Percutaneous Drainage of 300 Intraperitoneal Abscesses with Long-Term Follow-Up

The purpose of the study was to evaluate the efficacy of percutaneous drainage of intraperitoneal abscesses with attention to recurrence and failure rates. A retrospective analysis of percutaneous treatment of 300 intraperitoneal abscesses in 255 patients (147 male, 108 female; average age: 38 years; range: 40 days to 90 years) for whom at least 1-year follow-up data were available was performed. Abscesses were drained with fluoroscopic, sonographic, or computed tomographic guidance. Nine abscesses were drained by simple aspiration; catheter drainage either by Seldinger or trocar technique was used in the remaining 291 abscesses with 6F to 14 F catheters. Initial cure and failure rates were 68% (203/300) and 12% (36/300), respectively. Sixty-one abscesses (20%) were either palliated or temporized. The recurrence rate was 4% (12/300) and nine of them were cured by recatheterization, whereas three of them were treated by medication or surgery. The overall success and failure rates were 91% (273/300) and 9% (27/300), respectively, with temporized, palliated, and recatheterized recurred abscesses. The 30-day mortality rate was 3.1% (8/255). The mean duration of catheterization was 13 days. Intraperitoneal abscesses with safe access routes should be drained percutaneously because of high success and low morbidity, mortality, and recurrence rates.     

Transesophageal drainage of mediastinal abscesses

Esophageal perforation with subsequent formation of a mediastinal abscess is a well-recognized clinical entity. Causes include perforation due to rigid and fiberoptic endoscopy, bouginage, breakdown of surgical anastomoses, and protracted vomiting. This disorder is associated with a high morbidity and, without intervention, a high mortality. In the past, surgery has been the treatment of choice. Although percutaneous drainage techniques have been used in some cases, they are frequently less attractive due to the location of the esophagus and its proximity to thoracic organs and vascular structures. In this study, eight abscesses caused by esophageal perforations were drained through a transesophageal route with minimal patient morbidity. These cases are presented with a discussion of the techniques and patient follow-up.     

Renal and related retroperitoneal abscesses: percutaneous drainage

Renal and related retroperitoneal abscesses cause significant morbidity and mortality and almost always require drainage. The authors report 18 cases of percutaneous drainage of renal and related retroperitoneal abscesses, all of which were successfully managed. In 11 of these cases (61%), percutaneous drainage constituted the only treatment required. In the remaining seven (39%), the patients' clinical status improved after percutaneous drainage, and they were able to undergo subsequent elective nephrectomy with fewer complications. These results are comparable to those achieved with percutaneous abdominal abscess drainage and justify the use of percutaneous drainage for renal and related retroperitoneal abscesses as the therapeutic procedure of choice.     

Percutaneous drainage of abdominal abcess

The mortality in undrained abdominal abscesses is high with a mortality rate ranging between 45 and 100%. The outcome in abdominal abscesses, however, has improved due to advances in image guided percutaneous interventional techniques. The main indications for the catheter drainage include treatment or palliation of sepsis associated with an infected fluid collection, and alleviation of the symptoms that may be caused by fluid collections by virtue of their size, like pancreatic pseudocele or lymphocele. The single liver abscesses may be drained with ultrasound guidance only, whereas the multiple abscesses usually require computed tomography (CT) guidance and placement of multiple catheters. The pancreatic abscesses are generally drained routinely and urgently. Non-infected pancreatic pseudocysts may be simply observed unless they are symptomatic or cause problems such as pain or obstruction of the biliary or the gastrointestinal tract. Percutaneous routes that have been described to drain pelvic abscesses include transrectal or transvaginal approach with sonographic guidance, a transgluteal, paracoccygeal-infragluteal, or perineal approach through the greater sciatic foramen with CT guidance. Both the renal and the perirenal abscesses are amenable to percutaneous drainage. Percutaneous drainage provides an effective and safe alternative to more invasive surgical drainage in most patients with psoas abscesses as well.     

Abscess drainage with CT and ultrasound guidance

The technique of catheter drainage of abscesses, while appearing to be a departure from standard surgical tenets, in reality adheres to accepted principles of abscess management. In properly selected candidates, most abscesses are adequately and safely drained by catheter. Catheter drainage has the advantages of avoidance of general anesthesia, less morbidity, and lower cost when compared with that of surgical drainage. Since catheter drainage does not preclude surgical drainage, in appropriate candidates percutaneous drainage should be considered initially for definitive therapy. Ultrasonography and CT have become the preferred methods of detecting abdominal abscesses and also of guiding percutaneous catheter drainage. Real-time sonography has the advantages of being inexpensive, "portable," and able to provide simultaneous imaging during catheter placement. CT provides greater accuracy in guiding drainage of small, deep abscesses, more accurate delineation of the extent and location of the collection, and better definition of the relationship of abscesses to bowel and blood vessels.     

Efficacy of the intradecidual sign and fallacy of the double decidual sac sign in the diagnosis of early intrauterine pregnancy

PURPOSE: To assess ultrasonographically (US) guided needle aspiration of breast abscesses as an alternative to surgical incision and drainage or indwelling catheter placement. MATERIALS AND METHODS: The authors reviewed hospital records from 1995 to 1997 for patients undergoing US-guided aspiration of breast abscesses. Two radiologists reviewed the US, mammographic, and US-guided aspiration studies for the size, appearance, and drainage of abscesses. The medical records were reviewed for follow-up data. RESULTS: Thirteen patients aged 15-69 years underwent US-guided percutaneous aspiration of 13 breast abscesses. All patients presented with a palpable mass, nine of which were retroareolar. At US, four abscesses were oval, nine (including three with septa) were irregularly shaped, and five had a thick rind. Of seven abscesses 2.4 cm or smaller, two were almost completely drained and five were completely aspirated. All seven abscesses resolved without surgery. Of six women with incompletely aspirated abscesses larger than 2.4 cm (one 3 cm, four 4 cm, one 7 cm), five required surgical referral; one of these cases was referred after repeat aspiration had been performed. CONCLUSION: Percutaneous aspiration of breast abscesses can enable diagnosis of abscesses and be used to treat small abscesses if they are completely drained. Partial drainage of abscesses larger than 3 cm may be palliative, but incision and drainage still may be necessary for definitive treatment.     

Computed tomography in the diagnosis and treatment of solitary splenic abscesses

Solitary splenic abscess is a rare entity and difficult to diagnose. Late recognition results in a high mortality. Recently percutaneous drainage has proved to be beneficial. The CT and ultrasound findings of two patients with splenic abscesses are reported. In one patient the solitary splenic abscess was drained percutaneously. In the other patient, a HTLV-III-positive man, a splenectomy was performed.     

Percutaneous drainage of renal and perinephric abscess

Computed tomography and ultrasonography are effective methods for diagnosis and localization of renal and perinephric abscesses. In patients with clinical suspicion of sepsis, diagnostic needle aspiration of these lesions can be safely performed extraperitoneally by using sectional imaging for guidance. When an abscess is confirmed, small catheters can be introduced percutaneously via the diagnostic aspiration route to provide immediate decompression as well as continuous and definitive drainage without need for surgery. In 8 cases so treated, there were no major complications, deaths, or recurrences. These results, obtainable without the risks of surgery, indicate that patients with renal or perinephric abscesses should be offered a trial of percutaneous drainage as a definitive method of therapy. Those cases not amenable to percutaneous drainage, or those in which the procedure has failed, can then be drained surgically. Percutaneous abscess drainage is widely applicable because it can be performed in any uroradiologic facility with access to sectional imaging.     

Complicated pancreatic abscesses: problems in interventional management

Twenty-five patients with grade D or E pancreatitis underwent percutaneous drainage. These patients required multiple computed tomography (CT) examinations, multiple catheter insertions, multiple catheter manipulations, and long-term catheter drainage. Eight of the 25 patients were successfully treated with catheter drainage alone. Sixteen underwent surgical drainage, ten after attempts at percutaneous drainage and six prior to radiologic drainage. Of the ten patients who had initial percutaneous drainage, only four were clinically improved from the drainage procedure alone. Although the fluid component of the abscess was often adequately drained in all ten patients, surgery was required to remove pieces of necrotic debris. Six patients who underwent surgical debridement had residual abscesses in the post-operative period and were all successfully treated with percutaneous drainage. One patient died from unrelated causes. Successful interventional management of patients with pancreatic abscesses requires intensive radiologic intervention and monitoring and may be better served by a combination of radiologic and surgical means.     

Percutaneous catheter drainage of tuberculous and nontuberculous psoas abscesses

Objective: To assess the utility of percutaneous catheter drainage in the management of tuberculous and nontuberculous psoas abscesses associated without any bony involvement or with minimal bony lesions that could not cause vertebral instability. Materials and method: Eleven patients with psoas, iliopsoas and pelvic abscesses were drained under computed tomography and ultrasono-graphy guidance. Results: There were 15 (10 tuberculous, 5 pyogenic) abscesses in 11 patients. Six of the tuberculous abscesses and one of the pyogenic abscess were associated with vertebral involvement. Vertebral lesions were located in one or two vertebrae without causing any serious disturbance in the vertebral stabilization. In one case, the abscess was bilateral. Nine cases were drained under computed tomography guidance, while two cases were drained under both computed tomography and ultrasonography guidance. One session drainage was sufficient for abscess resolution in uniloculated cases. In the two of four multiloculated cases, catheter drainage was performed twice. Relapse of the abscess was found in only one patient. The mean abscess volume was 520 ml and mean drainage duration was 12 days. None of the cases required surgery. Conclusion: Percutaneous drainage, chemotherapy and additional external brace application with the cases associated with bony lesion may be used for treatment of tuberculous and nontuberculous unilocule and multiloculated abscesses.     

Recurrent abdominal and pelvic abscesses: incidence, results of repeated percutaneous drainage, and underlying causes in 956 drainages

OBJECTIVE: We undertook this study to determine the incidence and results of repeated (secondary) percutaneous abscess drainage performed on recurrent abscesses after successful initial (primary) percutaneous abscess drainage. MATERIALS AND METHODS: Imaging studies from patients who underwent multiple drainages were reviewed to define a cohort of patients who underwent secondary percutaneous abscess drainage after successful initial percutaneous abscess drainage of the same abscess. Medical records of these patients were then reviewed to assess the results of secondary percutaneous abscess drainage. RESULTS: Forty-five abscesses in 43 patients required secondary percutaneous abscess drainage. Twenty-four of the 43 patients avoided surgery. Secondary percutaneous abscess drainage was successful in evacuating the abscess cavity in 39 (91%) of 43 patients. Duration of drainage and time until recurrence were not significant predictors for avoiding surgery. Mean duration of secondary percutaneous abscess drainage was significantly longer than mean duration of primary percutaneous abscess drainage, but duration of secondary percutaneous abscess drainage (25 vs 14 days, respectively; p = 0.007) did not differ significantly between patients who ultimately required surgery and those who did not (17 vs 11 days, respectively; p = 0.10). Time to recurrence ranged from 2 days to 1 year (mean, 51 days). CONCLUSION: After successful primary percutaneous abscess drainage, secondary percutaneous abscess drainage of recurrent abscesses succeeded in evacuating the abscess cavity in most patients, and surgery was avoided by slightly more than half. Patients with postoperative abscesses were significantly more likely to avoid surgery (p = 0.008), whereas patients with pancreatic abscesses were significantly more likely to require it (p = 0.03).     

Percutaneous drainage of subphrenic abscess: a review of 62 patients

Sixty-two patients who presented with subphrenic abscesses had the abscesses drained percutaneously. Diagnosis of a subphrenic collection was usually made with sonography. Initial percutaneous drainage was accomplished with a combination of sonography and fluoroscopic guidance. More recently (in the last 31 cases) most drainages were done with sonographic guidance alone. Successful catheter drainage was achieved in 85% with a complication rate of 4.8%. Failure of catheter drainage (defined as any patient who was not cured by percutaneous drainage alone) occurred in patients with multiple collections or in whom the primary cause of the abscess necessitated surgery, for example, perforated ulcer, acute cholecystitis. Considerations for successful drainage include understanding the anatomy of the subphrenic space, recognizing the importance of a correct access route (avoidance of the pleura and lung), and the long time necessary for adequate drainage (longer than 10 days in 60%). An angled subcostal approach to the subphrenic space was used in 56 (90%) of 62 cases. No complications occurred in this group. The one pneumothorax that occurred in the remaining six cases was a direct result of using an intercostal approach through the parietal pleura into a subphrenic collection. We conclude that percutaneous drainage is a safe and effective method of treatment of subphrenic abscesses.     

Complex ruptured amebic liver abscesses: the role of percutaneous catheter drainage

The failure of medical therapy for amebic liver abscess may be followed by its perforation, a complication associated with high mortality. We assessed the role of percutaneous catheter drainage in management of the sequelae of ruptured amebic abscesses in 13 critically ill patients; 22 intrahepatic lesions, three of which were multiloculated, were drained. Catheters were also placed in 17 extrahepatic collections: pleural space (n = 5), subphrenic (n = 7), perihepatic/subhepatic (n = 3), greater sac of peritoneum (n = 2). No attempt at percutaneous drainage failed. Prompt resolution of clinical features following drainage was a uniform feature. Successful resolution of the abscesses occurred within 20 days in 11 patients. In the remaining two, catheters needed to be retained in situ for 35 and 50 days. The mean hospital stay was 15 days (range 10–20 days). 100% patient survival was achieved, without a single morbid episode. Our results suggest that patients with ruptured amebic abscesses can be effectively and safely managed by percutaneous catheter drainage irrespective of the extent of extrahepatic contamination.     

Percutaneous drainage of postappendectomy abscesses complicated by enteric communication

Four patients with postappendectomy abscesses complicated by enteric fistulae were treated by percutaneous drainage. Sinograms, obtained at the time of the initial drainage, demonstrated communication to the cecum in 3 patients and to the small bowel in 1 patient. Complete cure was attained in 3 patients by percutaneous drainage. In the fourth patient, surgery was performed after 7 days of catheter drainage. Percutaneous drainage of abscesses with enteric communication requires a modified technique, which includes longer-term drainage than for simple noncommunicating abscesses.     

Percutaneous abscess drainage in Crohn's disease

The effect of 18 percutaneous abscess drainage procedures on the clinical management of 10 patients with Crohn's disease was evaluated. Two abscesses occurred immediately after surgery (two patients), five were in the liver (three patients), and 11 were the result of direct spread of disease from adjacent transmural bowel involvement (seven patients). Both postoperative and all five hepatic abscesses were treated successfully with percutaneous drainage. In two of the seven patients with abscesses secondary to transmural bowel disease, percutaneous drainage resulted in resolution of the abscess without the need for any further surgical intervention. The remaining five patients had subsequent elective intestinal surgery in which a single-stage surgical resection and primary reanastomosis were performed successfully. Two of these patients had abscesses recur at the same location, prompting a repeat percutaneous drainage before surgery. No enterocutaneous fistulas secondary to percutaneous drainage developed in any of the 10 patients. These results indicate that percutaneous abscess drainage can be a valuable technique for treating abscesses that result as a complication of Crohn's disease.     

Percutaneous drainage of tuberculous iliopsoas abscesses under image guidance

Most intra-abdominal and other types of fluid collections are now successfully drained percutaneously under image guidance. The utility of percutaneous drainage of tuberculous abscesses, especially those associated with osseous changes, is, however, less well established. Six patients with tuberculous iliopsoas abscesses were successfully managed by percutaneous drainage combined with antituberculous therapy. The abscesses were bilateral in one patient and unilateral in the other five. Drainage was by needle aspiration under ultrasound (US) guidance in one patient, and by catheter under CT guidance in the other patients. Three patients had associated osseous changes. There were no procedural complications. Tuberculous iliopsoas abscess can be successfully treated by percutaneous drainage and appropriate antituberculous therapy.     

Percutaneous drainage of pyogenic liver abscesses

This report summarizes the results of percutaneous catheter drainage in 23 cases of primary or secondary pyogenic liver abscess. The overall success rate was 76%. Only three (60%) of five cases of secondary abscess (infected hematoma or infected tumor) were cured with catheter drainage, but 11 (91%) of the last 12 primary pyogenic abscesses were drained successfully. Six patients with abscesses of less than 4 cm in diameter required catheter drainage for less than 72 hr. Although six abscesses in the series appeared septated or multiloculated, only one required more than a single catheter for curative drainage. Diagnostic and technical considerations for successful drainage of hepatic abscesses are discussed. The differential diagnosis includes echinococcal disease and hepatic amebiasis. Therapeutically, specific measures should be taken to ensure proper catheter position to prevent contamination of the subphrenic, perihepatic, and pleural spaces. Percutaneous catheter drainage should be attempted as a first choice of treatment in all pyogenic hepatic abscesses.     

Radiologically-guided catheter drainage of intrathoracic abscesses and empyemas

Radiologically guided percutaneous catheter drainage was used in 38 patients to treat pleural empyemas (35 patients) and pulmonary abscesses (3 patients). Drainage was successful in 85.7% of empyemas including 11 cases with fistulous communications. Three percutaneously drained pulmonary abscesses required subsequent lobectomy. One patient died during the drainage procedure due to sepsis. No major complications related to the drainage procedure were observed. Guided percutaneous drainage proved to be a safe and successful alternative to closed drainage of pleural fluid collections. Correspondence to: H. Berger     

Percutaneous management of intrapulmonary air and fluid collections

The radiologist's role in the management of intrapulmonary air and fluid collections is becoming more important. Improvements in percutaneous interventional techniques now allow the radiologist to offer patients an alternative treatment option with less morbidity and mortality than surgical resection. The use of CT allows optimal catheter placement and enables safe and effective percutaneous evacuation of intrapulmonary collections. In summary, image-guided percutaneous catheter drainage should (1) be the initial procedure performed to diagnose and treat lung abscesses not responding to conservative therapy; and (2) because of its effectiveness and safety, be considered as a treatment option in the management of symptomatic patients with intrapulmonary mycetomas.     

Percutaneous drainage of renal and perirenal abscesses: results in 30 patients

The purpose of this study was to determine the efficacy of percutaneous drainage of renal and perirenal abscesses. Thirty-two abscesses, 10 renal and 22 renal with perirenal extension, in 30 patients (16 female, 14 male; age range, 5-83 years), were drained percutaneously. Twenty-one patients had had surgery recently and/or were immunosuppressed. Ten of the 13 postoperative patients had had surgical procedures involving the urinary tract. Size of the abscesses ranged from 10 to 650 ml, and all were drained via CT or fluoroscopic guidance. The type of drainage catheter used depended on the size of the abscess. Complications were unusual. A transient febrile episode without sequelae within the first 12 hr of catheter placement was the most common complication. All patients had their abscess catheter placed while in the hospital; 12 (40%) subsequently were followed up (2-50 days) as outpatients until their catheters were removed without complications. Percutaneous drainage alone was curative in 20 patients (67%) as determined by resolution of signs and symptoms or follow-up CT. Eight (27%) had improvement of signs and symptoms but required surgery to remove tumor (one patient) or a poorly functioning or nonfunctioning kidney (five patients), perform open pyelolithotomy (one patient), or drain a loculated abscess (one patient); all eventually were cured. Three patients (10%) with multiple medical problems died before resolution could be documented, although death was not thought to be directly related to failure of therapy. Our results indicate that percutaneous drainage alone is curative in the majority of cases of renal and perirenal abscesses. Many patients can be treated safely, in part, on an outpatient basis.