Periappendiceal abscesses: percutaneous drainage

Intra-Abdominal Abscesses: Emphasis on Image-Guided Diagnosis and Therapy

Infection of the peritoneal cavity can be divided into acute peritonitis and chronic abscess formation. While acute peritonitis is easier to diagnose and treatment is often straightforward, the diagnosis of an intra-abdominal abscess can be subtle and treatment can involve multiple diagnostic and therapeutic modalities. The advent of high-quality computed tomography and ultrasonography has revolutionized the care of these patients, and has allowed for the definitive management of these infections without open operation. We review the current techniques for the diagnosis, localization, and treatment of these serious infections, discuss important factors influencing the decision between percutaneous and operative approaches, and examine several other controversies In this challenging area.

Image-guided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy

BACKGROUND

Appendicitis is the most common cause of an acute abdomen in children. With perforation, multiple intraperitoneal collections can be seen at presentation. In this situation, surgical treatment alone is rarely effective.

OBJECTIVE

To determine the role of image-guided drainage in treating patients with acute appendicitis complicated by multiple intraabdominal collections.

MATERIALS AND METHODS

A retrospective review of patient charts and interventional radiology records was performed to identify all patients with acute complicated appendicitis treated by multiple image-guided drainage procedures. Data reviewed included the number of drainages and aspirations performed, drain dwell time, the clinical course and temperature profile, and the length of inpatient hospital stay and any complications experienced.

RESULTS

The study population comprised 42 children with a mean age of 107.6 months. A total of 100 drainage catheters were inserted and 56 aspirations were performed. Of the 42 children, 24 were successfully treated at a single sitting, while 18 returned for further intervention. The mean drain dwell time was 8.18 days. The mean inpatient stay was 15.02 days. Treatment of the acute presentation with image-guided intervention was successful in 92.3% of children.

CONCLUSION

Successful management of acute perforated appendicitis with multiple intraabdominal abscesses can be achieved with multiple minimally invasive image-guided drainage procedures.

Role of interventional radiology in the management of complications after pancreaticoduodenectomy

BACKGROUND

This study evaluated the role of interventional radiology (IR) procedures to manage complications after pancreaticoduodenectomy.

METHODS

A retrospective review was made of the records of patients with postsurgical complications managed with IR.

RESULTS

Among the 440 patients reviewed, the mortality, morbidity and reoperation rates were 1.6%, 36%, and 2%, respectively. Complications occurred in 159 patients, of which 39 (25%) required > or = 1 IR procedures. Of those 39 patients, 72% underwent percutaneous drainage of an intra-abdominal abscess, 18% underwent percutaneous biliary drainage, and 10% underwent angiography for gastrointestinal bleeding or pseudoaneurysm. The reoperation rate among the 159 patients with complications was 6% (n = 9). Reoperation was avoided in 90% of patients receiving IR. Four patients underwent reoperation despite IR for persistent abscess, pancreatic fistula, anastomotic disruption, or mesenteric venous bleeding.

CONCLUSIONS

The majority of complications occurring after pancreaticoduodenectomy can be managed effectively using IR, thus minimizing morbidity and the need for reoperation.

Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis

OBJECTIVE

A systematic review of the nonsurgical treatment of patients with appendiceal abscess or phlegmon, with emphasis on the success rate, need for drainage of abscesses, risk of undetected serious disease, and need for interval appendectomy to prevent recurrence.

SUMMARY BACKGROUND DATA

Patients with appendiceal abscess or phlegmon are traditionally managed by nonsurgical treatment and interval appendectomy. This practice is controversial with proponents of immediate surgery and others questioning the need for interval appendectomy.

METHODS

A Medline search identified 61 studies published between January 1964 and December 2005 reporting on the results of nonsurgical treatment of appendiceal abscess or phlegmon. The results were pooled taking the potential clustering on the study-level into account. A meta-analysis of the morbidity after immediate surgery compared with that after nonsurgical treatment was performed.

RESULTS

Appendiceal abscess or phlegmon is found in 3.8% (95% confidence interval (CI), 2.6-4.9) of patients with appendicitis. Nonsurgical treatment fails in 7.2% (CI: 4.0-10.5). The need for drainage of an abscess is 19.7% (CI: 11.0-28.3). Immediate surgery is associated with a higher morbidity compared with nonsurgical treatment (odds ratio, 3.3; CI: 1.9-5.6; P < 0.001). After successful nonsurgical treatment, a malignant disease is detected in 1.2% (CI: 0.6-1.7) and an important benign disease in 0.7% (CI: 0.2-11.9) during follow-up. The risk of recurrence is 7.4% (CI: 3.7-11.1).

CONCLUSIONS

The results of this review of mainly retrospective studies support the practice of nonsurgical treatment without interval appendectomy in patients with appendiceal abscess or phlegmon.

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.

Percutaneous drainage of abdominal abscesses in pediatric Crohn's disease

OBJECTIVE

Crohn's disease is complicated by abscesses in 10-30% of patients during their lifetime. The goal of our study was to illustrate that, besides surgical treatment, percutaneous abscess drainage plays a major role in treating children with Crohn's disease.

MATERIALS AND METHODS

This retrospective study included 14 pediatric patients (age range, 12-17 years; median age, 15 years) with proven Crohn's disease. Percutaneous abscess drainage was performed for 15 abdominal or pelvic abscesses or for both abdominal and pelvic abscesses. The abscess was an initial manifestation of Crohn's disease in four patients and complicated well-known disease in 10 patients. Abscesses occurred spontaneously (n = 11), after surgery (n = 3), or after infliximab treatment (n = 1). Their volume ranged from 8 to 442 mL (mean, 113 mL). Fistulas with the bowel were detected in eight cases.

RESULTS

Sixteen percutaneous abscess drainages were performed under sonographic or CT guidance (or both) using 6- or 8-French catheters. The procedure was performed with the patient under conscious sedation (n = 14) or anesthesia (n = 2). The duration of the drainage was 1-30 days (mean, 11 days). An enterocutaneous fistula, medically treated with success, was the only complication observed. Complete resolution of the collection was observed in eight abscesses and partial resolution in seven. Resection of the diseased bowel segment with primary anastomosis was possible in 12 patients. In two patients, percutaneous abscess drainage was not followed by surgery.

CONCLUSION

Percutaneous abscess drainage is a valuable procedure in pediatric patients with Crohn's disease presenting with pelvic or abdominal abscesses (or both). It improves the general status of the patient and allows a less invasive and easier subsequent surgical procedure. Percutaneous abscess drainage should be performed before definitive treatment.

Percutaneous Drainage of 300 Intraperitoneal Abscesses with Long-Term Follow-Up

The purpose of the study was to evaluate the efficacy of percutaneous drainage of intraperitoneal abscesses with attention to recurrence and failure rates. A retrospective analysis of percutaneous treatment of 300 intraperitoneal abscesses in 255 patients (147 male, 108 female; average age: 38 years; range: 40 days to 90 years) for whom at least 1-year follow-up data were available was performed. Abscesses were drained with fluoroscopic, sonographic, or computed tomographic guidance. Nine abscesses were drained by simple aspiration; catheter drainage either by Seldinger or trocar technique was used in the remaining 291 abscesses with 6F to 14 F catheters. Initial cure and failure rates were 68% (203/300) and 12% (36/300), respectively. Sixty-one abscesses (20%) were either palliated or temporized. The recurrence rate was 4% (12/300) and nine of them were cured by recatheterization, whereas three of them were treated by medication or surgery. The overall success and failure rates were 91% (273/300) and 9% (27/300), respectively, with temporized, palliated, and recatheterized recurred abscesses. The 30-day mortality rate was 3.1% (8/255). The mean duration of catheterization was 13 days. Intraperitoneal abscesses with safe access routes should be drained percutaneously because of high success and low morbidity, mortality, and recurrence rates.

Transgluteal Approach for Draining Pelvic Fluid Collections in Pediatric Patients

PURPOSE

To evaluate a transgluteal approach for draining pelvic fluid collections in pediatric patients.

MATERIALS AND METHODS

Institutional review board approval and informed consent for interventional procedures were obtained. From September 1995 to December 2002, 140 abdominopelvic fluid collections were drained at two institutions. Retrospective analysis of a prospectively gathered procedural database revealed that a transgluteal approach was used to drain 53 of these 140 collections (38%) in 51 patients (29 female, 22 male; mean age, 11.2 years; age range, 0.2-19 years). All patients received antibiotics before the procedure. A retrospective analysis was conducted of the patients' medical records and diagnostic imaging and interventional procedure findings, including the reason for referral; location, volume, and character of collections; method and equipment used for evacuation; duration of therapy; evidence of complications; results of microbiologic examination of specimens; and success rates.

RESULTS

Transgluteal drainage was performed with computed tomographic (CT) guidance in 45 of the 53 collections (85%), with fluoroscopic guidance in three (6%), and with a combination of both modalities in five (9%). A drainage catheter was successfully placed in 49 collections; four small collections were aspirated without drain placement. Infected fluid was obtained from 41 collections, and serosanguineous fluid was obtained from 12 collections. The mean volume aspirated was 80 mL (2-600 mL). A positive culture was obtained at 28 of the 53 procedures. The mean duration of catheter placement was 4 days (range, 2-14 days). There were no major complications.

CONCLUSION

The transgluteal approach to the drainage of abdominopelvic fluid collections with imaging guidance is safe and effective.

Management of appendiceal masses

OBJECTIVE

To evaluate the outcome of patients treated for appendiceal abscess, and managed either conservatively or surgically, and to describe the short and long-term outcome as well as incidence of interval appendicectomy in those treated conservatively.

DESIGN

Retrospective study.

SETTING

University hospital, Sweden.

PATIENTS

Ninety-three patients with the diagnosis of appendiceal abscess, 50 treated conservatively and 43 who were operated on, with a mean age of 46 (14-93) years. Mean (range) follow-up for patients operated on was 65 (11-135) and for those treated conservatively 66 (6-136) months.

MAIN OUTCOME MEASURES

Course of acute disease, recorded complications, recurrence of appendicitis and incidence of interval appendicectomy during follow-up.

RESULTS

The duration of pain before admission was 4 (0.5-82) days for those operated on and 7 (2-60) days for those treated conservatively. A palpable mass was more common in the conservatively managed group. Complications were common among patients who were operated on. No interval appendicectomies were done during the second half of the study period. 4 of the patients treated conservatively (8%) had an underlying tumour diagnosed at follow-up.

CONCLUSIONS

Operative management of patients with appendiceal masses seems to be associated with a high risk of postoperative complications and the risk of a more extensive surgical procedure. If possible, a conservative approach should be advocated. Because of inaccurate radiological imaging during the acute phase and the risk of an underlying malignancy, routine follow-up is necessary. Routine interval appendicectomy cannot be recommended.

Initial nonoperative management for periappendiceal abscess

PURPOSE

Our goal was to compare initial operative and nonoperative management for periappendiceal abscess complicating appendicitis.

METHODS

This study is a retrospective review of 155 consecutive patients with appendicitis complicated by periappendiceal abscess treated between 1992 and 1998. Eighty-eight patients were treated initially nonoperatively, and 67 patients were treated operatively. All patients had localized abdominal tenderness and either computed tomography or intraoperative documentation of an abscess.

RESULTS

Our patient population consisted of 107 males and 48 females, with an average age of 33 (range, 16-75) years. Age, gender, comorbidity, white blood cell count, temperature, and heart rate did not differ significantly between groups. For the initial nonoperative management group, the failure rate was 5.8 percent and the appendicitis recurrence rate was 8 percent after a mean follow-up of 36 weeks. The response to treatment of the initial nonoperative group and the initial operative group was compared by length of stay (9 +/- 5 days vs. 9 +/- 3 days; P = not significant), days until white blood cell count normalized (3.8 +/- 4 days vs. 3.1 +/- 3 days; P = not significant), days until temperature normalized (3.2 +/- 3 days vs. 3.1 +/- 2 days; P = not significant), and days until a regular diet was tolerated (4.7 +/- 4 days vs. 4.6 +/- 3 days; P = not significant). Complication rate was significantly lower in the nonoperative group (17 vs. 36 percent; P = 0.008).

CONCLUSIONS

Initial nonoperative management of appendicitis complicated by periappendiceal abscess is safe and effective. Patients undergoing initial nonoperative management have a lower rate of complications, but they are at risk for recurrent appendicitis.

Bedside diagnostic ultrasound and therapeutic ultrasound-guided procedures in the intensive care setting

The availability, portability, safety, and other features of ultrasound have ushered this relatively new imaging modality into the everyday clinical practice of multiple disciplines. Features unique to ultrasound lend this imaging modality the opportunity for extensive use in the ICU. A review of its uses in this capacity includes bedside diagnosis of common disorders seen in the ICU setting, such as DVT, cholecystitis, and abscess. Bedside sonography also can aid in the treatment of such disorders, including DGC of pseudoaneurysms, fluid aspirations, and abscess drainages. This article is a review and could not possibly cover all bedside uses of ultrasound or provide in-depth information of specific uses described in this article. Hopefully, this article will spark an interest and prove as a starting point on a rewarding learning adventure.

Peritoneal abscesses due to bowel perforation: effect of extent on outcome after percutaneous drainage

PURPOSE

To determine the effect of extent of peritoneal contamination in enteric abscesses on final outcome and duration of percutaneous drainage.

PATIENTS AND METHODS

Results were retrospectively reviewed for 11 patients with varying degrees of peritoneal contamination secondary to subacute bowel perforation who were primarily treated with percutaneous drainage. Stepwise linear regression analysis of duration of drainage was performed with use of patient age and immune status, the site of bowel perforation, and the number of peritoneal compartments involved in the resultant contamination as independent variables.

RESULTS

In 10 of 11 patients (91%) treatment of the resultant intraperitoneal collections with percutaneous drainage was successful irrespective of the extent of peritoneal contamination. There was no correlation between duration of drainage and extent of peritoneal contamination but good correlation with patient age and site of bowel perforation (r = 0.82, P = .02).

CONCLUSION

In patients with enteric abscesses due to subacute bowel perforation, the duration of drainage and final outcome after percutaneous drainage are independent of the extent of peritoneal contamination.

Computerized tomographic scan-guided drainage of intra-abdominal abscesses. Preoperative and postoperative modalities in colon and rectal surgery

PURPOSE

Computerized tomographic (CT) scan-guided percutaneous drainage of intra-abdominal abscesses has changed the colon and rectal surgeon's approach to preoperative and postoperative intra-abdominal infections. This study is an effort to prove the efficacy of CT scan-guided percutaneous drainage.

METHODS

A retrospective study was performed on 133 patients who underwent CT scan drainage of intra-abdominal abscesses over a 6.3-year period.

RESULTS

67 patients had underlying lower gastrointestinal disease. Twenty-three of these patients (34 percent) had spontaneous abscesses and underwent drainage as a preoperative or final modality, whereas 44 patients (66 percent) were drained postoperatively. In 78 percent of patients, surgery was successfully avoided or delayed. Ten patients had acute diverticulitis associated with a large pelvic abscess. Eight patients underwent successful CT scan-guided percutaneous drainage, yielding an 80 percent success rate. Morbidity from the CT scan-guided percutaneous drainage procedure in spontaneous and postoperative groups was 0 percent and 9 percent, respectively. Mortality was 9 percent and 11 percent, respectively, and associated with an elevated Acute Physiology and Chronic Health Evaluation II (APACHE II) score.

CONCLUSION

CT scan-guided percutaneous drainage of intra-abdominal abscesses is an important adjunct to colon and rectal surgery because roughly 80 percent of spontaneous and postoperative abscesses were successfully managed.

Percutaneous abscess drainage: current applications for critically ill patients

Radiologically guided percutaneous abscess drainage (PAD) was first reported in 1977. Since this time, technological advances in imaging, improved catheter technology, and increased experience with the procedure have resulted in a tremendous expansion of the indications for PAD. This procedure currently has applications in nearly every organ system of the body. These changes have also contributed to improved success rates, with concurrent minimization of procedure-related complications. The advantages of PAD include simple, rapid performance; feasibility of bedside intensive care unit (ICU) performance; safety; avoidance of general anesthesia; and well-documented efficacy. This procedure has now become well entrenched in clinical medicine and probably ranks with the development of effective antibiotics as the most significant improvement in the treatment of abscesses in the past century. PAD is ideally suited for the treatment of critically ill ICU patients. We discuss technical developments over the past 15 years; general principles of patient preparation and catheters are also reviewed. Current applications of PAD in each organ system are discussed.

Percutaneous ultrasound-guided drainage of intra-abdominal abscesses

A retrospective review of 200 patients with intra-abdominal abscesses treated by percutaneous ultrasound-guided drainage is reported. Abscesses were simple in 151 patients (75.5 per cent) and complex in 49 (24.5 per cent). In 12 patients the abscess communicated with the gastrointestinal tract. There were 17 critically ill patients for whom percutaneous drainage was the only therapeutic option possible. The success rate was 94.7 per cent (143 of 151 patients) for simple abscess and 69 per cent (34 of 49) for complex abscess. The overall success rate was 88.5 per cent. The mortality rate was 1.3 per cent (two patients) for simple and 16 per cent (eight patients) for complex abscess. The overall mortality rate was 5.0 per cent. Percutaneous ultrasound-guided drainage should be the initial drainage procedure in patients with a simple abdominal abscess. The presence of a complex abscess should not prevent an attempt at percutaneous catheter drainage, particularly in high-risk patients, although the risk of failure is greater in such cases.

Contemporary management of the appendiceal mass

An appendiceal mass is the end result of a walled-off appendiceal perforation and represents a pathological spectrum ranging from phlegmon to abscess. Over the past decade, improved imaging and interventional radiological techniques have allowed a more accurate definition of pathology and thus a more specific and less invasive management than was previously possible. A management policy should be possible that allows over 80 per cent of patients presenting with an appendiceal mass to be safely spared an open operation.

Abdominal abscesses associated with enteric fistulas: percutaneous management

For many years, surgical dictum stated abdominal fistulas should be treated by means of surgical excision. Recent advances in percutaneous techniques have altered this. The authors reviewed 150 consecutive abdominal abscesses drained percutaneously over a 36-month period. Among these, 24 patients were found to have 26 fistulous communications to bowel, the pancreatic duct, or the biliary system. Initial drainage of their abscesses was performed in the hospital, but 17 of 24 patients were discharged with a tube in place and were followed up as outpatients. The duration of drainage ranged from 4 days to 3 months. Fistulas healed in 21 of 24 patients (88%) without surgical intervention. Complications were few and included inadvertent dislodgment requiring tube replacement (two patients) and inadvertent puncture of the transverse colon (one patient). Treatment of abdominal abscesses with fistulas by means of percutaneous methods is reliable and safe. Hospital stay may be minimized with outpatient management after drainage.

Intra-abdominal sepsis: the role of radiology

A wide range of imaging tools is available for the investigation of abdominal sepsis. Plain films and barium studies alone are generally regarded as inadequate and most patients will require ultrasound, CT or nuclear medicine studies to locate the source of sepsis. The choice of imaging modality depends on several factors, most important of which are the clinical condition of the patient and the presence or absence of localizing signs and symptoms. Ultrasound has the advantage of being portable and is therefore probably the best initial imaging method for the critically ill patient. It should also be the first investigation in patients with signs and symptoms localizing to the right upper quadrant, renal areas, subphrenic spaces or pelvis. Transvaginal ultrasound is particularly useful in examining the pelvis. CT is the imaging modality of choice for the pancreas and retroperitoneum and in patients who are poor candidates for ultrasound or in whom visualization on ultrasound is inadequate. In patients with PUO or evidence of sepsis without localizing signs or symptoms, nuclear medicine studies in the form of 67Ga citrate or labelled white cell scans are useful to localize the septic focus, although in most cases CT or ultrasound will subsequently be required for detailed anatomical definition. Imaging techniques have an increasingly important role to play in the treatment of sepsis, and guided aspiration and drainage may be performed with a high degree of accuracy under ultrasound or CT guidance, eliminating the need for surgical intervention in many individuals.

Percutaneous abscess and fluid drainage: a critical review

Pertinent radiologic and surgical literature regarding abscess drainage was reviewed. Noted is the heterogeneity of disorders categorized as abscesses, and the variety of therapeutic approaches presently available. Specific abscesses are discussed based on body location and/or associated organ system.

Percutaneous drainage of postappendectomy abscesses complicated by enteric communication

Four patients with postappendectomy abscesses complicated by enteric fistulae were treated by percutaneous drainage. Sinograms, obtained at the time of the initial drainage, demonstrated communication to the cecum in 3 patients and to the small bowel in 1 patient. Complete cure was attained in 3 patients by percutaneous drainage. In the fourth patient, surgery was performed after 7 days of catheter drainage. Percutaneous drainage of abscesses with enteric communication requires a modified technique, which includes longer-term drainage than for simple noncommunicating abscesses.

Imaging intraabdominal abscesses and nonoperative drainage procedures

With state-of-the-art imaging and interventional techniques, the diagnosis and management of intraabdominal abscesses have improved. Radionuclide scanning, ultrasound, and computed tomography are very accurate for the diagnosis and staging of intraabdominal abscesses, permitting the use of percutaneous drainage methods. Percutaneous abscess drainage (PAD) has gained wide acceptance and applications now include not only curative drainages but also certain palliative ones. Although some controversy exists relative to results and palliative procedures, PAD is now accepted as an effective alternative to operative drainage.

Intraabdominal abscesses--percutaneous catheter drainage versus operative treatment

From 65 patients with 73 abscesses 38 were treated by operation and 27 by PCD. The mean duration of drainage was 6.8 days (OP) and 7.4 days (PCD) respectively. In the surgical group 2 patients needed reintervention and 1 died due to sepsis. In the PCD group 1 patient had to be operated on because of insufficient drainage and 1 died after perforation of the colon. With modern techniques of imaging (Ultrasound, CT) PCD is a useful tool in the therapeutic regimen of intraabdominal abscesses. PCD has to be considered as definitive treatment or preparation for surgical eradication. Above all indication to PCD depends on localization and cause of the abscess.