Strategies in the management of pyogenic psoas abscesses.

The presentation and management of eight patients with pyogenic psoas abscesses treated at the National Naval Medical Center, Bethesda, Maryland, between January 1986 and July 1989 are presented. The psoas abscesses were secondary to underlying gastrointestinal disease in six patients and sacral osteomyelitis in one patient. In one patient, the etiology of the abscess could not be determined. The average duration of symptoms in these patients was 16 days. Computed tomography was useful in identifying the abscess, defining its complexity, and planning therapy in all eight patients. Seven patients had complex, multiloculated abscesses, and one patient had a simple abscess. Extraperitoneal drainage was used in all patients. The patients with multiloculated abscesses had open surgical drainage, while the patient with the simple abscess had percutaneous catheter drainage. Most patients with a gastrointestinal etiology for their abscess underwent staged resection 3 to 6 weeks after the drainage procedure. There were no deaths, recurrent abscesses, or fistulae in these patients. Two patients developed thromboembolic complications postoperatively. Extraperitoneal drainage with staged resection of underlying gastrointestinal pathology is a safe and effective way of treating patients with psoas abscesses.     

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.     

Review of pyogenic liver abscess at the Royal Adelaide Hospital 1980-1987

Pyogenic liver abscess is an uncommon condition which carries substantial morbidity and mortality if untreated. A review was undertaken of 31 patients who were admitted to the Royal Adelaide Hospital (RAH) between January 1980 and December 1987 and who were diagnosed as having pyogenic liver abscess. The aims of the study were to review the aetiology, current methods of investigation and treatment of the disease, and to formulate a management plan based on the findings. Hypoalbuminaemia, leukocytosis and elevated alkaline phosphatase were the most common findings. Hyperbilirubinaemia was not a usual feature. Computerised tomography (CT) scanning and ultrasound were the most useful imaging modalities in identification of the abscess. The sensitivity of CT scanning in evaluating the size of abscesses was lower than anticipated and this may lead to a higher than necessary rate of surgical drainage. A case is presented to illustrate this. Most abscesses were secondary and frequently due to extension of infection from biliary structures. Diseases causing diminished resistance to bacterial infection had a significant role in the pathogenesis. The overall mortality rate was 25%. Risk factors increasing mortality included advanced age, multiplicity of abscesses, depressed immune status and the presence of complications due to the abscess. Of patients who survived, four were treated with antibiotics alone, eleven with percutaneous drainage and antibiotics, and eight with surgery and antibiotics. We conclude that patients with hepatic abscesses should be managed initially by CT or ultrasound-guided aspiration. If pus is obtained a percutaneous drain should be inserted into the cavity and systemic antibiotics administered.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pelvic abscess or pseudoaneurysm: diagnostic and therapeutic dilemma following iliac arterial trauma.

Intra-abdominal abscesses often complicate operations for abdominal trauma and are particularly dangerous in patients whose injuries involve major vessels. We report our experience with 10 patients who developed pelvic abscesses among 75 survivors of iliac arterial injuries. Pseudoaneurysms of primarily repaired iliac arteries occurred in 8 of these 10 patients. Emergency operations were required for acute arterial thrombosis or hemorrhage in four patients; massive hemorrhage that complicated the drainage of pelvic abscesses led to the recognition of the pseudoaneurysms in the other four patients. Three of the eight patients with pseudoaneurysm died of postoperative complications; ischemic extremity sequelae occurred in all five survivors. The association of pelvic abscesses with the complications iliac arterial repairs has not been previously emphasized. The integrity of an arterial repair should be arteriographically confirmed before proceeding with drainage of a pelvic abscess that developed after iliac arterial trauma.     

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.     

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.     

Repositioning catheters in surgically drained abscesses

Primary percutaneous drainage of intraabdominal abscesses under local anesthesia is an accepted method of treatment, with low morbidity and mortality. This technique was extended to patients with recurrent or secondary abscesses after initial primary surgical drainage. Four patients had abscesses drained operatively but were reevaluated several weeks later for recurrent fever. Sinography demonstrated an inadequately drained abscess cavity. Under fluoroscopic control and using local anesthesia, new drains were inserted and repositioned to provide better drainage. Resolution of the abscess cavity was documented radiographically, with improvement in the patients' clinical status.     

Management of perianal sepsis in a district general hospital.

Perianal sepsis remains a common surgical problem. A total of 121 patients undergoing surgery for perianal abscess and/or fistulae over a 2-year period was studied. Of these, 50 patients (41.3%) had suffered from previous perianal sepsis (not necessarily resulting in hospital attendance). Ninety-one patients underwent incision and drainage of abscesses (ischiorectal and perianal) for the first time, whereas eight patients underwent drainage of recurrent abscesses. Fistulae were identified when the abscess was drained in 14 of 91 patients, and a further ten patients subsequently developed fistulae. Twenty-two patients presented with a discharging fistula. A high yield of bowel organisms was present in patients with coexisting fistulae (88%), recurrent abscesses (75%) and in those who subsequently developed fistulae (83%). We confirm that such a growth can be used to identify patients who will benefit from further examinations.     

Ultrasound-guided percutaneous drainage of intra-abdominal abscesses

The encouraging results of percutaneous abscess drainage (PAD) in simple intra-abdominal abscesses have led us to employ this method in patients with more complex abdominal inflammatory disease, such as those with multiple enteric communicating or multilocular abscesses and patients in whom the percutaneous approach requires puncture routes traversing uninvolved organs. Cure was achieved in 74 per cent of all patients (83 of 112 patients) who underwent PAD, but in only 50 per cent of patients with multiple intra-abdominal abscesses (n = 16), 50 per cent of patients with complex pancreatic inflammatory disease (n = 8) and 57 per cent of patients with complex intraparenchymal abscesses (n = 7). PAD contributed to cure in eight of nine patients with enteric communicating abscesses. The transhepatic route to perihepatic abscesses proved to be safe. Complications occurred in nine patients (8 per cent). No relationship was noted between the severity or number of complications and the indication for PAD. Of the 29 failures of PAD, 17 patients were cured by either surgical intervention (14 patients) or a second PAD (1 patient) or a combination of the two methods (2 patients). Twelve patients (11 per cent) died, eight from sepsis due to inadequate drainage. Frequent reassessment by ultrasonography and computerized tomography (CT) in patients with prolonged sepsis after PAD is mandatory. These results justify a place for PAD in the management of the often critically ill patient with complex abdominal inflammatory disease.     

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.     

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.     

克罗恩病并发腹腔脓肿的临床特征与外科治疗

目的探讨克罗恩病(CD)合并腹腔脓肿的临床特征和外科治疗及预后。方法对2000-2005年间收治的142例CD患者其中合并腹腔脓肿的39例临床资料进行总结分析。结果本组CD患者合并腹腔脓肿的总发病率为27.5%,从发病到脓肿形成的时间范围为0-22年,平均5年。发病年龄(34.7±12.3)岁。24例(61.5%)患者既往有手术史;30例(76.9%)患者的脓肿发生在右侧腹,尤其是在吻合口附近(48.7%)。36例(92.3%)采取手术治疗,其中34例(34/36,94.4%)行手术引流加病变肠管切除,恢复良好。结论CD有较高的腹腔脓肿并发率,发病年龄多在35岁,将近50%发生在原吻合口;脓肿前的CD病程平均5年;手术方式以脓肿引流加病变肠管切除为主。     

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.     

Closed automatic programmed aspiration-irrigation method in the treatment of abdominal abscesses

Treatment of 124 patients with abdominal abscesses is analysed. Sixty-four patients (a test group) were treated by air-tight drainage of the abscess cavity with double-tube silicone drains and automatic fraction irrigation of the purulent cavity in the postoperative period. Other methods of intraabdominal abscess drainage were used in 60 patients (a control group). The advantages of closed programmed aspiration-irrigation treatment are shown.     

Stereotactic operation for brain abscess

Stereotactic management of brain abscess (stereotactic aspiration with external drainage) was performed in 14 patients. Fifteen abscesses in 14 patients were successfully aspirated by this method. After aspiration of the abscess, all patients underwent external drainage for an average of 14.5 days. No complications during aspiration or during external drainage (such as bleeding or infection, respectively) were encountered in our series. Ten out of 14 patients (71.4%) showed excellent prognosis, and 3 of 14 (21.4%) showed good outcome. Only one patient died after the operation, but this was due to lung cancer. Our operative results are quite satisfactory in comparison with operative results reported by other authors.     

Tandem Subdiaphragmatic and Pleural Sequelae due to Lost Gallstones following Cholecystectomy

We report two similar thoracoabdominal complications we encountered due to retained gallstones after cholecystectomy. These patients had had an open cholecystectomy after a failed laparoscopic attempt, with spillage of gallbladder debris intraoperatively. They were admitted more than 12 months later with subdiaphragmatic abscesses. Attempted computerized axial tomography (CT) guided drainage of these abscesses resulted in these patients developing pleural fluid collections, which required surgical drainage. The patients underwent exploratory laparotomies, and drainage of the subdiaphragmatic abscesses had revealed gallstones within the abscess cavity.A detailed presentation of these cases, with review of cur-rent literature and clinicopathologic issues for discussion are described.     

Use of the computerized tomographic scan in the diagnosis and treatment of abscesses

Over a 5 year period, 89 patients underwent one or more computerized tomographic scans to locate an abscess during 92 hospitalizations. The scans were a most sensitive (93 percent), specific (98 percent), and accurate (96 percent) means of abscess detection. Thirty-nine patients had positive scans. Sixteen patients were treated directly by open surgical methods, 1 of whom required percutaneous drainage in the postoperative period for incomplete drainage. An additional 23 patients underwent attempted percutaneous abscess drainage. In 17 patients, drainage was successful. Five patients underwent percutaneous drainage and later required laparotomy, two of whom underwent unavoidable surgical procedures and three surgery for incomplete drainage. Overall, percutaneous abscess drainage was successful in 83 percent. Of 11 deaths, 8 occurred in the group with computerized tomographic scans negative for abscess. Three of these were false-negative scans. Three deaths occurred in the group with scans positive for abscess. All were of patients with hepatic abscesses treated by open surgical drainage, one after failed percutaneous drainage. Twelve patients had multiple organ failure, and 8 of these patients died, for a mortality of 67 percent. The computerized tomographic scan is the diagnostic procedure of choice in the diagnosis of abscesses. In selected patients, percutaneous abscess drainage is also a successful means of abscess treatment and avoids the complications of a laparotomy. The onset of multiple organ failure in the surgical patient should alert the diagnostician to the possibility of a septic focus. The role of early laparotomy in these patients is uncertain. We recommend early use of the computerized tomographic scan in the septic surgical patient. Prompt diagnosis and treatment of abscesses, whether by open or percutaneous routes, may avert the development of multiple organ failure and reduce morbidity and mortality.     

The iliopsoas abscess: aetiology, therapy, and outcome

Background and aims The treatment strategy for patients with a retroperitonally localised abscess is controversial as it remains open which fluid collections should be drained by open access or by percutaneously inserted drainage.Patients Therefore, the data of 40 consecutively treated patients with an iliopsoas abscess were analysed retrospectively.Results Ten patients suffered from a primary abscess and ten from a post-operative abscess; further, in 20 patients, the aetiology of the abscesses were due to Crohn’s disease, neoplasia, spondylitis or other relevant concomitant diseases. Eight of 40 patients were initially treated by image-guided percutaneous drainage (PD), the other by open access drainage. Six patients died (15%), all of them had been operated; 15 (37.5%) patients had a recurrence of their abscess and needed re-operation. Factors predicting a poor outcome were age, APACHE II score, bi-lateral abscesses and a post-operative or bony cause, but the bacteriological findings did not influence the outcome.Conclusions We suggest an algorithm for treatment of iliopsoas abscesses depending on number and volume of the abscesses.     

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.     

Intraabdominal abscess formation after major liver resection

A series of 138 major liver resections undertaken between 1971 and 1987 were reviewed. Intrabdominal abscesses developed in 11 (8%) patients, a mean of 23 days (range 10-42) after operation and two died (mortality 18%). Eight developed after 63 right hepatectomies, two after 24 right lobectomies, one after 34 left hepatectomies and none after left lobectomies (17). Patients who developed intra-abdominal abscesses underwent significantly longer operations (mean (SEM) 400 (48) compared with 275 (21) min) (p less than 0.05) and had significantly more bleeding during the operation (7,600 (1,750) compared with 3,200 (430), p less than 0.01) than those who did not. The amounts recovered from the abdominal drains, both before and after the diagnosis, were comparatively greater in patients with abdominal abscesses. Antibiotic prophylaxis was given to 10 of 11 patients who did and 89 of 127 patients who did not, form abscesses. We conclude that the risk of intra-abdominal abscess formation after major liver resection is increased: when a large amount of liver tissue is removed (right hepatectomy or lobectomy); when there is a lot of intraoperative bleeding; and when the operation takes a long time. Antibiotic prophylaxis did not affect the risk of abscess formation this series.