. This study was undertaken to compare the results of percutaneous drainage vs. antibiotic therapy alone in patients with Hinchey II diverticulitis.

METHODS

This was a case-control study of all patients who presented in our institution with Hinchey Stage II diverticulitis between 1993 and 2005. Thirty-four patients underwent abscess drainage under CT-scan guidance (Group 1), and 32 patients were treated with antibiotic therapy alone (Group 2), in most cases because CT-scan-guided abscess drainage was considered technically unfeasible by the interventional radiology team. Initial conservative treatment was considered a failure when: 1) emergency surgery had to be performed, 2) signs of worsening sepsis developed, and 3) abscess recurred within four weeks of drainage.

RESULTS

The median size of abscess was 6 (range, 3-18) cm in Group 1 and 4 (range, 3-10) cm in Group 2 (P = 0.002). Median duration of drainage was 8 (range, 1-18) days. Conservative treatment failed in 11 patients (33 percent) of Group 1, and in 6 patients (19 percent) of Group 2 (P = 0.26). Ten patients (29 percent) in Group 1 and five patients (16 percent) in Group 2 underwent emergency surgery (P = 0.24); there were four postoperative deaths (26.6 percent) in this subgroup. Twelve patients (35 percent) in Group 1 and 16 patients (50 percent) in Group 2 subsequently underwent an elective sigmoid resection (P = 0.31). In this subgroup of patients, there was neither anastomotic leakage nor postoperative death.

CONCLUSIONS

Emergency surgery for Hinchey Stage II diverticulitis carries a high mortality rate and should be avoided. To achieve this, antibiotic therapy alone seems to be a safe alternative, whenever percutaneous drainage is technically difficult or hazardous. Actually, our data did not demonstrate any benefit of CT scan-guided percutaneous abscess drainage, suggesting that the role of interventional radiology techniques in this indication deserves further critical evaluation.

[Percutaneous drainage of abdomino-pelvic collections. Indications, techniques, and results]

Extra-parenchymal collections in the abdomen and pelvis are a not infrequent occurrence in gastrointestinal pathologies. Twenty years of experience have proved percutaneous drainage to be a safe and effective therapeutic modality. Several studies have demonstrated the efficacy of radio-guided percutaneous drainage which can serve as a substitute for open surgical drainage in 70% of cases. This therapeutic modality should be considered for every case of abdomino-pelvic collection.

Postoperative anatomic and pathologic findings at CT following colonic resection

CT is frequently used for postoperative evaluation in patients who have undergone colonic resection. This pictorial article reviews and demonstrates the CT findings of normal postoperative anatomic changes, as well as different postoperative complications following various colonic operative techniques.

Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan

BACKGROUND

Percutaneous abscess drainage guided by computed tomography scan is considered the initial step in the management of patients presenting with Hinchey II diverticulitis. The rationale behind this approach is to manage the septic complication conservatively and to follow this later using elective sigmoidectomy with primary anastomosis.

METHODS

The clinical outcomes for Hinchey II patients who underwent percutaneous abscess drainage in our institution were reviewed. Drainage was considered a failure when signs of continuing sepsis developed, abscess or fistula recurred within 4 weeks of drainage, and emergency surgical resection with or without a colostomy had to be performed.

RESULTS

A total of 34 patients (17 men and 17 women; median age, 71 years; range, 34-90 years) were considered for analysis. The median abscess size was 6 cm (range, 3-18 cm), and the median duration of drainage was 8 days (range, 1-18 days). Drainage was considered successful for 23 patients (67%). The causes of failure for the remaining 11 patients included continuing sepsis (n = 5), abscess recurrence (n = 5), and fistula formation (n = 1). Ten patients who failed percutaneous abscess drainage underwent an emergency Hartmann procedure, with a median delay of 14 days (range, 1-65 days) between drainage and surgery. Three patients in this group (33%) died in the immediate postoperative period. Among the 23 patients successfully drained, 12 underwent elective sigmoid resection with a primary anastomosis. The median delay between drainage and surgery was 101 days (range, 40-420 days). In this group, there were no anastomotic leaks and no mortality.

CONCLUSION

Drainage of Hinchey II diverticulitis guided by computed scan was successful in two-thirds of the cases, and 35% of the patients eventually underwent a safe elective sigmoid resection with primary anastomosis. By contrast, failure of percutaneous abscess drainage to control sepsis is associated with a high mortality rate when an emergency resection is performed. The current results demonstrate that percutaneous abscess drainage is an effective initial therapeutic approach for patients with Hinchey II diverticulitis, and that emergency surgery should be avoided whenever possible.

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..

Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters

OBJECTIVE

Our objective was to determine whether abscess size can be used as a discriminating factor to guide management of patients with diverticular abscesses.

MATERIALS AND METHODS

We performed a word search of our CT database between July 2001 and July 2002 for the CT diagnosis of diverticulitis. CTs were retrospectively reviewed as consensus opinion of two reviewers. CTs were evaluated for presence of an abscess, its location, maximum diameter, and feasibility of percutaneous abscess drainage. Abscesses were categorized into smaller than 3 cm and larger than or equal to 3 cm, and the management of these groups was compared.

RESULTS

Thirty-one abscesses were noted in 30 (17%) of 181 patients with a CT diagnosis of diverticulitis. Twenty-two (73%) of 30 patients had 23 abscesses, all of which were smaller than 3 cm and were treated and resolved with antibiotics alone (p < 0.001). Eight (36%) of 22 required surgical treatment. Eight (26%) of 31 abscesses had a maximum diameter larger than or equal to 3 cm. Four (50%) of eight patients with abscesses 3.4-4.1 cm were treated with antibiotics alone. Four (50%) of eight abscesses, all larger than 4.1 cm, were treated with CT-guided drainage and one abscess required repeat drainage. After resolution of symptoms, surgery was performed in five (62.5%) of eight of the larger abscesses.

CONCLUSION

Patients with abscesses smaller than 3 cm in size can be treated with antibiotics alone and, in some cases, as outpatients, and may not uniformly require surgery. This is also likely true for patients with abscesses 3-4 cm in size, although our results in this group were limited by a small sample size. Patients with abscesses larger than or equal to 4 cm can be managed with CT-guided abscess drainage followed by referral for surgical treatment.

Gas Distribution in Intraabdominal and Pelvic Abscesses on CT Is Associated with Drainability

OBJECTIVE

Intraabdominal and pelvic abscesses are treated by percutaneous image-guided drainage, under sedation or general anesthesia. This study attempts to determine if the CT features of gas distribution are associated with "drainability." Our premise was that gas may be trapped deep in a collection as bubbles, if the material is thick. Gas may rise to the surface if the material is thin, forming either an air-fluid level or superficial bubbles.

MATERIALS AND METHODS

Patients with intraabdominal and pelvic abscesses were identified by the interventional radiology database, after research ethics board approval. Patients without prior CT were excluded. The imaging and clinical records were analyzed retrospectively. Intracollection gas distribution was recorded as superficial bubbles, deep bubbles, or air-fluid levels. Collections were classified accordingly: type 1, air-fluid levels; type 2, superficial or deep bubbles and air-fluid levels; type 3, superficial bubbles; type 4, deep bubbles; and type 5, no gas.

RESULTS

One hundred five abscesses were examined in 61 patients, ranging in age from 2-17 years. Eight of 8 of type 1, 16 of 16 of type 2, 19 of 21 of type 3, 8 of 13 of type 4, and 43 of 47 of type 5 were drainable. The abscesses of all patients with an air-fluid level were drainable. Of abscesses with deep bubbles, 61.5% were drainable, versus 90.5% of those with superficial bubbles. Of those with superficial gas (superficial bubbles or air-fluid levels), 95.6% were drainable. In comparison with superficial gas, abscesses with deep trapped gas were associated with a longer duration of drainage, longer hospital stay, lower percentage of successful drainage, and higher percentage of residual collections. The difference is significant for drainability (p = 0.0048; p = 0.0331 after statistical adjustment for multiple testing).

CONCLUSION

Distribution of gas in an intraabdominal or pelvic abscess is associated with drainability. Abscesses with superficial gas (superficial bubbles or air-fluid levels) have a greater chance of being drained successfully than do abscesses with deep trapped gas.

Anastomotic leakage following low anterior resection: results of a standardized diagnostic and therapeutic approach

BACKGROUND AND AIMS

This study analyzed the results of a standardized approach in anastomotic leakage following low anterior resection for rectal cancer without performance of a protective ileostomy during the primary operation.

PATIENTS AND METHODS

The study included all 306 patients with rectal cancer electively undergoing low anterior resection with retroperitonealization of the anastomosis over 9 years. The diagnostic procedure for anastomotic leakage included serum laboratory investigations and abdominal CT together with contrast enema. Minor leakages, i.e., small leakages and pelvic abscess, were treated with rectoscopic lavage and/or CT-guided drainage of the abscess, respectively. Major leakage was defined as broad insufficiency with or without septicemia. Nonseptic patients were treated by ileostomy and rectoscopic treatment. In septic patients a revision of the anastomosis with loop ileostomy was performed.

RESULTS

Anastomotic leakage was diagnosed in 30 patients (overall 9.8%; 12 major, 18 minor leakages). Common clinical signs were pelvic pain and fever. No patient developed a peritonitis. The most accurate diagnostic instrument was CT (96.7%).

CONCLUSION

Retroperitonealization appears to prevent peritonitis in patients with anastomotic leakage following low anterior resection. A differential treatment leads to good results in terms of mortality and anorectal function.

Can failure of percutaneous drainage of postoperative abdominal abscesses be predicted?

BACKGROUND

Percutaneous drainage (PD) of complex postoperative abscesses associated with a variety of factors such as multiple location or enteric fistula remains a matter of debate. Accordingly, this retrospective study was designed to determine the predictive factors for failure of PD of postoperative abscess, in order to better select the patients who may benefit from PD.

METHODS

From 1992 to 2000, the data of 73 patients who underwent computed tomography (CT)-guided PD for postoperative intra-abdominal abscess, were reviewed. PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. The possible association between failure of PD and 27 patient-, abscess-, surgical-, and drainage-related variables were assessed using univariate and multivariate analysis.

RESULTS

Successful PD was achieved in 59 of 73 (81%) patients. The overall mortality was 3% but no patient died after salvage surgery. Multivariate analysis showed that only an abscess diameter of less than 5 cm (P = 0.042) and absence of antibiotic therapy (P = 0.01) were significant predictive variables for failure of PD.

CONCLUSIONS

CT-guided PD associated with antibiotic therapy could be attempted as the initial treatment of postoperative abdominal abscesses even in complex cases such as loculated abscess or abscess associated with enteric fistula.

Abscesses in Crohn's disease: outcome of medical versus surgical treatment

GOALS

To compare the long-term outcome of medical, percutaneous, and surgical treatment of abdominal and pelvic abscesses complicating Crohn's disease.

STUDY

All patients with Crohn's disease and an abdominal abscess treated at one institution during a 10-year period were retrospectively identified. We reviewed hospital and outpatient records and contacted patients for telephone interviews. Outcome measures included abscess recurrence, subsequent surgery for Crohn's disease, and medications used at the time of most recent follow-up.

RESULTS

Fifty-one subjects were identified, with a mean follow-up of 3.75 years. Fewer patients developed recurrent abscesses after initial surgical drainage and bowel resection (12%) than patients treated with medical therapy only or percutaneous drainage (56%) (p = 0.016). One half of the patients treated nonoperatively ultimately required surgery, whereas only 12% of those treated with initial surgery required reoperation during the follow-up period (p = 0.010). Most failures of nonoperative therapy occurred within 3 months. Medication use was similar between the treatment groups at the time of most recent follow-up.

CONCLUSIONS

In this series, surgical management of abscesses in Crohn's disease was more effective than medical treatment or percutaneous drainage for prevention of abscess recurrence. However, nonoperative therapy prevented subsequent surgery in half of the patients and may be a reasonable treatment option for some patients.

Management of postoperative peritonitis after anterior resection: experience from a referral intensive care unit

PURPOSE

Anastomotic leakage is the main cause of death after anterior resection. If it causes a single abscess, it may be successfully cured by percutaneous drainage, but in case of extensive peritoneal infection (multiple abscesses and generalized peritonitis), it is associated with a 40 to 60 percent mortality. This study aimed at evaluating aggressive, one-stage surgical management in such cases.

METHODS

All patients referred to our surgical intensive care unit during the past ten years with generalized, multilocular, intra-abdominal sepsis after anterior resection were reviewed. There were 32 patients, with a mean age of 65 years, among which 15 (47 percent) were referred from other institutions. The mean Acute Physiology and Chronic Health Evaluation II score on admission was 18. All patients underwent a laparotomy with complete peritoneal exploration, intraoperative lavage, fecal diversion, capillary drainage of the pelvis excluding the rectal stump or the leaking anastomosis from the peritoneal cavity, and primary closure of the abdomen. A Hartmann's operation was done in 22 cases, and conservation of the anastomosis with proximal colostomy was done in 10 cases. The choice was based on the size of the leak, the viability of the colon, and the site of the anastomosis.

RESULTS

Four patients died (12 percent), and five patients (16 percent) had recurrent sepsis. When the anastomosis had been conserved, restoration of continuity was achieved in all cases. After Hartmann's operation 8 patients of 19 survivors kept a permanent stoma; 7 had undergone a low anterior resection.

CONCLUSIONS

Extensive intra-abdominal infection after anterior resection may be efficiently controlled by a surgical approach combining peritoneal debridement, fecal diversion, and capillary drainage of the pelvis. Intestinal continuity may be restored after diversion stoma or Hartmann's procedure after high anterior resection. This is not the case after a Hartmann's operation after a low colorectal anastomosis, and this procedure should be avoided whenever possible.