Percutaneous management of breast abscesses. An experience of 39 cases

This is a review of our experience with percutaneous drainage by means of needle aspiration or catheter drainage of breast abscesses under ultrasound (US) guidance, and a suggested management algorithm. A retrospective study of the 39 patients (36 women, 3 men; mean age: 28.9 years) with breast abscesses who were treated by percutaneous US-guided procedures over a period of 13 years (1989 to 2002) was carried out. Of the 36 women, 34 were nonlactating and two lactating. Needle aspiration was used in the cases of fluid collections < or = 3 cm and catheter drainage in fluid collections of > 3 cm. Postdrainage care and US evolutive controls were carried out on an outpatient basis. Fine-needle aspiration cytology was performed in masses unresolved after postdrainage. Mammography was performed in patients over 30 years old. In all cases, US examination revealed images of fluid collection. A single needle aspiration was sufficient in 19 cases; 3 patients needed a second aspiration to resolve the breast abscess. A total of 15 cases were resolved by means of percutaneous catheter drainage. In 2 of the 17 patients who underwent catheter drainage, the mass persisted postdrainage; histologic findings showed a chronic abscess requiring surgical intervention in one and a breast carcinoma in the second. Mean follow-up was 8.4 months. Recurrence of breast abscess occurred in 4 patients, and these were resolved by surgical excision. Percutaneous drainage procedures in breast abscesses are a safe and effective alternative to incision and drainage. Needle aspiration is employed in cases of small abscesses and catheter drainage in abscesses larger than 3 cm. Although, in chronic abscesses, the treatment of choice is surgical excision, percutaneous drainage remains as an intermediate therapeutic option.     

Ultrasonically guided percutaneous drainage of abdominal fluid collections: A long-term study of its therapeutic efficacy

Fifty patients underwent ultrasonically guided percutaneous drainage (US-GPD) either with needle aspiration or catheter drainage. The procedures resulted in 70% complete recovery, 20% partial success and 10% of failures. The same patients were followed with clinical examination and sonography for a mean time of 36.3 months (minimum follow-up: 12 months). During the follow up period, 10 relapses occurred and one patient, considered for surgery after partial percutaneous treatment of a pyogenic liver abscess, recovered completely under conservative treatment. An analysis of the factors potentially related to the recurrence was made. It was found that one-step needle aspiration of abdominal abscesses and percutaneous treatment of chronic pancreatic pseudocysts are more prone to relapses. We conclude that US-GPD is an efficacious therapy for abdominal fluid collections, but an adequate drainage technique and a careful selection of the patients is crucial to avoid the possibility of relapse.     

Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview

Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.     

Percutaneous transcatheter occlusion of cystic duct stump in postcholecystectomy bile leakage

Postoperative cystic duct fistula is an uncommon complication after cholecystectomy. Nonoperative management includes endoscopic retrograde or percutaneous transhepatic biliary drainage, and percutaneous catheter drainage of fluid collections. Transcatheter occlusion of the leaking cystic duct remnant proved a valuable alternative treatment when biliary stenting failed for technical reasons.     

Abdominal CT following liver transplantation

Computed tomography (CT) is one of several imaging modalities employed in the evaluation of complications following orthotopic liver transplantation. Abdominal CT scans were performed in 92 (48%) of the first 190 liver transplant patients at our institution. These studies were retrospectively reviewed to determine the indications for CT in this population and to determine the incidences of the various CT findings. The major indication (70%) was detection of bile leakage, hemorrhage, or abscess. The role of CT was primarily to discover such abnormal fluid collections and guide their percutaneous drainage. This article describes a wide spectrum of common and uncommon findings following liver transplantation and illustrates their CT features.     

鼻胆管引流治疗胆囊切除术后胆漏

目的:探讨经内镜逆行胰胆管造影(ERCP)和经内镜鼻胆管引流(ENBD)在胆囊切除术后胆漏诊治中的应用价值。方法:对胆囊切除术后有腹痛、发热、B超引导穿刺引流出胆汁而诊断为胆漏的患者进行ERCP检查,并行ENBD。结果:15例患者ERCP检查均成功,10例发现有造影剂漏出,其中2例伴有明显胆管损伤,2例合并有胆总管结石。除2例胆管损伤患者接受手术治疗外,其余13例均经ENBD治疗成功,2例胆总管结石患者成功接受了EST网篮取石术。结论:对于胆囊切除术后出现胆漏的患者,ERCP是理想的诊断方法,而且还可以通过ENBD结合腹腔引流得到有效治疗。     

Percutaneous cholecystostomy in critically Ill patients

Sixteen critically ill patients underwent percutaneous cholecystostomy because of suspected acute cholecystitis. The procedure was technically successful, although 11 of 16 patients died subsequently because of various complications of their underlying primary disorders. We reviewed this series to reassess the value of percutaneous cholecystostomy. Four of 11 patients with definite acute cholecystitis (group 1) were cured by this technique, but three required surgery because of gallbladder wall necrosis. Two of these were among four cases which had demonstrated pericholecystic fluid collections on computed tomography (CT) or ultrasound of the abdomen. There were also five patients (group 2) in whom acute cholecystitis or its relationship to patients' symptoms were not fully determined, and four of them did not improve after percutaneous cholecystostomy. We conclude that this technique has a lower success rate in critically ill patients than reported previously.     

Endoscopic ultrasound-guided transmural drainage of infected pancreatic fluid collections with placement of covered self-expanding metal stents: a case series

Endoscopic ultrasound-guided transmural drainage (EUS-GTD) has become the standard procedure for treating symptomatic pancreatic fluid collections. The aim of this series was to evaluate the efficacy and safety of covered self-expanding metal stent (CSEMS) placement for treating infected pancreatic fluid collections. From January 2007 to May 2010, 22 patients (18 M/4F; mean age 56.9) with infected pancreatic fluid collections (mean size, 13.2 cm) at two Italian centers were evaluated for EUS-GTD. In 20 of the 22 patients, EUS-GTD with CSEMS placement was indicated. Early complications occurred in two patients: one patient developed a superinfection, which was managed conservatively, and one experienced stent migration and superinfection, and was managed surgically. The CSEMSs were removed without difficulty in 18 patients after a median of 26 days, while stent removal failed in one patient due to inflammatory tissue ingrowth; instead it was removed during surgery performed for renal cancer. Clinical success was achieved without additional intervention in 17 patients during a mean follow-up of 610 days; only one symptomatic recurrence was observed. In our experience, EUS-GTD with CSEMS placement appears safe for the treatment of infected pancreatic fluid collections.     

Drainage of gallbladder fossa fluid collections with endoprosthesis placement under endoscopic ultrasound guidance: a preliminary report of two cases

Collections of fluid in the gallbladder fossa can be detected by ultrasound in as many as 29% of patients following cholecystectomy. Traditionally, persistent collections are treated by percutaneous drainage and bile duct decompression. We present two cases of persistent gallbladder fossa fluid collections which were refractory to bile duct decompression but which were successfully drained by endoscopic ultrasound-guided endoprosthesis placement. Under endoscopic ultrasound (EUS) control, a 19-gauge needle was inserted through the duodenal wall into the gallbladder fossa fluid collection. A guide wire was coiled within the collection, and an endoprosthesis was placed over the wire. Endoprosthesis insertion was successful in both cases, resulting in rapid symptomatic and radiographic improvement. EUS-guided drainage offers a minimally invasive alternative to percutaneous treatment of persistent gallbladder fossa fluid collections following cholecystectomy.     

The role of CT-guided percutaneous drainage of loculated air collections: an institutional experience

Objective

The purpose of this study is to describe our experience with the role of CT-guided percutaneous drainage of loculated intra-abdominal collections consisting entirely of gas.

Materials and methods

An IRB-approved retrospective study analyzing patients with air-only intra-abdominal collections over an 8-year period was undertaken. Seven patients referred for percutaneous drainage were included. Size of collections, subsequent development of fluid, and microbiological yield were determined. Clinical outcome was also analyzed.

Results

Out of 2835 patients referred for percutaneous drainage between 2004 and 2012, seven patients (5M, 2F; average age 63, range 54–85) met criteria for inclusion with CT showing air-only collections. Percutaneous drain placement (five 8 Fr, one 10 Fr, and one 12 Fr) using Seldinger technique was performed. Four patients (57%) had recently undergone surgery (2 Whipple, 1 colectomy, 1 hepatic resection) while two (29%) had a remote surgery (1 abdominoperineal resection, 1 sigmoidectomy). Despite the lack of detectable fluid on the original CT, 6 patients (86%) had air and fluid aspirated at drainage, 5 (83%) of the aspirates developed positive microbacterial cultures. Four patients (57%) presented with fever at the time of the initial scan, all of whom had positive cultures from aspirated fluid. Four patients (57%) had leukocytosis, all of whom had positive cultures from aspirated fluid.

Conclusions

Although relatively rare in occurrence, patients with air-only intra-abdominal collections with signs of infection should be considered for percutaneous management similar to that of conventional infected fluid collections. Although fluid is not visible on CT, these collections can produce fluid that contains organisms.

     

Indications et choix de technique de drainage en cas de pancréatite aiguë grave ?

Definition of severe acute pancreatitis includes organ failure or/and pancreatic or peripancreatic fluid collections. Three types of emergency drainage can be discussed in such a situation: Biliary drainage by early endoscopic sphincterotomy, transpapillary endoscopic drainage in case of early pancreatic fistula, and peripancreatic fluid collections drainage using four different approaches (percutaneous radiologic drainage, retroperitoneal drainage by surgical laparoscopy, transgastric or transduodenal endoscopic drainage and open surgical necrosectomy). The purpose of this mini-review is to focus on the current indications and choices of these different types of drainage approach.     

Transrectal and transvaginal sonographic intervention of infected pelvic fluid collections: a complete approach

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.     

Percutaneous, computed tomography-guided drainage of deep pelvic abscesses via a transgluteal approach: a report on 30 cases and a review of the literature

Aim

Percutaneous drainage of abdominal and pelvic abscesses is a first-line alternative to surgery. Anterior and lateral approaches are limited by the presence of obstacles, such as the pelvic bones, bowel, bladder, and iliac vessels. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous, transgluteal approach by reviewing our clinical experience and the literature.

Materials and methods

We reviewed demographic, clinical and morphological data in the medical records of 30 patients having undergone percutaneous, computed tomography (CT)-guided, transgluteal drainage. In particular, we studied the duration of catheter drainage, the types of microorganisms in biological fluid cultures, complications related to procedures and the patient’s short-term treatment outcome.

Results

From January 2005 to October 2011, 345 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A transgluteal approach was adopted in 30 cases (10 women and 20 men; mean age: 52.6 [range 14–88]). The fluid collections were related to post-operative complications in 26 patients (86.7 %) and inflammatory or infectious intra-abdominal disease in the remaining 4 patients (acute diverticulitis: n = 2; appendicitis: n = 1; Crohn’s disease: n = 1) (13.3 %). The mean duration of drainage was 8.7 days (range 3–33). Laboratory cultures were positive in 27 patients (90 %) and Escherichia coli was the most frequently present microorganism (in 77.8 % of the positive samples). A transpiriformis approach (n = 5) was more frequently associated with immediate procedural pain (n = 3). No major complications were observed, either during or after the transgluteal procedure. Drainage was successful in 29 patients (96.7 %). One patient died from massive, acute cerebral stroke 14 days after drainage.

Conclusion

When an anterior approach is unfeasible, transgluteal, percutaneous, CT-guided drainage is a safe, well tolerated and effective procedure. Major complications are rare. This type of drainage is an alternative to surgery for the treatment of deep pelvic abscesses (especially for post-surgical collections).     

Ultrasound guided percutaneous drainage of abdominal abscesses in the hands of the clinician: a multicenter Italian study

Objective: Image guided percutaneous drainage is a well established therapeutic technique. The results of these procedures, when performed directly by the clinician and under sonographic guidance, in respect to other imaging techniques are not yet clarified. Methods: The 886 cases of ultrasound guided drainage were collected from eight italian clinical institutions and the results were analyzed according to location of the abscess, drainage technique, underlying diseases, microbiological findings, immunological patient status and previous surgical intervention. Results: We observed an overall cure rate of 90.4%. The best results were obtained in hepatic abscesses, both amoebic and pyogenic (cure rate 98.7 and 94.3%). Slightly lower cure rates were obtained in abdominal and splenic abscesses, postoperative collections and severely immunocompromised patients. The frequency of complications was low (6.6%) and mostly related to catheter drainage. No drainage-related deaths occurred. Conclusions: The study confirms the high clinical efficiency and safety of ultrasound guided percutaneous drainage, even when performed directly by the clinician. The sonographic guidance showed similar efficacy, more manageability and lower costs than other imaging techniques and it should be preferred whenever possible. For hepatic abscesses, ultrasound guided needle aspiration showed good results and less complications than catheter drainage.     

Single-step endoscopic ultrasonography-guided drainage of peripancreatic fluid collections with a single self-expandable metal stent and standard linear echoendoscope

Endoscopic ultrasonography (EUS)-guided drainage of peripancreatic fluid collections (PFCs) is a well described alternative to surgery or percutaneous drainage. However, it is limited by the requirement for a large working channel that allows multiple plastic stent placement, which is only commercially available on therapeutic linear echoendoscopes. Herein, we describe the drainage of PFCs with a single self-expandable metal stent (SEMS) using a single-step technique and standard linear echoendoscope. Seven cases were identified during a retrospective chart review, and included all patients who had undergone EUS-guided drainage of PFCs during a 6-month period. The mean age was 46 years (range 25 - 70 years) and all patients were symptomatic. The mean diameter of PFCs was 8 cm (range 4.1 - 12.5 cm). Previous percutaneous drainage had failed in three patients. A total of 10 PFCs were drained. Three patients had two cysts drained by the same stent and one patient had two separate procedures to drain two distinct cysts. The SEMS was in place for a mean of 13 weeks (range 4 - 34 weeks). Successful placement of SEMS was achieved in all seven cases. Patients were followed for a mean of 18 weeks (range 7 - 35 weeks), and symptom improvement was achieved in all cases. Complete resolution of PFC was achieved in 9 /10 cysts. No complications were encountered. Single-step EUS-guided drainage of PFCs using a single 10-mm SEMS and a standard linear echoendoscope appears to be a feasible endoscopic technique with excellent technical and clinical success rates.     

Pleural drainage using modified pigtail catheters

An 8.3-Fr modified pigtail catheter has been developed for chronic percutaneous drainage of pericardial effusions. Placement of this catheter using a modified Seldinger technique is virtually atraumatic. To test the safety and efficacy of this catheter for pleural drainage, it was used to manage eight collections of pleural fluid and nine pneumothoraces in a total of 12 infants and children. There were no placement complications. Fluid accumulations were satisfactorily drained in every instance. Pneumothoraces were treated definitively with a single catheter, except when a bronchopleural fistula was present. Percutaneous pigtail drainage of pleura fluid or air is simple, safe, effective, and substantially less traumatic than standard chest-tube placement.     

Management of patients with malignant obstructive jaundice. Nursing perspective from the interventional radiology room

Most patients with obstructive jaundice caused by primary pancreaticobiliary malignancies and metastatic disease cannot be cured by surgical resection when diagnosed. Biliary drainage in the management of obstructive jaundice therefore represents one of the most important issues in the palliative treatment of these patients. For more than 20 years, percutaneous transhepatic biliary drainage procedures have allowed a nonsurgical approach to the management of malignant biliary obstruction. Improvements in radiologic access systems have extended the use of the percutaneous biliary approach, especially since the advent of metallic stents. Nursing care of these patients before, during, and after the percutaneous biliary intervention is challenging. Patient and family need to be educated about the aim and consequences of the procedure as well as its complications. To care for these patients, the nurse must understand the techniques of percutaneous transhepatic biliary drainage. The purpose of this article is briefly to review the etiology of biliary obstruction, the current treatments to relieve obstructive jaundice, and the basic steps of biliary intervention techniques. The nursing management throughout the procedure, the patient preparation before the procedure, and most importantly, the postprocedural nursing care are discussed.     

CT引导下经皮穿刺置管引流在胰腺术后腹腔感染患者中的应用疗效

目的 探讨CT引导下经皮穿刺置管引流应用于胰腺术后腹腔感染的可行性、安全性及疗效。方法 回顾性纳入胰腺术后腹腔积液合并感染并接受CT引导下经皮穿刺置管引流的患者,分析穿刺置管对患者腹腔积液感染的治疗效果。结果 纳入8例胰腺术后患者,术后均出现腹腔积液合并腹腔感染。共完成10次CT引导下穿刺置管引流,置管13根,穿刺成功率100%。穿刺管引流液淀粉酶含量较高者达92.3%(12/13),细菌培养阳性率达100%,联合应用抗生素治疗后均治愈。结论 CT引导下经皮穿刺置管引流是胰腺术后腹腔积液感染治疗的重要手段,安全有效、创伤小。     

超声引导下置管引流在肝移植术后腹腔并发症中的应用

目的探讨超声引导下置管引流在原位肝移植术后腹腔并发症中的价值。方法回顾40例在超声引导下采用Seldinger法置管引流治疗原位肝移植术后腹腔并发症的资料。结果40例超声引导下置管引流均一次成功,包括肝内胆汁瘤置管3例,经皮肝内胆管置管3例,胆漏置管12例,膈下积液置管引流9例,腹腔积液置管引流13例。其中13例为导管堵塞或分隔性积液而重新置管。置管后分别引流出胆汁、脓液或积液,引流后症状有不同改善,无严重并发症发生。结论超声引导下置管引流对原位肝移植术后腹腔并发症有重要价值。     

经皮肾镜超声碎石术后留置肾造瘘管患者的护理

目的 探讨对多发性肾结石患者经皮肾镜超声碎石术（PCNL）后留置肾造瘘管有效的护理措施.方法 选择2012年9月-2013年8月接受PCNL并术后留置肾造瘘管的46例多发性肾结石患者作为干预组,患者接受系统性的护理干预;选择2011年9月-2012年8月另外46例接受PCNL并术后留置肾造瘘管的多发性肾结石患者作为对照组,患者围术期仅接受常规护理.观察并统计两组患者置管并发症发生情况以及焦虑自评量表（SAS）评分、Barthel指数（BI）和住院时间,并在护理结束后对患者进行护理满意度调查.结果 干预组发生肾造瘘管内出血1例,周围感染0例,造瘘管移位1例,引流不畅1例,并发症发生率为6.5％;对照组发生肾造瘘管内出血3例,周围感染2例,造瘘管移位3例,引流不畅2例,并发症发生率为21.7％,两组并发症发生率比较差异有统计学意义（x2=4.389,P=0.036）.干预组SAS评分、BI和住院时间分别为（2.4±1.1）分、（79.6±6.4）和（7.8±1.2）d,对照组分别为（3.8±1.7）分、（68.4±7.7）和（10.3±2.7）d,两组比较差异均有统计学意义（t值分别为4.682,6.741,9.473;P ＜0.05）.干预组满意度为95.7％ （44/46）,对照组满意度为78.3％ （36/46）,两组比较差异有统计学意义（x2=9.531,P=0.007）.结论 多发性肾结石患者PCNL术后对肾造瘘管进行护理能有效减少并发症的发生,缓解患者的焦虑情绪,获得患者认可.