A comparative evaluation of percutaneous catheter drainage for resistant amebic liver abscesses

Resistance to drug treatment is a well-known problem in the management of patients with amebic liver abscesses. We undertook a comparison of the various modalities of treatment currently used for such cases on a prospective, randomized basis. Fifty patients with 56 amebic liver abscesses found to be resistant to drug therapy were included in the study. Repeat trial of conservative therapy, therapeutic needle aspirations, percutaneous catheter drainage, and open surgical drainage were the modalities of treatment employed. The responses to the various modalities were compared for clinical relief, morbidity, failure of response, period of hospital stay, and resolution of abscess cavity. The most impressive results were seen with percutaneous catheter drainage. This new modality of treatment is recommended for all resistant cases of amebic liver abscess.     

Pyogenic liver abscess. Modern treatment

Historically, open surgical drainage has been the treatment of choice for pyogenic liver abscess. The records of 54 patients with pyogenic liver abscess were reviewed to determine whether earlier diagnosis with current imaging tests and definitive treatment with antibiotics, aspiration, or catheter drainage was an effective alternative to open drainage. Twenty-nine patients were treated with broad-spectrum antibiotics and diagnostic aspiration. Twenty-three (79%) recovered uneventfully, and six required catheter or operative drainage. Twenty-three patients (including five who failed aspiration) underwent drainage with percutaneously placed catheters. Nineteen (83%) recovered; four required open surgical drainage. Of seven patients who required open surgical drainage, six recovered. One (2%) of the 54 patients died following failed aspiration and catheter and surgical drainage. Four patients were successfully treated with antibiotics alone without aspiration. These results confirm that pyogenic liver abscess can be successfully treated with broad-spectrum antibiotics and aspiration or percutaneous catheter drainage. Open surgical drainage is reserved for patients in whom treatment fails or who require celiotomy for concurrent disease.     

Aspiration of breast abscess under ultrasound guidance: outcome obtained and factors affecting success

OBJECTIVE: To assess ultrasonographically (US) guided needle aspiration of breast abscesses as an alternative to surgical incision and drainage. METHODS: In our prospective study, 30 patients with 31 breast abscesses (one patient had bilateral breast abscess) underwent percutaneous breast abscess drainage under US guidance with local anaesthesia and oral antibiotics between 1 January 2004 and 31 March 2005. These patients consisted of 16 (53.3%) non-lactating and 14 (46.7%) lactating women, with ages ranging from 18 to 68 years (median, 28 years). The racial distribution comprised 26 (86.7%) Malays, three (10%) Chinese and one (3.3%) Indian. All patients had the chief complaint of breast swelling and 25 (83.3%) had breast pain. Clinically, 28 (93.3%) were found to have a palpable mass. Nine (30%) lesions were in the upper outer quadrant of the left breast. US diameters ranged from 1 to 15 cm (median, 4 cm). The pus volumes varied from 1 to 200 mL (median, 14 mL). RESULTS: Fifteen (50%) patients required only a single aspiration, 10 required multiple aspirations and five required incision and drainage. Those patients in whom needle aspiration failed had multiloculated lesions irrespective of abscess volume and size. CONCLUSION: Needle aspiration with ultrasound guidance is an effective treatment for breast abscess irrespective of abscess volume and size.     

Renal and perirenal abscesses in patients with otherwise anatomically normal urinary tracts

PURPOSE: We characterized evaluation, management and outcomes in a group of patients diagnosed with renal and perirenal abscesses who had otherwise anatomically normal urinary tracts. MATERIALS AND METHODS: We reviewed our experience with renal/perirenal abscesses at University of Texas Medical Branch from 1991 to 2002. Treatment was determined by physician preference in each individual. RESULTS: Of 70 patients with renal/perirenal abscesses 26 had otherwise anatomically normal urinary tracts, 24 (92%) had at least 1 possible contributory factor, such as diabetes mellitus, and only 38% had the correct diagnosis at initial presentation. The abscess was intranephric in 39% of cases, intranephric and perinephric in 19%, and perinephric only in 42%. Of the 26 patients 18 were treated with percutaneous drainage or aspiration of the abscess and 12 (66.7%) had positive cultures. Eight of the 12 patients (67%) with positive abscess cultures had the same organism in urine and/or blood. All 26 patients were treated with broad-spectrum intravenous antibiotics. In most patients abscess size influenced additional treatments, such as percutaneous needle aspiration or catheter drainage. None of the patients required open surgical drainage, nephrectomy or nephrostomy tube placement. At a mean followup of 10 months all patients had complete radiographic resolution of the abscess without further complications except 1 who had pyelonephritis and another who was found to have a poorly perfused kidney. CONCLUSIONS: With accurate diagnosis and minimally invasive therapy patients with renal and/or perirenal abscesses and otherwise anatomically normal urinary tracts have excellent functional and anatomical outcomes.     

Aspiration drainage of splenic abscesses

The successful use of guided percutaneous needle aspiration in the management of four patients with solitary splenic abscess is described. Two patients had needle aspiration alone and two patients, with large splenic abscesses, had drainage tubes inserted. The procedures were well tolerated and allowed rapid microbiological diagnosis with selection of appropriate antibiotic therapy. The techniques were useful in patients felt to be poor anaesthetic risks, and the complications of splenectomy were avoided.     

Laparoscopic Drainage of Pyogenic Liver Abscess

Background and Objectives:

Pyogenic liver abscesses are mainly treated by percutaneous aspiration or drainage under antibiotic cover. If interventional radiology fails, surgical drainage becomes necessary. Recently, we performed laparoscopic liver abscess drainage successfully, and we aimed to focus on the topic in light of a systematic review of the literature.

Methods:

A 22-year-old man was admitted with a 4.5-cm multiloculated abscess in the left lobe of the liver. The abscess did not resolve with antibiotic-alone therapy. Percutaneous aspiration was unsuccessful due to viscous and multiloculated contents. Percutaneous catheter placement was not amenable. Laparoscopic abscess drainage was preferred over open abscess drainage. We used 3 trocars, operation time was 40 minutes, and blood loss was minimal. In the mean time, we searched PubMed using the key words [(liver OR hepatic) abscess*] AND [laparoscop* OR (minimal* AND invasiv*)].

Results:

Postoperative recovery of the patient was uneventful, and the patient was asymptomatic after 3 months of follow-up. In the literature search, we found 53 liver abscesses (51 pyogenic and 2 amebic) that were treated by laparoscopy. Mean success rate was 90.5% (range, 85% to 100%) and conversion rate was zero.

Conclusion:

Treatment of liver abscess is mainly percutaneous drainage. Laparoscopic drainage should be selected as an alternative before open drainage when other modalities have failed.     

Management of lactational breast abscesses

The purpose of the present prospective study was to compare incision and drainage against needle aspiration for the treatment of breast abscesses in lactating women. During the 3-year study period, patients with breast abscesses were randomized 1:1 to undergo either incision and drainage (23 patients) or needle aspiration (22 patients). Ultrasound guidance was not used for any of these patients. Age, parity, localization of abscess, whether or not nipples were cracked, duration of symptoms and lactation, abscess diameter, pus culture results, breast infection history during any previous period of lactation, healing time, recurrence, cosmetic outcome in the case of incision and drainage, and volume of pus removed and number of aspirations needed in the case of aspiration were recorded. The treatment value of each of these techniques was investigated. Student's t-test, Fisher's exact test, a Chi-square test and the Mann-Whitney U-test were used for statistical analysis. In the incision and drainage group all patients were treated successfully, but 1 patient (4%) had a recurrence 2 months after complete healing and 16 patients (70%) in this group were not pleased with the cosmetic outcome. In the needle aspiration group, overall 3 patients were treated with a single aspiration and 10 patients (45%) with multiple aspirations, but 9 patients (41%) did not heal following needle aspiration and subsequently required incision and drainage in addition. No recurrences were observed in the needle aspiration group during the follow-up period. The risk factors for failure of needle aspiration for breast abscesses were abscesses larger than 5 cm in diameter, unusually large volume of aspirated pus, and delay in treatment. In conclusion, breast abscesses smaller than 5 cm in diameter on physical examination can be treated with repeated aspirations with good cosmetic results. Incision and drainage should be reserved for use in patients with larger abscesses.     

Needle aspiration of breast abscesses

BACKGROUND: Traditional treatment of breast abscesses involves incision and drainage, with and without ultrasound guidance. These procedures cause considerable discomfort and morbidity for the patient. This study was conducted to determine whether needle aspiration of breast abscesses without ultrasound guidance was an effective treatment modality. METHOD: In our prospective study, 30 patients with 33 breast abscesses were treated by needle aspiration of pus, oral antibiotics, and repeat aspiration, if necessary. All were outpatients, and ultrasonography was not used. Twenty-five of the 30 patients were lactating. RESULTS: Eighteen patients required only a single aspiration, 9 patients required multiple aspirations, and 6 patients required incision and drainage (overall cure rate, 82%). Those patients in whom needle aspiration was successful had a significantly smaller volume of pus on initial aspiration (4.0 mL versus 21.5 mL, P = 0.002) and were more likely to have presented earlier than those not cured by aspiration (5.0 days versus 8.5 days, P = 0.006). CONCLUSION: Needle aspiration without ultrasound guidance is an effective treatment for breast abscesses.     

单发及多发细菌性肝脓肿临床资料的对比分析

摘要：目的:探讨单发及多发肝脓肿的临床特点及诊治方法。方法:回顾性分析近25年间收治的148例细菌性肝脓肿患者的临床资料，按单发及多发性肝脓肿分组，比较两组临床特征、治疗方法及预后。结果:胆源性在多发性肝脓肿组的比例明显高于单发组（P=0.018），平均年龄、就诊时间及住院天数多发性肝脓肿组也明显高于单发组(P=0.023,0.043，0.015)。多发性肝脓肿患者的碱性磷酸酶水平较高（P=0.021）， 血清白（清）蛋白水平较低（P=0.039）。单发肝脓肿最常见部位在肝右叶(P=0.002)，而多发性肝脓肿更易累及左右两叶(P<0.001)。大肠杆菌是两种肝脓肿最常见的致病菌。单纯抗生素治疗多用于多发脓肿的患者（P=0.022），经皮穿刺置管引流则多用于单发性肝脓肿（P=0.021）。多发性肝脓肿患者发生急性呼吸窘迫综合征（ARDS）的比例较高（P=0.03）。肝脓肿相关的病死率在多发性肝脓肿患者中明显为高（P=0.025）。结论:与单发性肝脓肿相比，多发性肝脓肿病例具有年龄较大、症状持续时间较长、常合并胆道疾病、脓肿多侵及肝脏两叶、容易发生ARDS和病死率较高的特点，治疗多采用手术和/或单纯抗生素治疗。     

Breast Abscesses: Diagnosis, Treatment and Outcome

BACKGROUND: The aim of our study was to analyze diagnostic results, different treatment modalities, and the outcome of patients with breast abscesses treated at our institution in a multi-modality breast team, to determine whether minimally invasive treatments are successful. METHODS: 110 patients with mastitis and suspected breast abscesses at our institution between January 2000 and end of September 2007 were retrospectively analyzed. Abscesses were diagnosed using ultrasonography (US), and the material obtained using US-guided fine needle aspiration (FNA) was further examined. RESULTS: 29% of the patients were treated conservatively with antibiotics only, 51% were treated with US-guided FNA or drainage placement. 11% of the patients underwent additional surgery after minimally invasive treatment (i.e. conversion rate). 9% of the patients underwent primary surgery. Early complications occurred in 7% of patients treated minimally invasive but not in patients treated with surgery alone. Late complications occurred in 5% of patients who underwent minimally invasive treatments and in 30% of patients who underwent surgery. CONCLUSIONS: US-guided FNA as a minimally invasive therapy in combination with antibiotics was found to successfully treat most breast abscesses and, in cases where a larger volume of pus was involved, the placement of an additional drainage catheter was effective.     

Intrahepatic pyogenic abscesses: treatment by percutaneous drainage

During a 6 year period, 18 liver abscesses in 12 patients were identified by computerized tomography. Five patients had presumed hematogenous seeding. Five patients previously had bilioenteric anastomoses, stents, or both to relieve obstructive jaundice. Four patients with abscesses had recent abdominal operations. Diagnosis was established by guided needle aspiration and treatment was provided by percutaneous catheter drainage. Organism-specific antibiotics were administered to all patients. Patients were evaluated for recurrence by serial computerized tomographic studies and were clinically followed up for a minimum of 15 months. Ten of 12 patients (83 percent) and 16 of 18 abscesses (89 percent) were successfully treated by percutaneous catheter drainage. Two failures required operative intervention. In summary, the low morbidity and high success rate in treating hepatic abscesses by percutaneous drainage suggests that this therapy be tried before operative intervention is considered.     

Pathology, diagnosis and therapy of liver abscess

Bacterial hepatic abscesses are a rare but serious disease. They develop either secondary to injuries or ischemia of the liver, infections in the drainage area of the portal vein, systemic sepsis or biliary infections. An abscess secondary to injuries or ischemia of the liver or infections in the drainage area of the portal vein, is usually caused by a mixed flora consisting of gramnegative aerobes and anaerobic bacteria. Hepatic abscesses secondary to systemic sepsis contain Staphylococci or Streptococci, while in abscesses on the basis of biliary infections gramnegative organisms are found. Clinically, one can find signs of systemic sepsis, pain in the right upper quadrant and a tender enlarged liver. Jaundice is absent unless a biliary obstruction is present simultaneously. The diagnosis is confirmed by ultrasonography or computerized tomography. An uncertain diagnosis can be confirmed by aspiration under ultrasonographic or computertomographic guidance. The therapy consists of administration of antibiotics and surgical or percutaneous drainage. Surgical drainage via laparotomy is always mandatory if one suspects a primary infectious focus within the abdomen. The mortality of multiple liver abscesses is 20 per cent, that of single abscesses 10 per cent. Amebic abscesses have been observed in nonendemic regions sporadically after travel or spontaneously. Clinical and radiological manifestations are the same as for bacterial abscesses. They are differentiated from bacterial abscesses by positive serology for amebiasis or aspiration which yields the typical anchovy paste. Most important complications are hepato-bronchial fistulae, empyema and amebic pericarditis. The therapy consists of a nitroimidazole and a luminal amebicide. Except for diagnostic reasons aspiration is only indicated for large abscesses of the left lobe of the liver. Mortality of an uncomplicated amebic liver abscess should be under one per cent.     

Cannula aspiration of peritonsillar abscesses.

Peritonsillar abscesses may be treated by needle aspiration, incision and drainage, or abscess tonsillectomy. A modification of the technique of needle aspiration is described. This technique minimizes the risk of vascular damage during needle aspiration and is more reassuring to the patient.     

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.     

Spinal epidural abscess successfully treated with percutaneous,computed tomography-guided,needle aspiration and parenteral antibiotic therapy: case report and review of the literature

OBJECTIVE AND IMPORTANCE: We describe a case of a posterior spinal epidural abscess that was successfully treated with percutaneous, computed tomography-guided, needle aspiration and parenteral antibiotic therapy. CLINICAL PRESENTATION: A 48-year-old man experienced acute pain in the paralumbar region for 1 week, followed by gait disturbance and micturition difficulty. Laboratory studies demonstrated leukocytosis and hyperglycemia. Blood cultures yielded Staphylococcus aureus. Magnetic resonance imaging scans of the thoracolumbar spine revealed a posterior spinal epidural abscess located between L2 and the lower cervical spine. INTERVENTION: The patient's low back pain persisted despite 10 days of antibiotic therapy. Therefore, percutaneous, computed tomography-guided, needle aspiration was performed. The low back pain was relieved dramatically and immediately after the procedure. The spinal epidural abscess completely resolved after 6 weeks of antibiotic treatment. CONCLUSION: Surgical decompression and antibiotic therapy are the treatments of choice for patients with spinal epidural abscesses. Selected patients may be treated nonsurgically. Rarely, percutaneous drainage of the abscess has been reported to be helpful. Our case suggests that percutaneous, computed tomography-guided, needle aspiration might be a rational alternative to surgical decompression for treatment of spinal epidural abscesses.     

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.     

Treatment of bacterial brain abscess by repeated aspiration--follow up by serial computed tomography

Bacterial brain abscess often requires repeated aspiration before the abscess finally resolves. However, there are no guidelines for treatment by aspiration; for example, when should the abscess be tapped again, or when can an abscess be treated by antibiotics alone without further aspiration. Eleven patients with bacterial brain abscess treated by aspiration were evaluated to establish treatment guidelines for brain abscess, in particular the abscess size on serial computed tomography (CT) after aspiration. CT was performed about 24 hours after aspiration to evaluate the size of the abscess, and almost weekly during follow up. The diameter of the brain abscess before and after the initial and last aspirations were reviewed. In eight of the 11 patients, abscesses were aspirated repeatedly: two to three times in most patients. The diameter of the abscesses was 2.5-4.5 cm (mean 3.5 cm) before the last aspiration, and 1.4-3.4 cm (mean 2.3 cm) after the last aspiration, or when continuous drainage was discontinued. Perifocal edema was moderately decreased within 3 weeks after the last aspiration by medical treatment alone, with a concomitant decrease in the volume of the abscess. There were no deaths, and most patients had a favorable outcome. These results suggest that after the diameter of the abscess becomes less than 2 to 3 cm and does not increase anymore on serial CT, medical treatment alone can be anticipated to give satisfactory results without further aspiration.     

Rate of malignancies in breast abscesses and argument for ultrasound drainage

BACKGROUND: Biopsy of a breast abscess wall has been performed for years without evidence. Aspiration of breast abscesses has been increasing in popularity without widespread acceptance. METHODS: A 10-year retrospective review of 206 surgical biopsies after incision and drainage of breast abscesses. A literature review of breast abscess treated with ultrasound-guided aspiration. RESULTS: Over 10 years, 4.37% (9/206) patients were diagnosed with malignancy in the abscess cavity wall tissue. None of the 197 patients with a negative biopsy returned with breast cancer. Single, multiple, and combined aspiration success rates of 79.8% (364/458), 11.0% (50/458), and 90.9% (482/532) with surgical intervention necessary in 9.1% (50/532). Ultrasound versus hand guidance (92.5% versus 81.9 %, P < .01) improved success rate. CONCLUSIONS: The rate of associated malignancies with breast abscess is very low and does not warrant mandatory surgical drainage. The use of ultrasound-directed aspiration of breast abscesses is effective and should be first-line therapy.     

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.