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.     

Treatment of intra-abdominal sepsis

Twenty-three surgeons at three McGill University hospitals were interviewed about their treatment of intra-abdominal sepsis. They described their use of antibiotics, operative practices and other treatment of generalized peritonitis and intra-abdominal abscesses. If more than 75% of respondents used a given method, its use was considered "uniform" unless substantial interhospital variation existed for that method. Treatment was variable in 18 situations. Only four of these involved systemic antibiotic use--drug regimens in appendicitis and intra-abdominal abscess, and duration of antibiotic therapy following appendicitis and perforated duodenal ulcer. The other 14 examples of variation were in operative management. In generalized peritonitis, they were: use of diagnostic paracentesis; abdominal lavage with saline alone versus saline plus antibiotic use; whether the peritoneum should ever be left open; the use or avoidance of drains; primary versus delayed wound closure in appendicitis, bowel perforation and trauma with gastrointestinal perforation and, finally, wound lavage with saline alone or with antibiotics. Treatment of intra-abdominal abscesses varied in regard to the diagnostic and therapeutic roles of percutaneous needle aspiration, the preferred route of drainage of a pelvic abscess, the use of an extra- or trans-serosal approach to a subphrenic abscess, local versus full abdominal exploration for a single abscess and the type of drain used. The authors conclude that operative management of intra-abdominal sepsis varies widely among surgeons. This fact invalidates many "controlled" trials of antibiotics and should focus attention less on drugs and more on surgical treatment.     

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.     

Subphrenic abscess with special reference to intrathoracic complications

We will summarize briefly the outstanding points of our study. Subphrenic abscess is a complication that can occur after any abdominal operation or any inflammatory process in the abdomen. It too frequently is not recognized until serious thoracic complications have developed. Thoracic complications which are late complications of subphrenic abscess are responsible for the high mortality rate of subphrenic abscesses. Early recognition and treatment of subphrenic abscess will prevent thoracic complications.The extraserous approach to subphrenic abscesses is the safest and most effective means of treating subphrenic abscess.     

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.     

Management of pyogenic liver abscess in the era of computed tomography

The advent of high-resolution imaging has allowed earlier diagnosis of pyogenic liver abscess. Because radiologically guided percutaneous drainage (PCD) of liver abscesses is controversial, the authors studied 40 patients with liver abscess admitted to the Toronto Hospital between 1982 and 1987 to determine the role of PCD versus operative drainage (OD). The diagnosis of pyogenic liver abscess was made at autopsy (4 patients), at laparotomy (6) or by radiologically guided aspiration of pus (30). Ultrasonography and computed tomography were highly sensitive (85% and 96% respectively) in detecting liver abscess. Of the 36 patients treated for liver abscess all received antibiotics intravenously; 31 also underwent a drainage procedure. Treatment with antibiotics alone was associated with a success rate of 80% and a death rate of 20%. The success rate for those who had PCD was 75% with a death rate of 13%; 2 patients in this group of 16 subsequently required OD for cure. In the 15 patients initially treated with OD, success and death rates were 87% and 13% respectively. For solitary abscesses, success rates wer comparable for PCD and OD (86% and 90% respectively). For unilobar multiple abscesses the success rate was 100% for both PCD and OD, but for bilobar multiple abscesses the rates were only 40% and 67% respectively. Complication rates were similar for both methods of drainage. The authors conclude that pyogenic liver abscess can now be safely and efficaciously managed with a combination of antibiotics and PCD.     

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.     

Selective management of subphrenic abscesses.

Although extraserous drainage of subphrenic abscesses has gained wide acceptance, there is some renewed enthusiasm for the more frequent use of a transperitoneal operation because it affords the opportunity to discover unsuspected pathologic conditions, particularly heterotopic abscess. In 44 patients with postoperative subphrenic abscesses, the approach to drainage was selected on the basis of the clinical circumstances. Among 28 patients whose abscesses were drained extraserously, the incidence of heteroptic and recurrent abscesses was low. No serious complications of peritoneal or wound soilage occurred after transperitoneal drainage in 16 patients, yet the problems of inadequate drainage and heteroptic abscess were not eliminated. Celiotomy prior to definitive abscess localization was required for 13 patients. Five patients died. The operative approach should be based on the clinical assessment of the patient and particularly on the probability that multicentric intra-abdominal pathologic conditions exist.     

Abscess of the spleen: diagnosis and treatment. Apropos of 12 cases

Twelve cases of splenic abscess, seen at our hospital between January 1980 and June 1987, were reviewed retrospectively. The most common causes of splenic abscesses were subacute endocarditis and intra abdominal sepsis. Diagnosis was suspected on clinical grounds and was always confirmed by sonography and/or computerized tomography. Two patients were drained unsuccessfully under CT scan guidance and underwent splenectomy. The other patients were operated primarily. One patient developed a subphrenic abscess postoperatively. One patient died from intractable cardiac failure due to subacute endocarditis. The authors stress the role of CT scan in the diagnosis of splenic abscess and recommend early splenectomy in cases of failure of percutaneous drainage.     

Giant horseshoe intra-abdominal abscess.

A study of 12 patients with giant horseshoe abscess of the abdominal and pelvic cavities seen at the Surgical Services of the University of Cincinnati Medical Center has emphasized the complexity and bizarre nature of these lesions. These infections represented a huge abscess or series of communicating abscesses extending from one subphrenic space along the corresponding paracolic gutter into the pelvis, up and along the opposite paracolic space, and into the other subphrenic space. Since these lesions occurred infrequently, they were often not recognized until they had become far advanced and had produced profound effects on the patients. The diagnosis was difficult and obscured by various factors including the postoperative state after laparotomy for complex diseases or serious injuries of the biliary tract, the genitourinary tract, or the alimentary tract. An important etiologic component of the formation of these giant abscesses was the continuing escape and collection of large volumes of fluid resulting from lesions of the biliary tract, postoperative hemorrhage, or an unrecognized large perforated peptic ulcer. Nine patients were treated successfully and 3 died. The many diagnostic and therapeutic problems presented by the patients with this interesting and complex lesion have emphasized the importance of earlier and more accurate diagnosis, early and adequate surgical drainage, intelligently applied antibiotic therapy and appropriate supportive treatment. Failure to recognize and drain effectively each of the component sections of this lesion led to continuing sepsis with prolonged morbidity, progressive debility, and death.     

Expanded criteria for percutaneous abscess drainage

The original criteria for percutaneous abscess drainage were limited to simple abscesses (well-defined, unilocular) with safe drainage routes. We expanded these entry criteria to include complex abscesses (loculated, ill-defined, or extensively dissecting abscesses), multiple abscesses, abscesses with enteric fistulas or whose drainage routes traversed normal organs, as well as complicated abscesses (appendiceal, splenic, interloop, and pelvic). Using these expanded criteria, cure was achieved nonoperatively in 92 (73.6%) of 125 abscesses with ten deaths (9%), and 11 complications (9%). Cure was achieved in 82% of simple abscesses, but only 45% of complex abscesses. There was no correlation between size, depth, drainage route, or etiology of the abscess (spontaneous v postoperative) with either cure or complications. We recommend a trial of percutaneous drainage in all simple abscesses and most complex abscesses with clinical response as the key determinant of the need for operative intervention.     

肝移植术后发生腹腔脓肿的原因和治疗体会

目的 探讨肝移植术后腹腔脓肿的发生原因及治疗方法.方法 回顾性分析314例患者肝移植术后的资料,其中发生腹腔脓肿8例.对此8例患者的原发病、术前肝功能状况、伴发感染状况、手术时间、无肝期时间、术中出血量、术后是否发生膈下血肿、抗排斥反应方案以及胆道并发症等因素进行分析,并对患者的治疗方法进行总结.结果 腹腔脓肿发生率为2.2%(8/314).发生时间为术后1～50个月,其中6例为肝脓肿,2例为膈下脓肿.8例患者肝移植术后均伴有胆道并发症,其他因素均无特异性.8例腹腔脓肿的诊断依靠临床症状、影像学检查和细菌学检查.诊断明确后,8例患者经应用敏感抗生素、脓肿穿刺引流及手术治疗,其中有6例脓肿得以控制,2例因感染无法控制,分别于肝移植术后6个月和9个月死亡.结论 肝移植术后腹腔脓肿的发生可能与胆道并发症关系密切;经积极治疗,患者可以获得长期存活.     

Percutaneous drainage of lung abscess

Patients with primary lung abscess who do not respond to medical management are usually candidates for a lobectomy. Percutaneous tube drainage, used routinely and with good results before the antibiotic era, has nearly been forgotten. Seven patients with lung abscesses and severe sepsis were in critical condition, not permitting pulmonary resection. They were treated by tube drainage. Prompt clinical recovery occurred in all, with complete resolution of abscesses within 4 to 24 days. When medical therapy of lung abscess fails, tube drainage should be considered in preference to a lobectomy. It is safe and curative and avoids unnecessary loss of functioning lung parenchyma. Lobectomy should be considered in patients who have major life-threatening bleeding or massive pulmonary necrosis.     

Pyogenic liver abscess. Diagnostic and therapeutic strategies.

A retrospective review of 26 adult patients admitted to University of California, Davis, Medical Center (UCDMC) with pyogenic liver abscess (1980-1986) was performed to ascertain the impact of rapid diagnosis and percutaneous drainage. Ultrasonographic examinations and computed tomography (CT) scans were highly sensitive and noninvasive imaging modalities. Sixteen patients had solitary abscesses and seven had multiple microscopic abscesses. The median time interval from admission to diagnosis and therapy was 2 and 3 days, respectively. Origin of the abscess was determined in 22 patients, the biliary tree being the most common source. Medical therapy was successful in three patients with microabscesses but failed in two. Nine patients had percutaneous drainage; two required repetitive percutaneous catheter placement, and two proceeded to surgical drainage. Twelve patients had surgical drainage; one required repetitive surgical drainage. Postdrainage complications were minimal in all groups. Overall mortality role was 11.5% (two patients). Deaths were related to delay in diagnosis, gram-negative sepsis at presentation, and biliary origin of the abscess.     

NOTES for the management of an intra-abdominal abscess: transcolonic peritonoscopy and abscess drainage in a canine model

Background

We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure.

Methods

We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy.

Results

We studied 12 dogs: 8 had subphrenic balloon implants and 4 had inter-bowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the “abscess” in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications.

Conclusion

Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.     

Percutaneous abdominal abscess drainage: Portland area experience

After reviewing 21 patients who have had percutaneous abdominal abscess drainage, we believe that the procedure should be considered for those abscesses that are unilocular without septations, with safe access being a key variable dictating the use of percutaneous abdominal abscess drainage rather than surgery. A computerized tomographic scan of the abdomen should be employed at some stage of the percutaneous abdominal abscess drainage procedure to facilitate safe access to the abscess and to distinguish a synchronous abscess where present. In addition, we believe that percutaneous abdominal abscess drainage should be considered for postsurgical abscesses only and not those that are spontaneous in nature or where the original abnormality cannot be accurately surmised. With regard to catheter management, frequent irrigation of the catheter must be carried out at least every 4 to 6 hours, with high levels of antibiotics present in the blood before irrigation. This must be done to obviate the most frequent and potentially lethal complication of the procedure, namely sepsis. Percutaneous abdominal abscess drainage, although safe for the most part, is capable of inducing considerable morbidity. Our data suggest that percutaneous abdominal abscess drainage is not as efficacious as previous reports have suggested. Traditional surgical drainage techniques are best utilized for those abscesses that are multiple, highly viscous, inaccessible, spontaneous, or unresponsive to percutaneous abdominal abscess drainage.     

The subphrenic abscess. Surgical and/or percutaneous drainage

The results indicate that the low risk percutaneous drainage of subphrenic abscesses is only feasible in carefully selected patients. The surgical intervention remains the method of choice for the drainage of subphrenic abscesses in conditions such as multiple and complicated abscesses, unfavourable access to the abscess cavities or other pathological conditions. An early and decisive diagnosis is crucial for effective treatment of subphrenic abscesses either by percutaneous drainage or surgical intervention and antibiotic therapy.     

Abdominal abscess. A surgical strategy

To reassess the role of laparotomy and extraserosal drainage in the treatment of patients with abdominal abscess, we analyzed the course of 79 patients who underwent 97 operations to treat 120 abdominal abscesses during a five-year period. In 66 clinical episodes the abscess was drained by the most direct approach. Sepsis resolved with a single operation In 80% of these patients, five patients (8%) required a second operation for drainage for an abscess, and eight patients (12%) died. In 31 clinical episodes, the abscess was drained by a laparotomy. Sepsis resolved with a single operation in 61% of these patients, seven patients (21%) had a second abscess, six patients (19%) required a second operation to drain a metachronous abscess, and six patients (19%) died. When the location or number of abscesses was diagnosed incorrectly, the success rate of therapy fell substantially. Since most abdominal abscesses can now be accurately diagnosed preoperatively, most abscesses should be drained by a direct approach. Exploratory laparotomy is indicated when preoperative localization is unsuccessful, when sepsis has not resolved after other methods of drainage, or when the patient has a concomitant abdominal condition that must be treated surgically.     

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.     

Hepatectomy without abdominal drainage. Results of a prospective study in 61 patients.

The increasingly simple postoperative course of major surgery has challenged the routine use of drainage after most abdominal surgical procedures. Therefore a prospective study was designed to determine if abdominal drainage could be safely avoided after liver resection and was evaluated in 61 consecutive patients. There was one postoperative death (1.7%) from variceal bleeding. Four other patients (6.7%) developed an abdominal complication: two right subphrenic hematomas requiring reoperation in one case and two incisional ascitic leaks requiring incisional repair in one patient. There was neither a subphrenic abscess nor bile peritonitis. Postoperative hospitalization was 11.5 +/- 3 days in the entire group and 8.5 +/- 1 days in patients without complications. These results suggest that liver resection can be performed safely without abdominal drainage and that the routine use of drains is unnecessary.