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.     

Surgical versus percutaneous drainage of intra-abdominal abscesses

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

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.     

Laparoscopic drainage of bilateral tuberculous psoas abscesses

Psoas abscess secondary to Mycobacterium tuberculosis infection is rare in industrialized countries. Standard treatment options for psoas abscess of any etiology include percutaneous drainage under radiographic guidance and surgery, which is reserved for failure of conservative therapy. A case of bilateral tuberculous psoas abscesses is reported and a surgical method of drainage utilizing a totally extraperitoneal laparoscopic approach is described.     

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目的　研究导丝法经皮脓肿引流 (PAD)治疗腹腔脓肿。方法　自 1993年以来 ,对 5 1例病人经超声和CT证实并定位腹腔脓肿。穿刺获取脓液后 ,置入导丝 ,再置入并保留口径较粗的引流管持续引流。结果　PAD成功率为 84 .3%。平均愈合时间为 (2 3± 8)d。 8例需再次剖腹进行手术引流。结论　PAD创伤小 ,引流效果好。适用于病程迁延、重危与手术风险大的病人 ,可完全治愈单发脓肿病人 ,亦为需要再次手术引流的病人缓解病情 ,降低手术风险     

Operative vs percutaneous drainage of intra-abdominal abscesses. Comparison of morbidity and mortality

This retrospective case-controlled study compares the morbidity and mortality of 27 percutaneously drained (PD) abscesses with 27 that were surgically drained (SD). Patients were matched for age, sex, diagnosis, and abscess etiology and location. There was no difference in severity of illness (acute physiology score [APS] = 8.3 vs 10.2), comparable morbidity (29.6% vs 40.7%), or mortality (11.0% vs 7.4%) between PD and SD groups. Duration of drainage was significantly longer in the PD group; however, this is explained in part by the 48% vs 18.5% difference in associated fistulae. Failures of the SD group had a higher mean APS (15) than both failures of the PD group (APS = 9.3) and successes of the SD group (APS = 8.6). All three PD group deaths and half of the SD group deaths were related to ongoing sepsis. Surgical drainage of intra-abdominal abscess is as successful as PD. Percutaneous drainage is reasonable initial treatment for intra-abdominal abscess; however, early assessment of clinical status and frequent reassessment are mandatory to ensure that failures are dealth with early. We present a drainage algorithm.     

Impact of bacterial culture positivity of the drainage fluid during the early postoperative period on the development of intra-abdominal abscesses after gastrectomy

Purpose

The aim of this study was to evaluate the impact of positive bacterial cultures of the drainage fluid (D-cultures) during the early postoperative period on the incidence of intra-abdominal abscess formation following gastrectomy.

Methods

From January 2012 to June 2013, we prospectively performed D-cultures on postoperative day (POD) 1 in consecutive gastric cancer patients who underwent gastrectomy. The univariate and multivariate analyses were performed to identify the risk factors for intra-abdominal abscess formation without anastomotic leakage.

Results

The rate of positive D-cultures was 6.4 % on POD 1. According to a univariate analysis, the use of combined organ resection (P = 0.011), the drain amylase level on POD 1 (P = 0.016) and the D-culture status on POD 1 (P = 0.004) were found to be significantly associated with the incidence of intra-abdominal abscesses. A multivariate analysis demonstrated that D-culture positivity on POD 1 was the only independent predictor of intra-abdominal abscess formation (P = 0.011).

Conclusions

The present study demonstrated that bacterial culture positivity of drainage fluid during the early postoperative period has a significant impact on the development of intra-abdominal abscesses after gastrectomy.     

Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis

Purpose  

Nowadays, endoscopic techniques are widely used in surgical procedures. Retroperitoneoscopy has been an extremely valuable tool for a wide variety of urologic disorders, whereas, it has limited use in orthopedic procedures.     

Diagnosis and treatment of intra-abdominal abscesses

Intraabdominal abscesses are life threatening complications of inflammatory processes or major surgery. Ultrasonography, computed tomography and scintigraphy are the diagnostic methods of choice. Diagnostic percutaneous puncture can be followed by therapeutic percutaneous drainage (PD). The diagnosis "intraabdominal abscess", however, is not sufficient for a rational therapeutic strategy. Therapy of intraabdominal abscesses (IAA) depends upon etiology and localization of the process and the individual situation of the patient.     

Diagnosis and treatment of intra-abdominal abscesses

Despite recent advances in the diagnosis and management of intra-abdominal abscesses, these infections still cause substantial morbidity and mortality. Low pH, large bacterial inocula, poor perfusion, the presence of hemoglobin, and large amounts of fibrin (which impedes antibiotic penetration) make the abscess a cloistered environment that is penetrated poorly by many antimicrobial therapies. Therefore, management of these infections requires prompt recognition, early localization, and effective drainage, as well as appropriate antimicrobial use. Although various imaging techniques, such as ultrasonography, gallium scans, and indium-labeled white-blood-cell scans, can be used for the diagnosis and localization of intra-abdominal abscesses, computer-assisted tomography is the most useful study. Once the diagnosis is made and the abscess is localized, treatment should begin promptly. Percutaneous or open surgical drainage should be used. Broad-spectrum antibiotics should be given until culture and sensitivity data are obtained. Once these data are obtained, a therapy with appropriate coverage that is likely to work in the abscess environment should be chosen. Percutaneous drainage is inappropriate for abscesses in the posterior subphrenic space or in the porta hepatis, for those among loops of small bowel, for suspected echinococcal cysts, and for abscesses containing necrotic or neoplastic tissues. Finally, surgeons need to be cognizant of risk factors, such as advanced age, obesity, complex abscesses, and high Acute Physiology and Chronic Health Evaluation (APACHE) II or APACHE III scores, which correlate with poor outcomes for these patients.     

Laparoscopic drainage of postappendectomy- retained fecalith and intra-abdominal abscess in the pediatric population

Retained fecalith after an appendectomy is an uncommon complication frequently associated with intra-abdominal abscess. Treatment options include percutaneous, open, or laparoscopic drainage of the abscess and retrieval of the fecalith, as antibiotics and drainage alone are usually insufficient. Laparoscopy offers the advantages of enhanced visualization of the abdomen, improved cosmesis, and a quicker return to normal daily activities. The principles of laparoscopic treatment include the careful identification of all anatomic landmarks, as the abscesses are frequently adherent to intra-abdominal structures compromising the safety of the operation. In this paper, we present 2 cases of laparoscopic drainage of an intra-abdominal abscess with retrieval of a fecalith in pediatric patients 1 and 6 weeks after an initial appendectomy and a review the literature.     

Prevention of intra-abdominal abscesses with fibrinolytic agents

Fibrin deposition during secondary peritonitis predisposes to abscess formation by protecting bacteria from host-defence mechanisms. To test the hypothesis that local fibrinolytic therapy can prevent the formation of intra-abdominal abscess, daily injections of the fibrinolytic enzymes trypsin and tissue plasminogen activator (t-PA) were administered intraperitoneally to Wistar rats inoculated intraperitoneally with infected fibrin clots. After 5 days, trypsin (1 mg/ml) had significantly (p less than 0.001) reduced abscess formation in animals inoculated with monomicrobial Bacteroides fragilis clots (20% versus 87%) or mixed Escherichia coli-B. fragilis clots (11% versus 91%). Bacteroides fragilis abscesses were also completely prevented with t-PA (0.25 mg/ml). The number of B. fragilis organisms present in residual abscesses in the trypsin-treated group was significantly (p less than 0.05) lower than in the control group (8.2 +/- 0.2, n = 7 versus 5.7 +/- 1.4, n = 4, log CFU/g abscess). In-vitro studies demonstrated that trypsin had no bactericidal effect on B. fragilis, suggesting enhanced clearance of bacteria. From these studies it appears that controlled fibrinolysis at operation may be a useful adjunct to surgery and systemic antibiotics in preventing abscess formation postoperatively.     

An objective appraisal of the role of computed tomographic (CT) guided drainage of intra-abdominal abscesses

Computed tomographic (CT) guided drainage is an important tool in the treatment of intra-abdominal abscess. Its most important role is in the treatment of small, unilocular, well-placed abscesses. Success rates in our experience diminish considerably in abscesses involving necrotic tumors or those infected with yeast. As is frequently characteristic of new technologic procedures, the initial evaluation of the success rate of the procedure is overly optimistic. The procedure carries a considerable complication rate (13%) and mortality rate (15%). Most importantly, success is usually evident early; within the first 24 to 48 hours. After this length of time, careful evaluation to consider further treatment should be contemplated.     

Diagnosis of intra-abdominal abscesses. A review

Intra-abdominal abscess, resulting either from primary intraperitoneal disease or as a complication of surgery, remains a serious problem with high patient mortality if not treated early and adequately. The initial attempt at diagnosis rests on strong clinical evidence supported by nonspecific laboratory findings. The most helpful advance over conventional x-ray studies has been the advent of noninvasive imaging techniques such as ultrasonography or computed tomography. Radioisotopic scanning with gallium or indium makes possible a generalized survey of the peritoneal cavity, but only after a delay from the time of injection. Ultrasonography is somewhat limited in utility, particularly in the left subphrenic space, and CT scanning remains the technique with highest resolution. These noninvasive imaging techniques also have the potential for directed percutaneous catheter drainage.     

Factors influencing the treatment of intra-abdominal abscesses

Forty-eight consecutive patients with 68 intra-abdominal abscesses who had operative or radiologic attempts at drainage were analyzed. Patients who had radiologic drainage were older and had simple abscesses more often. Simple abscesses were treated successfully in a high percentage of patients using both operation and radiologic drainage. Mortality was higher for patients with complex abscesses, and most of these patients required operative treatment. Successful abscess resolution was eventually achieved in 79 percent of patients.     

Percutaneous drainage of abscesses in the postoperative abdomen that is difficult to explore

We have evaluated our experience with computerized tomography and ultrasonography guided percutaneous drainage of extrahepatic abdominal fluid collections in a group of 22 patients. The most common goal was to avoid or delay surgery on abdomens in which reoperation would be difficult, mainly in high-risk patients. Drainage of pancreatic fluid collections or abscesses was also attempted in a small number of the patients. Percutaneous drainage was curative in 69 percent of those with nonpancreatic abscesses but in only 33 percent of those with abscesses associated with the pancreas. There were no complications attributable to the procedure or to delays in subsequent surgical drainage. Two patients died from problems not directly related to the use of percutaneous drainage. Percutaneous catheter drainage of nonpancreatic abdominal abscesses can play a useful role in patients who are carefully selected because they possess a complex abdominal anatomy distorted by previous surgery and infection or they are at high risk if surgical exploration is carried out.     

Diverticulitis,pelvic and other intra-abdominal abscesses

Diverticular disease is a common condition in the Western world and it carries significant morbidity and healthcare cost. Patients with diverticular disease may present acutely or to out-patients, and the management should be stratified using clinical judgement and appropriate investigation including radiology. Intra-abdominal abscess is a common complication of diverticular disease, but it can also be due to any intra-abdominal organ disease. Conservative management is safe but in the “unwell” patient, other options such as: radiological drainage, laparoscopic washout and drainage, and surgical resection can be life-saving. Careful selection of patients using current stratification tools will help with management. All patients with intra-abdominal abscesses require follow-up and possibly further investigations. This article discusses current evidence and controversies underlying today's management of diverticulitis, diverticular abscess and other intra-abdominal abscesses.     

Intestinal bacteria translocate into experimental intra-abdominal abscesses

Experimental intra-abdominal abscesses were initiated by surgical implantation of a fibrin clot contaminated with either Bacteroides fragilis, Bacteroides thetaiotaomicron, or B fragilis-Escherichia coli. Seven days after surgery the numbers of bacteroides (per gram) in B fragilis and B thetaiotaomicron abscesses were typically log10 8.4 +/- 0.5 (n = 6) and log10 6.4 +/- 0.6 (n = 4), respectively; B fragilis-E coli abscesses typically contained log10 8.9 +/- 0.5 B fragilis and log10 7.6 +/- 0.6 E coli (n = 5). Of 38 B fragilis abscesses, 14 B fragilis-E coli abscesses, and nine B thetaiotaomicron abscesses, additional intestinal bacteria were recovered from 21 (55%), 13 (93%), and seven (89%) abscesses, respectively. The additional organisms, in decreasing order of frequency, were enterococci, E coli, staphylococci, alpha-streptococci, lactobacilli, and Proteus species in numbers ranging from 2.5 log10 to 7.9 log10 per gram of abscess. Histologic sections of contaminated abscesses adherent to the intestine, liver, or spleen revealed normal tissue histology and no breakdown of the abscess wall. Thus, intestinal bacteria translocated into intra-abdominal abscesses by a mechanism that did not appear to be surgical soilage.