Percutaneous drainage of lung abscess

Most lung abscesses are successfully treated with antibiotics. However, occasional patients with lung abscesses that drain poorly, causing persistent fever and toxic symptoms, may require surgical intervention. Lobectomy is the most frequent surgical procedure. Some patients are debilitated and have underlying medical conditions such as heart disease, chronic pulmonary disease, or liver disease that may render surgical intervention risky. Recently there have been reports of percutaneous drainage of lung abscess with good results. We have successfully carried out percutaneous drainage of lung abscess in 4 patients and an infected bulla in 1. All patients had failed to respond to therapy with antibiotics and postural drainage. There was prompt disappearance of the fluid level in the cavity, decline in temperature, and abatement of toxic symptoms with drainage. The cavities closed gradually over the next 6–12 weeks. The patients tolerated the chest tube well and there were no side effects from the tube drainage. Percutaneous tube drainage is the surgical treatment of choice in the medically complicated patient with a poorly draining lung abscess.     

Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery

Intra-abdominal abscesses are a frequent source of morbidity and mortality following both elective and emergent surgery of the alimentary tract. CT-guided percutaneous drainage of intra-abdominal abscess is an alternative to immediate surgical intervention. We studied the clinical characteristics and outcomes of patients undergoing percutaneous drainage of intra-abdominal abscesses arising after elective colorectal procedures. We retrospectively identified 40 patients with postoperative intraabdominal abscess following elective colorectal surgery who underwent CT-guided percutaneous drainage with a Von Sonnenberg sump drain between 1990 and 1998. The most common presenting symptoms were pyrexia in 39 (97%), abdominal tenderness in 32 (80%), guarding in 1 (2.5%) and abdominal mass in 3 (7.5%); no patient had generalized peritonitis. The most common index procedure was proctocolectomy with ileoanal anastomosis and ileal Jpouch in 12 (30%) patients. Drainage was performed using an anterior approach in 32 (80%) and a transgluteal window in 8 (20%) patients. Thirty-five (87.5%) patients had a single collection, while 2 (5.0%) patients had 2 collections and 3 (7.5%) patients had 3 collections. Thirteen (32.5%) patients had perioperative steroids, 30 (75%) had preoperative antibiotics, and 40 (100%) had postoperative antibiotics. Follow-up at a mean of 35.8 days revealed complete resolution of abscess in 26 (65%) patients; 14 (35%) patients had residual or recurrent abscess successfully treated by repeat drainage in 8 patients and requiring laparotomy in 6. Percutaneous CT-guided abscess drainage is an effective method for treating intra-abdominal abscess following elective colorectal surgery. The primary success was 65% after the first and 85% after a second drainage. In conclusion, this technique should be considered as the treatment of choice in patients with localized intra-abdominal abscess without signs of generalized peritonitis. Received: 20 July 2002 / Accepted: 4 November 2002     

Percutaneous drainage of abscesses in patients with Crohn's disease

The hospital courses of 9 patients with intraabdominal abscesses and Crohn's disease who underwent abscess drainage utilizing percutaneous techniques were reviewed. Percutaneous methods brought about resolution of fever, leukocytosis, and the abscess cavity in 8 patients. In 5 of these, definitive cure was achieved with percutaneous drainage. In 3, single-stage bowel surgery and fistulectomy were performed following resolution of the abscess cavities and improvement of clinical signs and symptoms. All patients had uncomplicated postoperative courses. Percutaneous drainage should be the initial drainage procedure in treating postoperative abscesses, and, when performed preoperatively, can diminish surgical morbidity.     

Endoscopic transpapillary abscess drainage for a patient with giant pyogenic liver abscess

The primary modalities for management of liver abscesses are usually antibiotics and percutaneous drainage. However, in patients with ascites or bleeding tendency, the percutaneous puncture of liver abscesses may be unsuitable. We applied a new approach, nasobiliary tube drainage, for a giant pyogenic liver abscess following diagnostic endoscopic retrograde cholangiopancreatography. Pyogenic liver abscess is often biliary in origin, and this new approach includes assessment of biliary abnormality for the management of the abscess, enabling treatment of parients in whom puncture of the abscess is considered dangerous because of massive ascites around the liver. We propose that this procedure is useful in the management of a subgroup of patients with pyogenic liver abscess. To our knowledge, no previous reports of endoscopic transpapillary abscess drainage in pyogenic liver abscess are available.     

Percutaneous drainage of lung abscess.

The availability of effective antimicrobial agents has greatly decreased the need for surgical intervention in patients who have a pyogenic lung abscess. We describe 3 patients with lung abscesses caused by gram-negative bacteria who failed to respond to medical treatment and who were believed to be unable to withstand lobectomy. Percutaneous insertion of a drainage tube directly into the abscess brought about a dramatic clinical response, with prompt closure of the cavity. This procedure provides an alternative to thoracotomy and lobectomy in treating lung abscesses that fail to respond to medical therapy.     

Percutaneous drainage of pyogenic lung abscess

Although lung abscesses are successfully treated with antibiotics in 80-90% of cases, this conservative approach may occasionally fail. In cases of failure, pulmonary resection is usually advised. Although it remains controversial, an alternative therapy in such situations is percutaneous transthoracic tube drainage (PTTD). Herein we review the medical literature on PTTD from the last 25 y, focusing on its efficacy, indications, technique, complications and mortality. We conclude that PTTD is a safe, simple and efficacious tool for the management of refractory lung abscess. Complications relating to the procedure occurred in 9.7% of cases and included catheter occlusion, chest pain, pneumothorax and hemothorax. The overall mortality rate secondary to lung abscess was acceptable (4.8%).     

Hepatectomy for pyogenic liver abscess

BackgroundCommensurate with the advances in diagnostic and therapeutic radiology in the past two decades, percutaneous needle aspiration and catheter drainage have replaced open operation as the first choice of treatment for both single and multiple pyogenic liver abscesses. There has been little written on the place of surgical resection in the treatment of pyogenic liver abscess due to underlying hepatobiliary pathology or after failure of non-operative management.MethodsThe medical records of patients who underwent resection for pyogenic liver abscess over a 15-year period were retrospectively reviewed. The demographics, time from onset of symptoms to medical treatment and operation, site of abscess, organisms cultured, aetiology, reason for operation, type of resection and outcome were analysed. There were 49 patients in whom the abscesses were either single (19), single but multiloculated (11) or multiple (19). The median time from onset of symptoms to medical treatment was 21 days and from treatment to operation was 12 days. The indications for operation were underlying hepatobiliary pathology in 20% and failed non-operative treatment in 76%. Two patients presented with peritonitis from a ruptured abscess.ResultsThe resections performed were anatomic (44) and non-anatomic (5). No patient suffered a recurrent abscess or required surgical or radiological intervention for any abdominal collection. Antibiotics were ceased within 5 days of operation in all but one patient. The median postoperative stay was 10 days. There were two deaths (4%), both following rupture of the abscess.DiscussionExcept for an initial presentation with intraperitoneal rupture and, possibly, cases of hepatobiliary pathology causing multiple abscesses above an obstructed duct system that cannot be negotiated non-operatively, primary surgical treatment of pyogenic liver abscess is not indicated. Non-operative management with antibiotics and percutaneous aspiration/drainage will be successful in most patients. If non-operative treatment fails, different physical characteristics of the abscesses are likely to be present and partial hepatectomy of the involved portion of liver is good treatment when performed by an experienced surgeon.     

Outcome of surgical versus percutaneous drainage of abdominal and pelvic abscesses in Crohn's disease

OBJECTIVE: Abdominal and pelvic abscesses are a common complication of Crohn's disease. We studied the effect of the initial choice of therapy on time to resolution of abdominal and pelvic abscesses. METHODS: We recorded clinical, laboratory, and radiographic data on all adult patients with Crohn's disease and abdominal or pelvic abscesses treated at our institution from 1991 to 2001 and followed > or = 1 yr. Univariate analysis identified variables associated with initial choice of drainage modality. These variables were included in a Cox regression model to identify factors independently associated with time to resolution. RESULTS: Of 66 episodes identified, surgery was the initial modality in 29 and percutaneous drainage in 37. Median time to resolution was not different between surgical drainage (25.0 days, range 0-240) and percutaneous drainage (21.5 days, range 0-182) (p = 0.084). Older age, longer duration of symptoms prior to drainage, no fistula identified radiographically, immune modulator use, no rebound tenderness, and admission to the medical service were factors associated with percutaneous drainage as initial modality. These factors, when incorporated in a Cox regression model, did not significantly affect the time to resolution. Days from onset of symptoms to radiographic diagnosis or drainage were independently associated with time to resolution of the abscess. CONCLUSION: Time to resolution of abdominal or pelvic abscesses in Crohn's disease is similar with percutaneous drainage and surgery. One-third of patients treated with percutaneous drainage required surgery within 1 yr. Earlier intervention for abdominal and pelvic abscesses is associated with shorter time to resolution.     

Percutaneous drainage of liver and splenic abscess

42 patients with solitary (n = 34) and multiple (n = 8) abscesses of the liver (n = 36) and the spleen (n = 6) were treated with ultrasound guided percutaneous interventions. 38 patients (90%) underwent a total of 97 closed abscess aspirations using needles of 0.9 and 1.3 mm in diameter. In 4 cases (10%) percutaneous catheter drainage was performed. Intravenous antibiotics were used in all cases. Those patients with closed abscess aspiration additionally received local injection of aminoglycosides into the cavity. 40 out of the 42 patients could be treated successfully by percutaneous methods for a cure rate of 95.2%. Percutaneous drainage failure occurred in 2.4%. One patient with multiple liver abscesses and catheter drainage died from myocardial infarction (hospital mortality 2.4%). Complications of ultrasound-guided interventions included two minor bleedings, requiring no therapy, and one pleural empyema (complication rate 7.1%). There were no treatment related lethal complications. These results indicate that abscesses of the liver and the spleen up to 10 cm in diameter can be effectively treated by closed (repetitive) needle aspiration and antibiotic therapy with a relatively low rate of complications. About half of our patients with abscesses of more than 10 cm received percutaneous catheter drainage. On the basis of our experience surgical drainage of liver abscesses and splenectomy in splenic abscesses should be restricted to those cases with percutaneous drainage failure.     

Endoscopic ultrasound‐guided drainage of pelvic abscess without fluoroscopy guidance

Background and Aims: Few case series are reported on endoscopic ultrasound (EUS)‐guided drainage of pelvic abscesses under fluoroscopy guidance. We hypothesized that EUS‐guided drainage of pelvic abscesses without fluoroscopy is an effective alternative to surgery in patients whose abscesses are not amenable to percutaneous drainage techniques. The aim of this study is to evaluate the clinical efficacy of EUS‐guided trans‐rectal/transcolonic drainage of pelvic abscess without fluoroscopy. Methods: Fourteen consecutive patients with pelvic abscesses not amenable to percutaneous drainage underwent EUS‐guided drainage over a period of 22 months. Main outcome measures were the resolution of the pelvic abscess on repeat imaging and improved clinical symptoms. Results: Fourteen consecutive patients were enrolled. EUS‐guided aspiration was performed in three patients. In two patients, dilatation and aspiration was performed, while trans‐rectal stent was placed in nine patients. All patients became afebrile within 72 h. Stent was removed in all patients, after confirming the resolution of the abscess on repeat computed tomography after 7 days. One patient in whom only aspiration was done had recurrence of fever and abscess on the seventh day and was treated by surgical drainage. A follow‐up EUS done in 13 of the patients after 3 months revealed no recurrence, and all patients were asymptomatic at 6 months. The procedure was uneventful in all patients. Conclusion: Endoscopic ultrasound‐guided drainage without fluoroscopy is a safe and effective modality of treatment for pelvic abscesses not amenable to radiologically guided drainage, thus reducing the need for surgical intervention.     

Percutaneous versus open operative drainage of intra-abdominal abscesses.

This article has tried to provide some perspective on the results of surgical and percutaneous drainage of intra-abdominal abscesses and the impact of CT localization on the successful management of this problem. It is most likely that the recent decrease in mortality for intra-abdominal abscesses over the past decade is due to a variety of factors, including better antibiotics, more aggressive critical care, and earlier diagnosis and treatment of the intraabdominal problem. These factors combined to reduce the incidence of pre-drainage organ failure and the degree of physiologic derangement of these patients at the time of their abscess drainage. Percutaneous drainage and surgical drainage techniques should not be considered competitive but rather complementary. If an abscess is accessible by percutaneous techniques, it is reasonable to consider a nonoperative approach to the problem. It is also clear that patients should respond promptly to whatever technique is employed to drain their intra-abdominal abscess. An improvement should be seen clinically within 24 to 48 hours following drainage. Should improvement not be forthcoming, the patient must be aggressively re-evaluated with repeat CT and decisions made by the responsible surgeon in consultation with the radiologist as to the next appropriate course of action. As our review of the Wayne State University experience suggested, patients are never too sick for an appropriate operation. Although it appears that most abscesses can be successfully treated by percutaneous drainage, pancreatic abscesses with pancreatic necrosis should generally be treated by surgical debridement, usually accompanied by repeated explorations. In addition, splenectomy has not yet been replaced by percutaneous drainage of splenic abscesses.     

Management of abdominal and pelvic abscess in Crohn's disease

Patients with Crohn’s disease may develop an abdominal or pelvic abscess during the course of their illness.This process results from transmural in ammation and penetration of the bowel wall,which in turn leads to a contained perforation and subsequent abscess formation.Management of patients with Crohn’s related intra-abdominal and pelvic abscesses is challenging and requires the expertise of multiple specialties working in concert.Treatment usually consists of percutaneous abscess drainage(PAD)under guidance of computed tomography in addition to antibiotics.PAD allows for drainage of infection and avoidance of a two-stage surgical procedure in most cases.It is unclear if PAD can be considered a definitive treatment without the need for future surgery.The use of immune suppressive agents such as anti-tumor necrosis factor-α in this setting may be hazardous and their appropriate use is controversial.This article discusses the management of spontaneous abdominal and pelvic abscesses in Crohn’s disease.     

Medical vs surgical management of spinal epidural abscess

BACKGROUND: We compared the clinical features and outcomes of patients with spinal epidural abscess treated with prolonged parenteral antibiotics alone or combined with computed tomography-guided percutaneous needle aspiration drainage with those of patients undergoing surgical decompression. METHODS: A retrospective analysis of 57 cases of spinal epidural abscess treated at an academic teaching hospital during a 14-year period. RESULTS: The lumbar region was most frequently involved, and 46% of patients were immunocompromised. Staphylococcus aureus was the most frequently encountered pathogen. For 60 treatment courses, management included medical only (25 patients), medical plus computed tomography-guided percutaneous needle aspiration (7 patients), or surgical drainage approaches (28 patients). Prolonged use of parenteral antibiotics alone or combined with percutaneous needle drainage yielded clinical outcomes at least comparable with antibiotics plus surgical intervention, irrespective of patient age, presence of comorbid illness, disease onset, neurologic abnormality at time of presentation, or abscess size. CONCLUSION: Patients with spinal epidural abscess can be safely and effectively treated with conservative medical treatment without the need for surgery.     

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.     

Endoscopically drained abdominal abscess compressing the sigmoid

Intra-abdominal abscesses (IAA) complicate numerous medical and surgical pathologic conditions. Accurate radiological diagnosis combined with percutaneous or surgical drainage and antibiotics is the current standard of care for IAA. We herein report a case of a 52-year-old woman with a 10-day history of fever and abdominal pain. An intra-abdominal abscess externally compressing the sigmoid was revealed and successfully drained during colonoscopy.     

Treatment of Intra-Abdominal Abscesses in Crohn’s Disease: A Nationwide Analysis of Patterns and Outcomes of Care

Background

Abdominal abscesses are a common complication in Crohn’s disease (CD). Percutaneous drainage of such abscesses has become increasingly popular and may deliver outcomes comparable to surgical treatment; however, such comparative data are limited from single-center studies. There have been no nationally representative studies comparing different treatment modalities for abdominal abscesses.

Methods

We identified all adult CD-related non-elective hospitalizations from the Nationwide Inpatient Sample 2007 that were complicated by an intra-abdominal abscess. Treatment modality was categorized into 3 strata—medical treatment alone, percutaneous drainage, and surgery. We analyzed the nationwide patterns in the treatment and outcomes of each treatment modality and examined for patient demographic, disease, or hospital-related disparities in treatment and outcome.

Results

There were an estimated 3,296 hospitalizations for abdominal abscesses in patients with CD. Approximately 39 % were treated by medical treatment alone, 29 % with percutaneous drainage, and 32 % with surgery with a significant increase in the use of percutaneous drainage since 1998 (7 %). Comorbidity burden, admission to a teaching hospital, and complicated Crohn’s disease (fistulae, stricture) were associated with non-medical treatment. Use of percutaneous drainage was more common in teaching hospitals. Mean time to percutaneous drainage and surgical treatment were 4.6 and 3.3 days, respectively, and early intervention was associated with significantly shorter hospitalization.

Conclusions

We describe the nationwide pattern in the treatment of abdominal abscesses and demonstrate an increase in the use of percutaneous drainage for the treatment of this subgroup. Early treatment intervention was predictive of shorter hospitalization.     

Endoscopic drainage of lung abscesses: technique and outcome

BACKGROUND: Lung abscesses commonly respond well to antibiotic therapy. In patients in whom conventional therapy fails, either percutaneous catheter drainage or surgical resection are usually considered, but are frequently problematic. This study describes our experience with endoscopic lung abscess drainage in patients in whom antibiotic therapy fails. METHODS: Patients in whom antibiotic therapy for lung abscess (enlarging cavity or lack of improvement of clinical status) was unsuccessful were considered candidates if an airway connection to the cavity was present. Treatment decisions were made in a multidisciplinary chest conference. Pigtail catheters were placed via a guidewire approach into the cavities. The abscesses were flushed twice daily with gentamycin solution. If fungal infection was suspected, once-daily amphotericin B was added to the regimen. RESULTS: Forty-two patients, from January 2000 to May 2002 (17 woman and 25 men) were included in this study (mean age, 48.9 years). Catheter placement was successful in 38 patients and led to successful therapy after a mean of 6.2 days of treatment (range, 3 to 21 days). Two patients required transient ventilation after catheter placement; there were no other complications. CONCLUSIONS: Endoscopic lung abscess drainage in selected patients in whom antibiotic therapy fails is feasible and successful in experienced hands. This treatment represents an additional option for the chest physician other than percutaneous catheter drainage or surgical resection.     

Percutaneous abscess drainage

We have drained 50 abscesses in 40 patients. The success rate was 100% for entering the abscess cavities and 98% for establishing catheter drainage. The success rate for treating the abscess (i.e., no surgery required) was 88%. We drained all abscesses for which a safe access route was available, regardless of the abscess's characteristics. Abscesses which are not unilocular may be successfully treated by percutaneous drainage. In critically ill patients and those unsuitable for surgery, catheter drainage is useful until the patient becomes stable. When surgery is not feasible, percutaneous procedures may be the patient's only hope for survival.     

Computed tomography-guided percutaneous abscess drainage in intestinal disease

PURPOSE: This study was designed to assess the efficacy of computed tomography-guided percutaneous abscess drainage in intestinal disease. METHODS: Retrospective chart review of patients who underwent percutaneous abscess drainage for complications of intestinal disease with or without surgery between 1990 and 1994. RESULTS: Eighty-two patients with 111 abscesses were identified. Causes of abscess included anastomotic leaks (35 percent), postoperative complications without leak (30 percent), and diverticular disease (23 percent). Complete success (no surgery necessary) was achieved in 53 of 82 patients (65 percent). Nine patients (11 percent) who underwent interval surgery were classified as having partial successes. Twenty-six of 26 (100 percent) well-defined unilocular collections containing pus were successfully drained. Complex abscesses (loculated, poorly defined, multiple, associated with fistula, draining feces) were successfully drained in 35 of 55 patients (63 percent). Success rates varied inversely with the number of complicating factors present. Apache II scores of 15 or higher were associated with decreased success rates. CONCLUSION: Percutaneous abscess drainage is a highly successful technique for treatment of patients with intra-abdominal infection related to intestinal disease. Although several factors are associated with decreased success rates and multiple complicating factors combine to reduce success rates, no identifiable factor or combination of factors preclude the possibility of a successful outcome.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Pyogenic liver abscess as a complication of Crohn's disease

Pyogenic liver abscess in patients with Crohn's disease is not common, but the mortality has been reported to be high if diagnosis and treatment is delayed. Intra-abdominal abscesses, fistulous disease, and steroid therapy have all been reported to be important predisposing factors in the pathogenesis of this entity. We present a patient with Crohn's disease in whom multiple abscesses were encountered in the right lobe of the liver. The diagnosis of liver abscess was established by abdominal computed tomography and the patient was treated by percutaneous catheter drainage. Awareness of this rare complication is important because diagnosis is difficult to make and a high index of suspicion is required. Once suspected, aggressive diagnostic workup and treatment is indicated. Most patients with liver abscess can be successfully managed by percutaneous catheter drainage combined with antibiotic therapy if it is diagnosed before extensive necrosis has occurred.