Saline vs Tissue Plasminogen Activator Irrigations after Drain Placement for Appendicitis-Associated Abscess: A Prospective Randomized Trial

Complicated appendicitis in the pediatric patient: interventional perspectives

This pictorial review provides a comprehensive visual and textual overview of interventional radiology approaches in treating complicated appendicitis and other abdominal abscesses in children. This review discusses the incidence and complications associated with appendicitis in pediatric patients, highlighting the role of percutaneous drainage in managing appendicitis with abscesses. We present common mimics of intra-abdominal abscesses from other diseases such as tubo-ovarian abscesses, inflammatory bowel disease, and lymphomatous bowel involvement, emphasizing imaging pitfalls that can mimic appendiceal abscesses. The review also covers interventional radiology considerations, including antibiotic indications, local anesthesia considerations for children, the comparison between percutaneous and endocavitary approaches, and the roles of fibrinolytics are discussed here. Detailed discussions on catheter selection and insertion techniques, such as Seldinger and trocar, are provided along with post-procedure management strategies. These include drain maintenance, navigating drain associated complications, and determining when to remove the drain. Through high-quality images and concise descriptions, we illustrate procedural intricacies and clinical scenarios encountered in practice, offering a valuable educational resource for clinicians managing pediatric abscesses.

Irrigation with fibrinolytic agents versus saline for percutaneous drainage of abdominal abscesses: A meta-analysis with trial sequential analysis of randomized trials

INTRODUCTION

Fibrinolytic agents (FA) activate the fibrinolytic system, converting plasminogen into plasmin to break down fibrin. Their use for irrigation of abdominal abscesses is debated, and this meta-analysis evaluates their efficacy.

METHODS

We searched PubMed, Embase, and Cochrane Central for randomized controlled trials (RCTs) comparing FA and saline in percutaneous drainage of abdominal abscesses. Outcomes included length of hospitalization, duration of drainage, and drainage volume. We pooled mean differences (MD) and 95% confidence intervals (CI) using a random-effects model. We also performed a trial sequential analysis (TSA).

RESULTS

We included six RCTs encompassing 299 patients. In the overall analysis, FA increased drainage volume (MD 104.25 mL; 95% CI 35.72-172.77 mL; p = 0.003; I2 = 0%). In children, saline reduced hospitalization duration (MD -1.26 days; 95% CI -1.98 to -0.55 days; p = 0.0006; I2 = 0%), whereas FA increased drainage volume (MD 84.66 mL; 95% CI 5.77-153.54 mL; p = 0.04; I2 = 0%). In adults, FA significantly reduced hospitalization duration (MD -11.12 days; 95% CI -15.16 to -7.08 days; p < 0.00001; I2 = 0%) and duration of drainage (MD -6.53 days; 95% CI -9.25 to -3.81 days; p < 0.00001; I2 = 0%) while increasing drainage volume (MD 164.47 mL; 95% CI 26.16-302.78 mL; p = 0.02; I2 = 0%). On TSA, the required information size was achieved only for the adult subgroup's hospitalization and drainage duration.

CONCLUSION

In adults, FA reduce hospitalization and drainage duration and increase drainage volume. In children, saline seems more effective in reducing hospitalization duration, while FA increase drainage volume. These findings underscore the need for age-specific treatments and further research, especially in the pediatric population.

Dispelling the Myths of Percutaneous Catheter Drainage of Infected Abdominal Collections

When consulted for percutaneous catheter drainage (PCD) of abdominopelvic collections, interventional radiologists (IRs) should consider the appropriateness of this technique in the context of other options such as conservative, endoscopic, or surgical management. Whenever possible, published data should be considered prior to performing percutaneous drainage, especially as regards controversial scenarios such as the use of fibrinolytic therapy, the primary placement of large-bore drainage catheters, the drainage of cystic tumors, the drainage of splenic abscesses, and the treatment of collections lacking an in-line drainage window. This article examines past and present published data on PCD to dispel some common myths and guide IRs toward the best applications of PCD.

Management of complicated acute appendicitis in children: Still an existing controversy

Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.

Use of Tissue Plasminogen Activator in Abdominal Abscesses in Children-A Single-Center Randomized Control Trial

PURPOSE

To establish the efficacy of once-per-day intracavitary tissue plasminogen activator (tPA) in the treatment of pediatric intra-abdominal abscesses.

METHODS

A single-center prospective, double-blinded, randomized controlled trial of the use of intracavitary tPA in abdominal abscesses in children. Patients were randomized to either tPA-treatment or saline-treatment groups. Primary outcome was drainage catheter dwell (hours). Secondary outcomes were length of hospital stay, times to discharge, clinical and sonographic resolution, and adverse events (AEs).

RESULTS

Twenty-eight children were randomized to either group (n = 14 each). Demographics between groups were not significantly different (age P = .28; weight P = .40; gender P = .44). There were significantly more abscesses in the tPA-treated group (P = .03). Abscesses were secondary to perforated appendicitis (n = 25) or postappendectomy (n = 3). Thirty-four abscesses were drained, 4 aspirated, 3 neither drained/aspirated. There was no significant difference in number of drains (P = .14), drain size (P = .19), primary outcome (P = .077), or secondary outcomes found. No procedural or intervention drug-related AEs occurred. No patient in the saline-treated group required to be switched/treated with tPA.

CONCLUSION

No significant difference in the length of catheter dwell time, procedure time to discharge, or time to resolution was found. Intracavitary tPA was not associated with morbidity or mortality. The results neither support nor negate routine use of tPA in the drainage of intra-abdominal abscess in children. It is possible that a multicentre study with a larger number of patients may answer this question more definitively.