Fluid collections developing after pancreatic transplantation: radiologic evaluation and intervention

The usefulness of real-time sonography, duplex sonography, computed tomography (CT), cystography, diagnostic aspiration, and percutaneous drainage in the diagnosis and treatment of peri-pancreatic-transplant fluid collections was retrospectively assessed in 46 recipients of extraperitoneal pancreatic transplants. Forty-four abnormalities were identified in the extraperitoneal space at sonography, including four pancreatic pseudocysts associated with malfunction of the pancreatic duct, seven abscesses, six hematomas, nine urinomas, six early postoperative fluid collections that spontaneously resolved, six cases of pancreatitis, and six cases of vascular occlusion. Sonography (including pulsed Doppler sonography) was the procedure of choice in detecting fluid collections and diagnosing pancreatitis, rejection, vascular thrombosis, and pancreatic duct malfunction. CT was diagnostic in four of six hematomas; cystography was diagnostic in seven of nine urinomas. Sonographically guided percutaneous intervention enabled three patients to avoid surgery and allowed optimal surgical planning for six patients.     

Bile duct disruption and biloma after laparoscopic cholecystectomy: imaging evaluation.

Disruption of the biliary tree after laparoscopic cholecystectomy has been reported in 0-7% of cases, and likely represents the most significant postoperative complication. Documenting the presence and extent of a bile leak is often difficult. We reviewed the first 264 laparoscopic cholecystectomies performed at our institution and found seven cases of bile extravasation and/or biloma formation (prevalence, 2.7%). All patients were first seen in the early postoperative period with abdominal pain and low-grade fever. Sonography was performed in five of seven, CT in five of seven, hepatobiliary scintigraphy with diisopropyliminodiacetic acid in five of seven, and ERCP in four of seven cases. While sonography and CT were initially helpful in determining the presence of abdominal fluid collections, they were unable to differentiate between postoperative seroma, lymphocele, hematoma, and bile leak. Hepatobiliary scintigraphy was useful in demonstrating continuity of these fluid collections with the biliary tree and guiding further therapy. Four cases were managed with endoscopic biliary decompression, with the use of sphincterotomy or nasobiliary stent placement, with good clinical result. The other three cases were treated surgically with T-tube or external drainage. All patients did well clinically, without evidence of bile reaccumulation. Our experience suggests that sonography and CT are useful in detecting postoperative fluid collections, but cannot differentiate bile from other fluids. Hepatobiliary scintigraphy is valuable as a noninvasive means of investigating possible bile leaks and in guiding further therapy.     

CT in the management of periappendiceal abscess

Abdominal CT was the primary diagnostic method used to evaluate 40 patients with suspected periappendiceal abscess. Its subsequent impact on patient management was then analyzed for several categories of clinical presentation, including patients with and without a palpable right-lower-quadrant mass and postoperative patients. CT was reliable in distinguishing periappendiceal abscesses from phlegmons; 17 of 18 patients with phlegmons responded promptly to antibiotic therapy alone without need for surgery. Patients with larger, poorly localized abscesses underwent early surgical drainage. CT was successful in guiding percutaneous catheter drainage (nine patients) or aspiration (one patient) of well-localized periappendiceal abscesses in 10 of 11 patients. One attempted catheter drainage guided by sonography was technically unsuccessful. In patients without a palpable right-lower-quadrant mass, CT was helpful in establishing the diagnosis of periappendiceal inflammation. However, there were three false-positive diagnoses in patients with pericecal fluid collections including a ruptured cecal lymphoma, a ruptured cecal diverticulum, and a ruptured corpus luteum cyst. A diagnostic approach with CT is presented in patients with suspected periappendiceal abscess.     

US-guided transvaginal drainage of pelvic abscesses and fluid collections

Ultrasound (US)-guided transvaginal needle or catheter drainage was performed in 14 women for a variety of pelvic abscesses and fluid collections; tubo-ovarian abscesses and postoperative collections were most common. Diagnosis was achieved in all 14 patients (100%), including one patient with suspected ovarian carcinoma who underwent only diagnostic needle aspiration and no therapeutic drainage. Abscesses or fluid collections were evacuated in 13 of 13 patients (100%) with either needle (n = 7) or catheter (n = 6) drainage (with appropriate antibiotics). Twelve of the 14 patients (86%) were spared an operation; surgery was undertaken in two patients for a persistent tubo-ovarian phlegmon. No major complications were associated with drainage. Catheters were removed an average of 6.7 days after insertion. The success, safety, and advantages of US-guided transvaginal drainage in our early experience suggest its use as an alternative to standard percutaneous catheter procedures to diagnose and drain certain pelvic abscesses and fluid collections.     

Transperineal and transvaginal sonography of perianal inflammatory disease

OBJECTIVE: Perianal infection arises in small intersphincteric anal glands predominantly located at the dentate line. Documentation of fluid collections and the relationship of inflammatory tracts to the sphincter mechanism is important for surgical treatment. Transanal sonography for assessment of perianal inflammatory disease is limited because placement of the rigid probe into the anal canal does not allow assessment of disease in the perineal region. The purpose of this study was to validate the use of transperineal sonography in men and both transvaginal and transperineal sonography in women for evaluation of perianal inflammatory disease. SUBJECTS AND METHODS: Fifty-four patients, 28 men and 26 women, were imaged with transperineal and a combination of transperineal and transvaginal sonography, respectively. All patients were examined in the supine lithotomy and left lateral position with a transvaginal 8-to 4-MHz probe or a linear 12- to 7-MHz transducer. All fluid collections, sinus tracts, and fistulas were described by their location in relation to the sphincter mechanism and perineum. RESULTS: Forty-six of 54 patients had perianal fistulas or sinus tracts: 33 transphincteric, seven intersphincteric, and six extrasphincteric. Fifteen patients had an associated abscess. In the eight remaining patients, there were two anovaginal fistulas, one rectovaginal fistula, one prolapsed internal hemorrhoid, two perianal complex masses, and two vascular perianal or perirectal inflammatory masses. Twenty-six patients underwent surgical procedures involving the anorectal canal or perirectal region, and of these, preoperative sonographic findings were confirmed in 22 (85%) of 26 patients. Three patients refused surgery, and six are awaiting surgery at this writing. Fifteen patients were treated conservatively. CONCLUSION: Transperineal and transvaginal sonography are accurate, painless, and cost-effective methods for documenting perianal fluid collections and fistulas or sinus tracts or both.     

The occurrence of fluid collections following routine abdominal surgical procedures: sonographic survey in asymptomatic postoperative patients

To investigate the frequency and appearance of reactive effusions following abdominal surgery, a prospective real-time sonographic survey of 80 asymptomatic postoperative patients was conducted. Serial scans on the 4th, 8th, and 12th postoperative days disclosed localized abdominal fluid collections in 19% (15/80), 6% (5/80), and 2.5% (2/80) of cases, respectively. The only collection that enlarged was an abscess. Knowledge of the natural history of reactive postoperative effusions should help the ultrasonographer to detect pathologic fluid collections and abscesses in postsurgical patients.     

Radiographically guided percutaneous catheter drainage of pleural fluid collections

We reviewed the outcome of guided percutaneous catheter drainage of pleural fluid collections in 18 patients over a 5-year period. Catheter positioning was guided by fluoroscopy in 10 (56%) cases, CT in seven (39%), and sonography in one (6%). Included were 16 patients with empyemas and one each with a sterile hematoma and transudate. In nine of the patients, previous surgical chest tube drainage had been unsuccessful. The majority of collections were treated with a 12- or 14-French catheter and closed underwater seal drainage. Twelve (80%) of the 15 patients who had an adequate trial of guided drainage were cured. Propyliodone oil suspension contrast sinography after catheter placement showed two clinically unsuspected bronchopleural fistulas. Although an extensive multilocular pleural collection was a contraindication to percutaneous catheter drainage, the thick fibrous peel of a chronic empyema was not. Drainage of pleural fluid collections with radiographic guidance ensures proper catheter placement and is successful in a high percentage of cases.     

Acute appendicitis in children: value of sonography in detecting perforation.

OBJECTIVE. We determined the sonographic features of perforating appendicitis in children in order to determine the best criteria for establishing the diagnosis. MATERIALS AND METHODS. Sonograms of the right lower quadrants of 71 children with proved appendicitis were reviewed to determine the value of sonography in distinguishing between nonperforating and perforating appendicitis. The sonographic signs evaluated included the presence or absence of an appendix, an echogenic submucosal layer, increased periappendiceal echogenicity, free or loculated periappendiceal or pelvic fluid collections, and appendicoliths. The sonographic findings were correlated with the surgical and pathologic findings. RESULTS. Forty-five patients had nonperforating appendicitis, and 26 had perforating appendicitis. A sonographically visible appendix was present in all patients with nonperforating appendicitis and in 10 (38%) of 26 patients with perforation. An echogenic submucosa was noted in 27 (60%) of 45 patients with uncomplicated appendicitis but in only three (30%) of 10 patients with a visible appendix and perforating appendicitis (p < .05). In 19 of 26 patients with perforating appendicitis, sonography showed loculated periappendiceal or pelvic fluid collections; no patient with nonperforating appendicitis had a loculated fluid collection (p < .05). No statistically significant association was found between the presence or absence of perforation and free pelvic fluid, prominent periappendiceal fat, or an appendicolith. CONCLUSION. Our results indicate that sonography can be helpful in the diagnosis of perforating appendicitis. The best predictors of perforation are absence of the echogenic submucosal layer and the presence of a loculated fluid collection.     

CT of the abdomen after the Whipple procedure: value in depicting postoperative anatomy, surgical complications, and tumor recurrence

We performed a retrospective study of CT scans in 29 patients who had undergone the Whipple procedure (radical pancreaticoduodenectomy) to study the CT appearance of the postsurgical anatomy and assess the use of CT in the evaluation of early postoperative complications and recurrent tumor. In the postoperative period, the scans from 15 patients revealed seven transient fluid collections; four deep abscesses, three of which were successfully drained under CT guidance; three superficial abscesses; and five cases of ascites. In 19 patients, CT scans were obtained up to 4 years after surgery to search for recurrent tumor. The most frequent site of recurrence was the liver. CT correctly identified liver metastases in six of seven patients and was falsely positive in one. Recurrence also was found twice in retroperitoneal lymph nodes; one time each in the mesenteric root, spleen, and lung base; and twice causing afferent loop blockage. Surgical proof of recurrence was obtained in eight cases. Our experience suggests that an understanding of the normal postoperative anatomy following the Whipple procedure is essential in evaluating postoperative CT scans. Scans obtained for detection of tumor recurrence should be optimized for imaging the liver because this was the most frequent site of recurrence.     

腹盆腔感染性病变的CT及US影像分析

目的探讨腹盆腔化脓性感染与囊肿的CT和US影像特征及其鉴别方法。材料与方法分析25例，男12例，女13例，年龄21～80岁，腹盆腔感染性病变CT和US资料。胰周脓肿5例；阑尾及盆腔脓肿各4例；膈下脓肿3例，前列腺脓肿2例及其他脓肿7例。结果CT征象中包膜不规则增厚、包膜增强及外缘毛糙等对鉴别脓肿和囊肿有意义。US对77.2％病例可明确诊断感染性积液。CT和US对腹盆腔脓肿的检出率分别为100.0％、92.5％。CT的特异性为88.9％。结论CT对定性诊断有很高灵敏度和特异性。US声像图征象结合临床表现有诊断意义。     

Percutaneous evacuation of abdominal abscesses and fluid collections--aspiration or catheter drainage?

Ninety-three abdominal abscesses and fluid collections (pseudocysts, hematomas and bilomas) in 79 patients were treated under radiological guidance, for a total of 111 procedures (23 needle aspirations (NA) of 17 foci and 88 catheter drainages (CD) of 84 foci). In eight foci both methods were used. Catheter drainage was curative in 65% of abscesses and in 56% of pseudocysts and improved the patients' condition before surgery in another 11% or 10%, respectively. The aim of CD could not be achieved in 24% of the abscesses and in 34% of the pseudocysts. Needle aspiration showed little effect being curative in only 6% and partially beneficial in 24% as all the foci were considered. Complications occurred in 8% of CD:s and in 0% of NA:s. We suggest that radiologically guided CD of abscesses and fluid collections should be the primary therapeutic approach in all cases where this can be performed safely. The therapeutic effect of NA was poor.     

Sonography of thigh abscess: detection, diagnosis, and drainage

Sonographic characteristics and percutaneous catheter drainage of thigh abscesses in 18 patients are described. Most of these patients had underlying diseases including osteomyelitis, trauma, diabetes mellitus, rheumatoid arthritis, leukemia, lymphoma, sepsis, bleeding dyscrasia, and autoimmune disease. Previous procedures on these thigh collections included seven operations and 12 nondiagnostic ward aspirations. All collections were shown by sonography to be either anterior or anterolateral. Two cases referred for drainage were posteromedial; sonography showed these to be mycotic pseudoaneurysms. The abscesses were either anechoic or hypoechoic, and occasionally had debris and septations. Abscesses associated with underlying osteomyelitis abutted the femur; those related to other causes generally were more superficial within muscle or fascial layers. Sonographically guided catheter drainage successfully cured all patients, even those in whom ward aspiration or formal surgery had been unsuccessful. Sonography is a simple and inexpensive method of imaging and guiding the drainage of thigh abscesses. Percutaneous catheter drainage is the treatment of choice in cases in which simple emergency room or ward incision and drainage are inadequate.     

Interventional computed tomography

Due to the development and refinement of computed tomography (CT), sonography, and interventional techniques, the field of interventional radiology has seen tremendous growth in recent years. In particular, the precise anatomic detail provided by CT and sonography has allowed percutaneous biopsies and abscess drainages to be performed safely and effectively. Percutaneous biopsies are now becoming the most common interventional radiographic procedures in many institutions. The usual indications for a biopsy are to determine the etiology of a mass, neoplasm, or inflammation, and to determine whether masses in known oncologic patients represent scarring or residual viable tumor. Accuracy rates for most percutaneous CT-directed biopsies are well over 90%, and the complication rate is very low. CT-directed percutaneous abscess drainages are also safe and effective and, in most cases, will be preferable to surgical drainage. The initial indications for percutaneous drainage (single, unilocular fluid collections) have been greatly expanded to include multiloculated collections, interloop abscesses, periappendiceal abscesses, and even percutaneous cholecystotomies. Biopsy and drainage procedures, together with their accuracy rates, indications and complications, are reviewed in this monograph.     

Efficacy of percutaneous abscess drainage in patients with vancomycin-resistant enterococci

OBJECTIVE: We reviewed a 4-year experience draining fluid collections infected with vancomycin-resistant enterococci to determine the outcome of percutaneous intervention in patients with this highly resistant and increasingly common organism. MATERIALS AND METHODS: Charts of patients from whom vancomycin-resistant enterococci had been isolated during percutaneous drainage were reviewed to determine patient response to drainage, catheter management, and outcome of treatment. RESULTS: Twenty-one patients underwent percutaneous drainage of 28 fluid collections from which vancomycin-resistant enterococci were isolated, including 16 intraabdominal abscesses, seven biliary or urinary obstructions, and five empyemas. The drainage of 27 (96%) of 28 collections were technically successful. In seven patients, drainage provided the first isolation of vancomycin-resistant enterococci from the patient. Five patients also had blood cultures with positive findings for vancomycin-resistant enterococci, and 14 collections were coinfected with other bacteria or with fungi. Twenty collections (71%) or obstructions were successfully treated with percutaneous drainage. Drainage was unsuccessful in treating eight collections in seven patients. CONCLUSION: Despite high-level antibiotic resistance, fluid collections infected with vancomycin-resistant enterococci can be successfully drained percutaneously, resulting in a favorable likelihood of recovery for patients.     

Bacterial meningitis in infants: sonographic findings

A retrospective study was performed on 78 patients (newborn to 2 years old) with clinically proved bacterial meningitis. Sonograms were obtained during the acute illness and medical records were reviewed. The spectrum of sonographic features of meningitis included normal scans (30 patients), ventriculomegaly (11 patients), echogenic sulci (31 patients), extra-axial fluid collections (26 patients), abnormal parenchymal echogenicity (9 patients), evidence of ventriculitis (5 patients), and brain abscess (1 patient). In 46 patients, correlation between the sonographic findings and neurologic outcome on clinical follow-up (6 months to 4 years) was made. Findings of abnormal parenchymal echogenicity and/or moderate-to-marked ventriculomegaly were associated with significant neurologic sequelae; however, echogenic sulci and small extra-axial fluid collections did not appear to have any prognostic significance. Twenty-nine of the 78 patients had sonography without clinical indication of complications of meningitis, and in no patient was a significant abnormality found. Our study suggests that sonography is indicated only when there is clinical suspicion of complications.     

Adnexal and cul-de-sac abnormalities: transvaginal sonography

Sixty-seven patients selectively chosen from 354 undergoing conventional transabdominal (TA) sonography for evaluation of a clinically suspected adnexal mass subsequently underwent transvaginal (TV) sonography either because the TA sonograms were technically suboptimal or because it was not possible to characterize with certainty an abnormality identified with TA sonography. TV sonography added diagnostically useful information in 25 of 28 patients with cystic pathologic changes in the adnexa uteri. Eight of 12 patients with tuboovarian abscess and nonspecific adnexal masses visualized with TA sonography had tube-shaped fluid collections characteristic of pyosalpinx identified with TV sonography. TV sonography added diagnostically useful information in all seven patients with diseases of the cul-de-sac (rectouterine fossa) and allowed differentiation of adnexal from primary uterine disease in three patients with TA sonograms on which findings were equivocal. It also expedited the diagnosis of a tubal pregnancy in ten of 14 patients and was useful in the detection of adhesions and perforated intrauterine devices. These results indicate that adjunctive TV sonography can provide important diagnostic information.     

Osteomyelitis: detection with US. Work in progress

Ten patients with clinically suspected osteomyelitis were studied with ultrasound (US). Five patients had abnormalities detectable on sonograms. An abnormal fluid collection was demonstrated adjacent to the bone in three of these five. US-guided aspiration of the fluid in two of the three patients revealed purulent or infected fluid that was thought to represent an inflammatory exudate dissecting in a subperiosteal or extraperiosteal location. Findings from subsequent radiographic and scintigraphic studies confirmed the diagnosis of osteomyelitis in these three patients. The other two patients with abnormal sonographic results had collections of fluid that were separated from the bone by a variable amount of soft tissue. These collections were confined to the soft tissue and did not appear to arise from the bone. Aspiration revealed a soft-tissue abscess in one patient and a seroma in the second. Findings in this preliminary study suggest that fluid around the bone seen on sonograms may indicate acute osteomyelitis.     

Percutaneous drainage of abdominal fluid collections in children

Percutaneous drainage of intraabdominal fluid collections was performed in 13 children. After initial diagnosis with either sonography or computed tomography, a smallbore aspiration needle (22 gauge) was guided into the collection, usually by sonography. In five patients, complete evacuation was possible using the aspirating needle alone. In seven others, the fluid was successfully drained via a catheter introduced percutaneously. In one patient, surgery was required for complete evacuation of a hematoma containing large blood clots. There were no complications.     

Percutaneous drainage of complicated abscesses and fluid collections

The original concept of percutaneous, radiological abscess drainage was confined to well circumscribed, solitary abscesses, that could be reached by a short access avoiding transgression of uninvolved organs or compartments. With increasing experience criteria for percutaneous abscess drainage have been expanded to radiological treatment of pancreatic, periappendiceal, diverticular, interloop and mediastinal abscesses and fluid collections. The authors present their experience with percutaneous treatment of such "complicated" abscesses in 140 patients.     

US-guided catheter drainage of postoperative head and neck fluid collections

PURPOSE: To analyze results of percutaneous catheter drainage of large fluid collections in the head and neck region noted in the immediate postoperative period. MATERIALS AND METHODS: Thirty-four consecutive patients with 41 large fluid collections in the head and neck detected 7-10 days after oncologic surgery underwent percutaneous catheter drainage. There were 29 men and five women, with a mean age of 52.2 years (95% CI: 47.8-56.7). Each patient had a surgical drain placed in the posterior neck triangle; three patients had low-grade fever and six had diabetes at the time of percutaneous catheter drainage. Conventional management consisting of serial needle aspirations at bedside followed by pressure dressing failed in 15 of 34 patients (44%). Ultrasound-guided drainage was performed and catheters were connected to vacuum balls for continuous suction drainage. RESULTS: The average fluid volume estimated by sonographic measurement was 84 cm(3) (95% CI: 57-112 cm(3)). The fluid content was serosanguinous in 46% (19 of 41), uncoagulated blood in 32% (13 of 41), pus in 15% (six of 41), and saliva in 7% (three of 41). The mean duration of catheter drainage was nine days (95% CI: 7-10 d) and mean fluid drainage was 287 mL (95% CI: 188-387 mL). Ninety-one percent of patients (31 of 34) were successfully treated with initial catheter drainage. Three patients had recurrent fluid collections at the same locations: two were treated with repeated catheter insertions and one required a limited open drainage. No complication related to catheter drainage was noted at 6-month follow-up. CONCLUSION: Percutaneous catheter drainage is effective for large fluid collections in the head and neck region noted in the immediate postoperative period irrespective of contents.