Outcome of percutaneous continuous drainage of psoas abscess: A clinically guided technique

Background:

Percutaneous aspiration of abscesses under ultrasonography (USG) and computer tomography (CT) scan has been well described. With recurrence rate reported as high as 66%. The open drainage and percutaneous continuous drainage (PCD) has reduced the recurrence rate. The disadvantage of PCD under CT is radiation hazard and problems of asepsis. Hence a technique of clinically guided percutaneous continuous drainage of the psoas abscess without real-time imaging overcomes these problems. We describe clinically guided PCD of psoas abscess and its outcome.

Materials and Methods:

Twenty-nine patients with dorsolumbar spondylodiscitis without gross neural deficit with psoas abscess of size >5 cm were selected for PCD. It was done as a day care procedure under local anesthesia. Sequentially, aspiration followed by guide pin-guided trocar and catheter insertion was done without image guidance. Culture sensitivity was done and chemotherapy initiated and catheter kept till the drainage was <10 ml for 48 hours. Outcome assessment was done with relief of pain, successful abscess drainage and ODI (Oswestry Disability Index) score at 2 years.

Results:

PCD was successful in all cases. Back and radicular pain improved in all cases. Average procedure time was 24.30 minutes, drain output was 234.40 ml, and the drainage duration was 7.90 days. One patient required surgical stabilisation due to progression of the spondylodiscitis resulting in instability inspite of successful drainage of abscess. Problems with the procedure were noticed in six patients. Multiple attempts (n = 2), persistent discharge (n = 1) for 2 weeks, blocked catheter (n = 2) and catheter pull out (n = 1) occurred with no effect on the outcome. The average ODI score improved from 62.47 to 5.51 at 2 years.

Conclusions:

Clinically guided PCD is an efficient, safe and easy procedure in drainage of psoas abscess.     

Percutaneous catheter versus open surgical drainage in the treatment of abdominal abscesses

In the past 3 years, percutaneous catheter drainage (PCD) was performed for 24 abdominal and retroperitoneal abscesses while open surgical drainage (OSD) was used for treatment of 24 similar abscesses at the affiliated hospitals of UMDNJ-Rutgers Medical School. Although the method of treatment was arbitrarily selected by the attending physician, the two groups were similar with respect to abscess location, underlying illnesses, and previous operations. In the PCD group, 17 of 24 abscesses developed after operations versus 16 of 24 in the OSD group. Location of abscesses were: PCD group: abdominal (9), renal (5), pelvic (4), subphrenic (3), hepatic (2), pancreatic (1); OSD group: abdominal (10), renal (4), subphrenic (4), pelvic (3), hepatic (2), pancreatic (1). With PCD, the abscesses were localized by ultrasound or computerized tomography scan; a 20- or 22-gauge needle passed into the cavity, followed by progressively larger guide wires, dilators, and catheters; the pus evacuated; and abscess cavity thoroughly irrigated with sterile saline. Percutaneous catheter drainage was successful in 22 of 24 cases. There were two inconsequential complications. The mean post-PCD hospital stay was 11.7 days. With OSD, five patients developed major complications, including three deaths from sepsis. The mean post-OSD stay for surviving patients was 21.2 days. The advantages of PCD versus OSD are: 1) precise noninvasive localization of abscesses, 2) avoidance of general anesthesia, 3) avoidance of major complications, and 4) shorter postdrainage hospital stay. Open surgical drainage should be reserved for cases where PCD fails to control sepsis, close fistulae, or when noninvasive scanning either fails to demonstrate a discrete abscess in the face of intra-abdominal sepsis or identifies an abscess that cannot be percutaneously drained without traversing the bowel.     

Determinants for successful percutaneous image-guided drainage of intra-abdominal abscess

HYPOTHESIS: Characteristics of intra-abdominal abscess can be used to predict successful outcome for percutaneous catheter drainage (PCD). METHODS: We performed a multicenter prospective study of patients who had intra-abdominal infections treated with PCD and intravenous antibiotics. Multivariate regression analysis determined predictors of successful outcome. RESULTS: The study included 96 patients (59% men; mean +/- SD age, 48 +/- 17 years; mean +/- SD Acute Physiology and Chronic Health Evaluation II score, 7.4 +/- 4.9). Postoperative abscess was present in 53% of patients. Isolated microorganisms included Bacteroides species (17%), Escherichia coli (17%), Streptococcus species (14%), Enterococcus species (10%), and fungi (11%). Single abscesses were present in 83% of patients. Computed tomographic guidance was used for drainage in 80% of patients, and ultrasound was used in 20%. The duration of abscess drainage was less than 14 days in 64%. Complete resolution of the infection with a single treatment of PCD was achieved in 67 patients (70%), and with a second attempt in 12 (12%). Thirty-three patients (34%) had PCD for the resolution of intra-abdominal sepsis prior to an elective, definitive procedure. Open drainage as a result of PCD failure was required in 15 (16%) and was more likely in patients with yeast (P<.001) or a pancreatic process (P =.02). Postoperative abscess (P =.04) was an independent predictor of successful outcome. CONCLUSIONS: Percutaneous catheter drainage of intra-abdominal infections was effective with a single treatment in 70% of patients and increased to 82% with a second attempt. A successful outcome is most likely with abscesses that are postoperative, not pancreatic, and not infected with yeast. Percutaneous catheter drainage is now a commonly used staging method for the resolution of intra-abdominal sepsis prior to corrective operation.     

Laparoscopic drainage of intraabdominal abscess after appendectomy: an alternative to laparotomy in cases not amenable to percutaneous drainage

Purpose

Postoperative abscesses after appendectomy occur in 3% to 20% of cases and are more common in cases of perforated appendicitis. Smaller abscesses are often amenable to antibiotic therapy, but surgical drainage remains the mainstay of treatment for larger collections. Surgical options generally include percutaneous drainage and open laparotomy. Laparoscopic drainage of these abscesses has not been well characterized in the pediatric population.

Objective

The aim of this study was to describe our experience with laparoscopic drainage of postappendectomy abscesses that were not amenable to percutaneous drainage.

Methods

This study is a retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis at a tertiary pediatric medical center during a 4-year period (2006-2009). The review focuses on patients who developed abscesses after appendectomy, were unable to undergo percutaneous drainage, and were treated with laparoscopic abscess drainage.

Results

Twelve patients (7 male and 5 female) underwent laparoscopic drainage of postappendectomy abscesses. The mean age was 8.5 years old (range, 3-14 years). A clinical diagnosis of postoperative abscess was made when fevers, pain, and leukocytosis persisted despite broad-spectrum antibiotics. Computed tomography was performed in all patients. Abscesses ranged between 3 and 11 cm in size. The mean length of time between initial appendectomy and drainage procedure was 10 days. There were no complications specifically related to the laparoscopic drainage procedure. The mean length of the drainage procedure was 77 minutes (range, 30-196 minutes). The mean hospital length of stay after laparoscopic drainage was 6.5 days (range, 3-13 days) with patients maintained on intravenous antibiotics until afebrile and without leukocytosis.

Conclusion

Laparoscopic drainage is a safe and effective alternative for intraabdominal abscesses that occur after laparoscopic appendectomy. We recommend it as an alternative to open laparotomy when percutaneous drainage is not an option.     

Percutaneous drainage of intra-abdominal abscesses following abdominal trauma

Between January 1, 1984, and June 30, 1987, we performed percutaneous catheter drainage (PCD) of 28 intra-abdominal abscesses in 21 postoperative trauma patients. During this period only three patients had abdominal re-exploration for drainage of abdominal abscess. The PCD patients were predominantly young men who had sustained penetrating abdominal injuries (81% GSW or SW; 19% MVA). Seventeen (81%) patients had multiple abdominal organ injuries with the colon being the most frequently injured (57%). Multiple abscesses were identified in 33% of the patients. All 21 patients had successful treatment of their abscesses by PCD alone. There was one complication (4.8%) from PCD (pneumothorax) and no deaths in this group. Our data suggest that in most cases, PCD can be safe, effective, and definitive treatment for postoperative intra-abdominal abscesses following abdominal trauma. We recommend PCD in all postoperative trauma patients who develop accessible abdominal abscesses before resorting to re-exploration.     

Predictive factors for failure of percutaneous drainage of postoperative abscess after abdominal surgery

Background

The aims of this study were to assess the efficacy of percutaneous drainage of postoperative abscess after abdominal surgery and to identify factors predictive of failed drainage.

Methods

Data from 81 patients with postoperative abdominopelvic abscesses treated with percutaneous drainage were reviewed. Percutaneous drainage failure was considered when surgery was needed to control the sepsis. Predictive variables were sought using univariate and multivariate analyses with logistic regression models.

Results

Successful drainage requiring 1 (n = 46) or 2 (n = 17) procedures was observed in 63 patients (78%; 95% confidence interval, 67%–86%). Surgery was needed in 18 patients (22%; 95% confidence interval, 14%–38%). Residual collection after a first percutaneous drainage was the single predictive factor for failed drainage on univariate and multivariate analyses (P = .0275).

Conclusions

Percutaneous imaging-guided drainage is a feasible and effective method for the treatment of abdominopelvic abscess, with a success rate of 78%. Residual collection is an independent predictor of unfavorable outcome after percutaneous drainage.     

Percutaneous catheter drainage of abscesses associated with enteric fistulae

In the past six years, percutaneous catheter drainage (PCD) has been performed in the treatment of 99 patients with abdominal and retroperitoneal abscesses. Of these 99 patients, 15 had abscesses associated with an enteric fistula. Fistula sites included small bowel (five), colon (three), complex (three), duodenum (two) and one each for the stomach and common duct. Two of these 15 patients had an initially successful PCD, ten developed recurrent abscesses after the first PCD and the procedure failed in the remaining three patients. Of the ten patients with recurrent abscesses, eight were successfully treated by a second PCD while two required small-bowel resection. Of the three failures, all three required operation and eventually died of septic complications. The diagnosis of fistula was made at the initial PCD in only six of 15 cases. There was a significant correlation between PCD failure and presence of an enteric fistula (P less than 0.001 by chi-square test). These data suggest that the diagnosis of fistula associated with abdominal abscess is elusive, but once established, most recurrent abscesses can be successfully treated by a second PCD. Operative treatment of recurrent fistula-related abscesses should be reserved for persistent fistula drainage after a second PCD or for unresolved sepsis following the initial PCD.     

Image-guided posterior transperineal drainage for presacral abscess: An analysis of 21 patients

Objective

The purpose of this study was to retrospectively evaluate the safety and efficacy of posterior transperineal drainage in patients with presacral abscess.

A Retrospective Study of 75 Cases of Splenic Abscess

Splenic abscess is an uncommon and life-threatening condition. Due to its nonspecific clinical picture, it remains a diagnostic challenge. Multiple radiological modalities are used for the diagnosis. In this retrospective study we analyzed 75 patients treated between 1999 and 2009. The patients were divided into three groups depending on the treatment received. Group I (n = 14) consisted of patients treated with only antibiotics, Group II (n = 19) patients were treated with percutaneous drainage and Group III (n = 42) with splenectomy. We tried to establish epidemiologic and clinical features and therapeutic options in splenic abscess. Our study suggests that percutaneous drainage is a safe and effective alternative to surgery especially in unilocular or bilocular abscesses thus allowing preservation of the spleen. It should be considered as the first line of treatment although splenectomy remains the final definitive procedure if percutaneous drainage fails.     

Surgical versus percutaneous drainage of intra-abdominal abscesses

The records of 83 patients with intra-abdominal abscesses treated between 1986 and 1990 were reviewed to determine if there were significant differences in the outcome of patients treated by surgical drainage (n = 41) or percutaneous drainage (n = 42). The two groups were matched for age, abscess location, and etiology. Parametric statistical evaluations included the Student's t test as well as analysis of variance; nonparametric statistics used were chi-square and Wilcoxon rank sums. No significant difference was found in mortality (surgical 14% versus percutaneous 12%) or morbidity (surgical 26% versus percutaneous 29%). The duration of hospital stay was similar. Although there was no significant difference between the two groups in severity of illness as measured by APACHE II scores, these scores were significant in determining prognosis. APACHE II scores were significantly higher in non-survivors of both groups (23 versus 13) and also higher in those developing complications. A subgroup of patients with diverticular abscess was identified in whom percutaneous drainage enabled later resection with primary anastomosis without complication. This study indicates that percutaneous drainage of an intra-abdominal abscess is as efficacious as surgical drainage and that APACHE II scores are prognostic of both potential mortality and morbidity.     

Current concepts of percutaneous abscess drainage in postoperative retention

In recent years, percutaneous abscess drainage (PAD) of intraabdominal abscesses has become an important tool with regard to the treatment of intraabdominal sepsis. The aim of this study is to assess the value of PAD in the treatment of postoperative retentions. Between 1995 and 1999, the postoperative course of 3 346 patients undergoing major abdominal surgery was analyzed. Mortality, morbidity, and comparison of different locations of intraabdominal abscesses were assessed. PAD was considered successful when the patient improved clinically within 24 hours, a decrease in the size of the abscess formation was noted, and complete recovery without further surgical intervention occurred. Out of 3 346 operated patients, 174 (5.2%) were diagnosed as having an intraabdominal abscess formation and were treated by PAD. In 63 patients the abscess developed within the upper quadrants, in 66 patients the abscess developed within the lower quadrants, and in the remaining 45 patients the abscess developed within the retroperitoneal cavity or pelvis. The success rate of PAD was 85.6% with a morbidity rate of 4.6%. The least successful location for PAD was the left upper quadrant. Patients with abscess drainage in the right upper and lower quadrant experienced a high success rate. One patient died due to the PAD procedure. Unsuccessful PAD was closely related to an increase in mortality. In the case of intraabdominal abscess formation after visceral surgery, PAD should be the primary procedure. Attention should be paid to abscess formations in the left upper quadrant because there is an increased likelihood of complications caused by PAD.     

An appraisal of surgical and percutaneous drainage for pyogenic liver abscesses larger than 5 cm

OBJECTIVE: To determine whether first-line treatment with percutaneous or surgical drainage of liver abscesses larger than 5 cm results in better clinical outcome. SUMMARY BACKGROUND DATA: Pyogenic liver abscesses larger than 5 cm are currently treated by intravenous antibiotics and either percutaneous (PD) or surgical drainage (SD). Percutaneous techniques have been increasingly performed in place of open drainage as first-line treatment. This paradigm shift has been fueled by the drive for low-risk and less-invasive procedures and the surgical option being reserved for percutaneous failures. Yet there is a lack of data to support percutaneous drainage over open surgical drainage as first-line treatment. METHODS: Over a 3-year period, 80 patients with liver abscesses larger than 5 cm amenable to PD and SD were included in the study. This situation was possible as 1 team of surgeons favored the use of PD and 1 team favored the use of SD as first-line treatment. The treatment outcomes in both groups were compared, and clinical end-points included time to defervescence of fever, failure of treatment, secondary procedures, hospital stay, morbidity, and mortality. RESULTS: PD was performed in 36 patients and SD in 44 patients as first-line treatment. Clinical, laboratory, and abscess parameters were comparable in both groups. Sixty-four of 80 patients (80%) had multiloculated abscess. The time to defervescence of fever was not statistically significant (PD versus SD, 4.85 versus 4.38 days; P = 0.09). However, SD had less treatment failures (3 versus 10, P = 0.013), less requirement for secondary procedures (5 versus 13, P = 0.01), and shorter length of hospital stay (8 versus 11 days, P = 0.03). There was no difference in morbidity or mortality rates. CONCLUSIONS: The results of our study show that for large liver abscesses more than 5 cm, SD provides better clinical outcomes than PD in terms of treatment success, number of secondary procedures, and hospital stay with comparable morbidity and mortality rates. SD should be considered as first-line treatment of large liver abscesses.     

Treatment of the intraabdominal abscesses through percutaneous ultrasound-guided drainage in oncological patients: Clinical and microbiological data

Aim of the study Oncological patients are particularly prone to the onset of septic complications such as abdominal abscesses. The aim of our study was to analyze clinical and microbiological data in a population of oncological patients, submitted to percutaneous ultrasound-guided drainage (PUD) for postoperative abdominal abscesses. Patients and methods Data from 24 patients operated on for neoplastic pathologies and treated with PUD for abdominal abscesses during the postoperative period were reviewed. In all cases cultural examination with antibiogram was performed. Results In 5 out of 24 patients (20.8%), the abdominal abscesses appeared after the discharge, with a mean hospital stay of 34.2 ± 24.9 days. In six out of 24 patients (25%) there were multiple abscesses localizations. The cultural examination was positive in 23 patients and negative only in one patient. Abscesses localized only in the upper abdominal regions had a significant prevalence of monomicrobial cultural examinations (57.1%) with respect to the results for abscesses placed in the lower abdominal regions, that were polymicrobial in 88.8% of cases (p = 0.027). An antibiogram demonstrated a stronger activity of beta-lactamines, chinolones, and glycopeptides with respect to aminogycosides, cephalosporins, and metronidazole. Conclusions In oncological patients, the planning of the empiric antibiotic therapy should be based on the anatomotopographic localization of the abdominal abscess and on the typology of the operation performed giving preference to beta-lactamines, chinolones and glycopeptides.     

Ultrasound-guided percutaneous drainage of infected pancreatic necrosis

Background

The role of percutaneous drainage in the management of infected pancreatic necrosis remains controversial, and ultrasound-guided technique is rarely used for this indication. The purpose of this study was to evaluate the safety and efficacy of sonographically guided percutaneous catheter drainage for infected pancreatic necrosis.

Methods

The patient group consisted of 16 men and 2 women. The mean age of the patients was 47 years. The median computed tomography severity index of acute pancreatitis was 10 points. Percutaneous catheter drainage was performed under sonographic guidance using preferably retroperitoneal approach, and transperitoneal access in selected cases. The medical records and imaging scans were reviewed retrospectively for each patient.

Results

Percutaneous catheter drainage resulted in a complete resolution of infected pancreatic necrosis in 6 of 18 patients (33 %). Twelve of 18 patients who were initially managed with PCD required eventually necrosectomy (67 %). The most common reason for crossover to surgical intervention was persistent sepsis (n = 7). Open necrosectomy was performed in 4 of these patients, and 3 patients underwent successful minimally invasive retroperitoneal necrosectomy. Five patients required conversion to open surgery because of procedure-related complications. In 3 cases, there was leakage of the necrotic material into the peritoneal cavity. Two other patients experienced hemorrhagic complications. Overall mortality rate was 17 %. The size of the largest necrotic collection in patients who were successfully treated with percutaneous drainage decreased by a median of 76 % shortly after the procedure, whereas it decreased only by a median of 16 % in cases of failure of percutaneous drainage.

Conclusions

Ultrasound-guided percutaneous catheter drainage used in infected pancreatic necrosis is a technique with acceptably low morbidity and mortality that may be the definitive treatment or a bridge management to necrosectomy. A negligible decrease in size of the necrotic collection predicts failure of percutaneous drainage.     

Percutaneous catheter drainage of abdominal abscesses associated with perforated viscus

Improvements in radiologic localization have made percutaneous catheter drainage (PCD) the initial procedure of choice for many intra-abdominal abscesses (IAA). During the past seven years 154 patients underwent PCD for treatment of abdominal abscesses. Fourteen of these patients had PCD as the initial treatment for IAA secondary to a perforated viscus and subsequently underwent an elective one-stage operation to treat the underlying disease. Etiologies of the abscesses included perforated appendicitis in six patients, sigmoid diverticulitis in three patients, Crohn's ileitis in two patients, and one case each of perforated gastric ulcer, perforated sigmoid carcinoma, and perforated gallbladder. Initial localization of the abscess was achieved by either CT or ultrasound. Seven abscesses were localized in the right lower quadrant, four were localized in the liver, and one was localized each in the left flank, right flank, subhepatic space, and pelvis. All patients subsequently underwent a definitive elective operation for their primary disease including six interval appendectomies, four sigmoid colectomies, two small-bowel resections, one subtotal gastrectomy and one cholecystectomy. There were no complications due to PCD and no deaths occurred. We conclude that PCD can be successfully performed as the initial treatment for IAA associated with a perforated viscus, obviating the first stage of the traditional two-stage surgical approach.     

Psoas abscess rarely requires surgical intervention

BACKGROUND: Surgeons are increasingly encountering psoas abscesses. METHODS: We performed a review of 41 adults diagnosed and treated for psoas abscess at a county hospital. Treatment modalities and outcomes were evaluated to develop a contemporary algorithm. RESULTS: Eighteen patients had a primary psoas abscess, and 23 had a secondary psoas abscess. Patient characteristics were similar in both groups. Intravenous drug abuse was the leading cause of primary abscesses. Secondary abscesses developed most commonly after abdominal surgery. Treatment was via open drainage (3%), computed tomography-guided percutaneous drainage (63%), or antibiotics alone (34%). Four recurrences occurred in the percutaneous group. Statistical analysis showed that the median size of psoas abscesses in the percutaneous group was significantly larger than in the antibiotics group (6 vs 2 cm; P < .001). The mortality rate was 3%. CONCLUSIONS: Initial management of psoas abscesses should be nonsurgical (90% success). Small abscesses may be treated with antibiotics alone, and surgery can be reserved for occasional complicated recurrences.     

Percutaneous management of pyogenic hepatic abscesses

Twelve patients (9 men, 3 women) with a mean age of 65 (54-78) years, with pyogenic hepatic abscesses were managed by percutaneous drainage between 1979 and 1987. Biliary origin was most common (4 patients), followed by hepatic abscesses as a late postoperative complication (seen in 3 patients) and hepatic abscesses occurring in association with acute appendicitis (2 patients). The origin was unknown in 3 patients. Diagnosis was reached by computed tomography or ultrasonography with a diagnostic delay of in mean 11 days. Seventeen abscesses were found among the 12 patients. The median abscess size (maximal diameter) was 7 (1-12) cm. Nine patients were treated with percutaneous drainage with an indwelling catheter within the abscess cavity for up to 3 weeks, while 3 patients were managed with percutaneous puncture and aspiration alone. The most commonly isolated organism from the drained hepatic abscess was E. coli. The course following percutaneous treatment was uneventful, without mortality and recurrence of the hepatic abscess during follow-up. One patient required surgical drainage of an additional hepatic abscess. Percutaneous drainage of hepatic abscesses, independent of origin, thus seems as a safe and reliable method, which should be considered as the treatment of choice if facilities and knowledge of percutaneous management are provided.     

The long-term results of percutaneous drainage of diverticular abscess

INTRODUCTION

Diverticulitis is a common condition occasionally complicated by abscess formation. Small abscesses may be managed by antibiotic therapy alone but larger collections require drainage, ideally by the percutaneous route. This minimally invasive approach is appealing but there is little information regarding the long-term follow-up of patients managed in this way. To address this question, we looked at a consecutive series of patients who underwent percutaneous drainage in our institution.

PATIENTS AND METHODS

A retrospective study was performed of patients undergoing percutaneous drainage of a diverticular abscess from 1999–2007.

RESULTS

A total of 26 abscesses were identified in 16 patients. In 69% of cases, the abscess was located in the pelvis. The mean size of the abscesses was 8.5 ± 0.9 cm. Drainage was performed under CT (83%) or ultrasound guidance. The mean duration of drainage was 8 days. Fistula formation following drainage occurred in 38% of cases. Eight patients (mean age, 71 years) underwent subsequent surgical resection 9 days to 22 months (mean, 7 months) following initial presentation. Eight patients with significant co-morbid conditions were managed by percutaneous drainage only. The 1-year mortality was 20% and resulted from unrelated causes. The long-term stoma rate was 13%.

CONCLUSIONS

Percutaneous drainage can safely be performed in patients with a diverticular abscess. It can be used as a bridge before definitive surgery but also as a treatment option in its own right in high-risk surgical patients. We believe percutaneous drainage reduces the need for major surgery and reduces the risk of a permanent stoma.     

The role of percutaneous drainage of pancreatic abscesses

Pancreatic abscess remains the most lethal form of intra-abdominal abscess despite a wide variety of operative approaches that have been advocated for its control. Mortality is frequent, and recurrent abscesses after operative drainage are common. Death often results from ongoing uncontrolled sepsis. The role of percutaneous drainage (PCD) of pancreatic abscesses is controversial. Recent experience with five patients who had pancreatic abscess and in whom a combination of operative drainage and PCD proved instrumental in survival leads the authors to recommend the consideration of both forms of drainage dependent upon the circumstances. Specifically, indications for PCD may include the following: use as a temporizing measure prior to celiotomy in a critically ill patient; use in postoperative patients who have recurrent abscesses and in whom the presence of dense inflammation precludes safe evacuation of pus; and use in the patient who has known portal hypertension and in whom massive bleeding is likely to result from celiotomy and abscess drainage.