Infected abdominal tumors: percutaneous catheter drainage

ACR Appropriateness Criteria® Radiologic Management of Infected Fluid Collections

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Percutaneous drainage and management of fluid collections associated with necrotic or cystic tumors in the abdomen and pelvis

PURPOSE

The purpose of the study was to evaluate the efficacy and safety of percutaneous drainage for palliation of symptoms and sepsis in patients with cystic or necrotic tumors in the abdomen and pelvis.

MATERIALS AND METHODS

This is a single center retrospective study of 36 patients (18 men, mean age = 51.1 years) who underwent percutaneous drainage for management of cystic or necrotic tumors in the non-postoperative setting over an 11-year period. Nineteen patients with intraabdominal fluid collections associated with primary malignancies included: cervical (n = 7), colorectal (n = 3), urothelial (n = 3), and others (n = 6). The 17 patients with fluid collections associated with intraabdominal metastases stemmed from the following primary malignancies: oropharyngeal squamous cell carcinoma (n = 3), colorectal (n = 3), ovarian (n = 2), lung (n = 2), melanoma (n = 2) along with others (n = 5). Indications for percutaneous drainage were as follows: pain (36/36; 100%); fever and/or leukocytosis (34/36; 94%), and mass effect (21/36; 58%). Seven patients underwent additional sclerosis with absolute alcohol. Criteria for drainage success were temporary or definitive relief of symptoms and sepsis control.

RESULTS

Successful sepsis control was achieved in all patients with sepsis (34/34; 100%) and 30/36 (83%) patients had improvement in pain. Duration of catheterization ranged from 2 to 90 days (mean = 22 days). There were four cases of fluid re-accumulation and one patient developed catheter tract seeding. Alcohol ablation was successful in two patients (2/7; 29%). Nearly all patients (34/36; 94%) died during the follow-up period.

CONCLUSIONS

Percutaneous drainage was effective for palliative treatment of symptomatic cystic and necrotic tumors in the majority of patients in this series.

Approaches to the difficult drainage and biopsy

Percutaneous abscess drainage and percutaneous biopsy are effective and widely used techniques in the diagnosis and treatment of patients with abdominal or pelvic abscesses and lesions. Some abscesses and lesions can initially appear unsuitable for percutaneous access for a variety of reasons. This article reviews the circumstances in which collections or lesions may appear undrainable or inaccessible to percutaneous biopsy, and it describes techniques for overcoming these circumstances.

ACR Appropriateness Criteria on percutaneous catheter drainage of infected fluid collections

Abnormal fluid collections occur throughout the body and represent a wide range of pathologies, including abscesses, pseudocysts, cysts, lymphoceles, seromas, bilomas, hematomas, urinomas, and infected neoplasms. Appropriate management often depends on clinical presentation, location, type of collection, early response to treatment, and the presence of complicating factors such as fistulas, septations, and increased viscosity. Physicians should carefully review clinical and imaging findings and make evidence-based recommendations for the best treatment, which may include antibiotics, needle aspiration, percutaneous drainage, endoscopic drainage, or surgical drainage. This paper addresses percutaneous catheter drainage and alternative treatment options for the management of fluid collections and is the result of evidence-based consensus by the ACR Appropriateness Criteria Expert Panel on Interventional Radiology.

The inaccessible or undrainable abscess: how to drain it

Percutaneous abscess drainage is a safe, effective, and widely used technique for the treatment of patients with abdominal or pelvic sepsis. The majority of abdominal and pelvic abscesses afford reasonably straightforward access and are amenable to percutaneous drainage. However, requests are occasionally received for drainage of abscesses or fluid collections that initially appear unsuitable for percutaneous drainage. Factors that render collections seemingly unsuitable for imaging-guided drainage include inaccessibility due to surrounding organs, difficult location, and thickened contents (eg, clotted blood, thick pus). Well-established alternative approaches (eg, transgluteal, transvaginal, transrectal) can be used to facilitate drainage of deep-seated collections that are inaccessible via more traditional routes. Other factors that may improve the accessibility of collections include modifications in patient positioning or in the use of imaging hardware (eg, angling of the computed tomography scanner gantry). Use of these techniques and modifications can allow percutaneous drainage of less accessible intraabdominal abscesses, thus eliminating the need for laparotomy.

Interventional radiology procedures in the liver. Biopsy, drainage, and ablation

Radiologically guided interventional procedures in the liver have continually increased, in number and variety, over the years. Factors promoting these advances include new technology, innovative ideas, and growing acceptance by clinicians and patients. Percutaneous biopsy and drainage procedures are firmly established techniques with low complication rates. Ablation by injected substances is useful for treating certain tumor types. The most exciting development is the introduction of percutaneous thermal techniques for tumor ablation. Although more experience is needed to optimize the use of focal thermal ablation, early results seem promising.

Clinical efficacy of ultrasound guided percutaneous drainage of abscesses in patients with leukaemia and lymphoma

Ultrasound guided percutaneous drainage (US-PD), a minimally invasive technique, has been reported as highly effective for the treatment of deeply located abscesses, particularly in immunocompromised patients. Therefore, we retrospectively studied its therapeutic efficacy and safety in a series of 14 patients with leukaemia and lymphoma. We collected the clinical and sonographic data of 14 patients with various types of leukaemia and lymphoma. These patients were consecutively observed in four clinical centres with long-term experience with ultrasound guided therapeutic techniques. The cases were analysed according to underlying disease, clinical features, location of the abscess, drainage technique, microbiological data and both short- and long-term outcome. In our series, 11 patients were treated with repeated ultrasound guided needle aspirations (US-NA) and 3 underwent catheter drainage (US-PCD). In 12/14 cases the procedure was successful (86%): the mortality rate was 14%. 5 patients died during the follow-up period because of the underlying disease, without abscess recurrence. No complications were reported. Our data suggest that ultrasound guided percutaneous drainage should be considered the first choice, minimally invasive procedure for the treatment of deeply located abscesses in patients with leukaemia and lymphoma.

Radiologic investigation and treatment of gastrointestinal fistulas

Diagnostic radiology has assumed an increasingly prominent role in the diagnosis, investigation, and treatment of gastrointestinal fistulas during the past 15 years. This development largely has been the result of the application of computed tomography and ultrasonography to the diagnosis of intra-abdominal inflammatory processes and the use of these cross-sectional imaging modalities to guide percutaneous abscess drainage by the interventional radiologist. Effective percutaneous techniques have been developed that allow many gastrointestinal fistulas to be managed nonoperatively with less morbidity and mortality.

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.