Psoas Abscess Complicating Crohn''s Disease

Psoas abscess classically was described as secondary to tubercular spondylitis but now more frequently is a complication of an intraabdominal process such as Crohn's disease. Less well recognized is that the fever, flexion contracture of the hip, and weight loss characterizing psoas abscess may be the first indications of Crohn's disease; in fact, gastrointestinal symptoms may be completely absent. Psoas abscess was the first sign of Crohn's disease in 11 of 46 reported patients. We present three additional patients; two were asymptomatic before psoas abscess formation. Only seven of 26 patients whose sole surgical procedure was drainage had subsequent resolution of the abscess. When drainage was combined with bowel resection, 14 of 18 patients (77.8%) were cured by the initial procedure. Thromboembolic complications occurred in four patients (8.3%). Effective therapy when psoas abscess complicates Crohn's disease, includes appropriate antibiotics, drainage, resection of fistulous intestine, and antithrombotic prophylaxis.     

Percutaneous drainage of intra-abdominal abscesses guided by real-time ultrasonography

From October 1982 to October 1984, a percutaneous drainage under realtime ultrasound guidance was performed in 53 patients with abdominal abscesses. The location of the abscesses was subphrenic (23), retroperitoneal (16), and intrahepatic (14). A safe access route was found by using ultrasound and fluoroscopy in 53 out of 55 patients (96 p. 100). Percutaneous drainage failed in 8 patients and 3 of these patients died. The causes of death were: cerebral abscess (1), renal failure after surgery for correction of a duodenal fistula (1), and pancreatic abscess (1). The other five patients were cured by surgical drainage. Two complications were observed: one case each of pneumothorax and purulent peritonitis. Forty-five patients were healed by percutaneous drainage without operation. The duration of the catheter drainage was 14 days +/- 13 (m +/- 1 SD). Our results suggest that percutaneous drainage under realtime ultrasound guidance is an efficient and safe way to treat abdominal abscesses.     

The role of percutaneous transhepatic abscess drainage for liver abscess

To evaluate the efficacy of percutaneous transhepatic abscess drainage (PTAD) as an initial choice of treatment for liver abscess, the medical records of 28 patients with liver abscess were retrospectively analyzed. The patients were predominantly men (23 of 28) with a mean age of 59 years (range, 19—86 years). Their chief complaints were fever (86%), right hypochondralgia (32%), and jaundice (11%). Fifteen of the 28 patients (54%) had hepatobiliary and pancreatic carcinoma, and 31% had postoperative liver abscess. PTAD was performed in 23 patients and surgical drainage in 5. The overall success rate for PTAD was 83%. The success rate for PTAD for patients with multiple abscesses was 83% (5 of 6), compared with a success rate of 82% (14 of 17) for patients with solitary abscess. The prognostic factors for survival were cancer and sepsis and the mortality rate for patients with cancer was 40% (6 of 15) while the mortality rate for patients with sepsis was 56% (5 of 9). As a complication of drainage, 1 patient (4%) in the PTAD group had pleural abscess due to the transpleural puncture. Our findings support the use of PTAD as the primary treatment for liver abscess, as it is safe and effective irrespective of the number of abscesses and the patient's condition.     

Role of Gallium-67 scintigraphy in the evaluation of occult sepsis in the medical ICU

Patients in intensive care units (ICUs) frequently have multiple infections or persistent fever despite management. The aim of this study was to evaluate the diagnostic contribution of gallium-67 scintigraphy in ICU patients with suspected occult sepsis. One hundred and seventeen patients (>18 years) who had undergone gallium-67 scintigraphy in the ICU of our medical center over a 3-year period were retrospectively reviewed and analyzed. Patients were categorized into Group 1 (n = 84), those with a known infectious source, but who still had persistent fever or sepsis despite antibiotic treatment or abscess drainage; or Group 2 (n = 33), those without an evident infectious source after clinical, physical, and imaging studies. Among the 117 patients, 19 (16.2%) had a new diagnosis. In Group 1, 12 patients (14%) had a new infection, including pneumonia (4 patients), bed sore infection (2 patients), pulmonary tuberculosis (2 patients), leg cellulitis (1 patient), psoas muscle abscess (1 patient), osteomyelitis (1 patient), and infective endocarditis (1 patient). In Group 2, seven patients (21.2%) had a new infectious source, including septic arthritis (3 patients), osteomyelitis (2 patients), neck abscess (1 patient), and cholecystitis (1 patient). Significant differences were not observed between patients with positive and negative findings on gallium-67 scintigraphy in characteristics, underlying diseases, laboratory data, and outcomes. Gallium-67 scintigraphy helped to detect new or additional infectious sites, particularly bone, joint, and soft tissues. However, differences in hospital stay and mortality were not observed between patients with positive and negative findings.     

Endoscopic biliary drainage in patients with amebic liver abscess and biliary communication.

BACKGROUND: Percutaneous drainage or surgery is required when amebic liver abscess (ALA) fails to respond to medical management. In some of these patients, non-response may be due to communication of ALA with the biliary tree. This report describes our experience with the use of endoscopic biliary draining in such patients. METHODS: Medical records of patients with ALA undergoing either needle aspiration or percutaneous pigtail drainage were retrieved; the indications for drainage were: abscess volume exceeding 250 mL, a thin rim of tissue (< 1 cm thick) around the abscess, systemic toxic features and failure to improve on medical treatment. Patients with abscess drain output >25 mL/day persisting for 2 weeks or presence of bile in the drain fluid underwent endoscopic biliary drainage. RESULTS: A total of 115 patients with ALA underwent percutaneous treatment. None of the 25 patients with needle aspiration needed any further treatment. Of the 90 who underwent catheter drainage, the catheter could be removed within one week in 77 patients; the remaining 13 patients (median age 42 years, range 24-65; all men) had an abscess-biliary communication. In them, the median catheter output was 88 mL/day (range 45-347) and 54 mL/day (28-177) at 2 days and 2 weeks after catheter placement. The drain fluid contained bile in all 13 patients and in addition contained pus in 10 patients. Eleven patients had a solitary abscess and two had multiple abscesses. Cholangiogram showed biliary communication in all 13 patients. All patients were treated with placement of 10F biliary endoprosthesis or 10F nasobiliary drain. Pigtail catheter was removed within 1 week in 11 of 13 patients. CONCLUSION: In patients with amebic liver abscess communicating with the biliary tree, biliary stenting may hasten clinical recovery and allow early removal of liver abscess catheter drain.     

Perianal Abscess and Fistula-In-Ano in Infants: A Different Entity?

PURPOSE The features of perianal abscess and fistula-in-ano in infants are different from those of older children, and there is controversy regarding their treatment. The aim of this study was to assess the efficacy of various methods used for their management.METHODS A retrospective analysis of the records was conducted for all infants younger than 24 months of age treated for perianal abscess, fistula-in-ano, or both from 1990 to 2002.RESULTS The study included 98 infants. Perianal abscess was found in 77 patients (75 males), and fistula-in-ano in 21. No infant had an underlying illness. Drainage was performed by needle aspiration in 47 patients and by incision and drainage in 5. Following drainage, 43 patients received antibiotics. Altogether, 6 infants were treated with antibiotics alone and 19 with local care alone. Twenty-eight boys (36.4 percent) had an evolution toward fistula-in-ano. Patients who received antibiotics following drainage were less likely to develop fistula-in-ano than were patients who underwent a drainage procedure alone (27.9 percent vs. 66.7 percent, P < 0.05). All patients with fistula-in-ano were male and had been previously treated for perianal abscess (21 patients elsewhere and 28 in our department). Spontaneous cure of fistula-in-ano occurred in 42.9 percent of them (average 3.2 months), and 57.1 percent underwent fistulectomy for persistent fistula-in-ano. Cryptotomy was added when an involved crypt was found (11 patients, 39.3 percent). No recurrence of fistula-in-ano was noted after fistulectomy.CONCLUSIONS Local treatment for perianal abscess during the early stage and drainage by needle aspiration during the progressive stage are effective. Antibiotics may be considered for patients undergoing drainage of perianal abscess. Fistula-in-ano can be managed conservatively for one to three months. For a persisting fistula, fistulectomy with cryptotomy (when abnormal anal crypts are found) is the preferred treatment.Reprints are not available.     

Cholangiocarcinoma Presenting as Pyogenic Liver Abscess: Is Its Outcome Influenced by Concomitant Hepatolithiasis?

Objective : The etiology of pyogenic liver abscess is changing. Malignant biliary obstruction has emerged as one of the most important causes. We explored the clinical course of pyogenic liver abscess caused by cholangiocarcinoma. Methods : The medical records of 19 patients with cholangiocarcinoma presenting as pyogenic liver abscess were reviewed. Of them, 57.8% (11 of 19) had concomitant hepatolithiasis. Escherichia coli and Klebsiella pneumoniae were the most common pathogens isolated from aspirates of the abscesses. Eight patients received percutaneous drainage, whereas 11 patients initially underwent surgical drainage because of the presence of ascites or coagulopathy or lack of awareness of the underlying cholangiocarcinoma. Results : Overall, the hospital mortality rate was 36.8% (seven of 19). Patients with hepatolithiasis had a hospital mortality rate of 54.5% (six of 11), compared with 12.5% (one of eight) in those without (   p < 0.01  ). Notably, 84.2% (16 of 19) of the patients died within 6 months after the diagnosis was made. Conclusions : Cholangiocarcinoma presenting as liver abscess has a dismal prognosis. Concomitant hepatolithiasis worsened the infectious process and adversely affected the survival.     

Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery

Intra-abdominal abscesses are a frequent source of morbidity and mortality following both elective and emergent surgery of the alimentary tract. CT-guided percutaneous drainage of intra-abdominal abscess is an alternative to immediate surgical intervention. We studied the clinical characteristics and outcomes of patients undergoing percutaneous drainage of intra-abdominal abscesses arising after elective colorectal procedures. We retrospectively identified 40 patients with postoperative intraabdominal abscess following elective colorectal surgery who underwent CT-guided percutaneous drainage with a Von Sonnenberg sump drain between 1990 and 1998. The most common presenting symptoms were pyrexia in 39 (97%), abdominal tenderness in 32 (80%), guarding in 1 (2.5%) and abdominal mass in 3 (7.5%); no patient had generalized peritonitis. The most common index procedure was proctocolectomy with ileoanal anastomosis and ileal Jpouch in 12 (30%) patients. Drainage was performed using an anterior approach in 32 (80%) and a transgluteal window in 8 (20%) patients. Thirty-five (87.5%) patients had a single collection, while 2 (5.0%) patients had 2 collections and 3 (7.5%) patients had 3 collections. Thirteen (32.5%) patients had perioperative steroids, 30 (75%) had preoperative antibiotics, and 40 (100%) had postoperative antibiotics. Follow-up at a mean of 35.8 days revealed complete resolution of abscess in 26 (65%) patients; 14 (35%) patients had residual or recurrent abscess successfully treated by repeat drainage in 8 patients and requiring laparotomy in 6. Percutaneous CT-guided abscess drainage is an effective method for treating intra-abdominal abscess following elective colorectal surgery. The primary success was 65% after the first and 85% after a second drainage. In conclusion, this technique should be considered as the treatment of choice in patients with localized intra-abdominal abscess without signs of generalized peritonitis. Received: 20 July 2002 / Accepted: 4 November 2002     

Early treatment of avascular necrosis in systemic lupus erythematosus.

Avascular necrosis (AVN) of the hips is associated with significant disability, and the majority of established cases require major surgery. In a retrospective analysis of 185 patients with systemic lupus erythematosus (SLE) 13 (7%) were found to have AVN. Of these, six had Raynaud's phenomenon, all had been on corticosteroids, and one had digital vasculitis. The mean duration of corticosteroid therapy was two years (range four months to five years). Five patients developed AVN two to 10 years after discontinuing steroids. The mean duration of disease at the onset of AVN was 6.85 years (range 1-19 years), and the mean age at onset of AVN was 31 years. Ten patients had severe multisystem involvement. None of the patients abused alcohol. Surgery was performed on 11 hips. Three had total hip replacement for stages 3 and 4 and seven had core decompression for stages 1 and 2. AVN progressed in two (28%) of these patients. In another patient core decompression failed for technical reasons. She subsequently required total hip replacement. The early detection of AVN to avoid the need for major surgery is stressed.     

Role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy

AIM： To evaluate the role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy.
METHODS： The medical records of thirteen patients with pyogenic liver abscess who underwent surgical treatment between January 1995 and December 2002 were retrospectively reviewed to determine the clinical presentation, indication and nature of surgery, and outcome of surgery.
RESULTS： The patients were predominantly women （10/13） with a mean age of 65 ± 17 years. Their main presenting symptoms were abdominal pain （100%） and fever （77%）. The aetiologies included biliary （n = 6）, cryptogenic （n = 3）, portal （n = 2）, and trauma （n = 2）. Seven patients underwent percutaneous drainage as the initial treatment. Of these, three patients developed peritonitis secondary to peritoneal spillage. Another four patients failed to respond because of multiloculation. Salvage surgery was required in these patients. Six patients proceeded to straight laparotomy： two had marked sepsis and multiloculated abscess that precluded percutaneous drainage, and four presented with peritonitis of uncertain pathology. Surgical procedures included deroofment and drainage （n = 9）, liver resection （n = 3）, peritoneal lavage （n = 2）, cholecystectomy （n = 4）, and exploration of common bile duct （n = 2）. One patient required reoperation because of bleeding. Three patients required further percutaneous drainage after surgery. The overall mortality was 46%. Four patients died of multiorgan failure and two patients died of pulmonary embolism.
CONCLUSION： Surgical treatment of pyogenic liver abscess is occasionally needed when percutaneous drainage has failed due to various reasons. Mortality rate in this group of patients has remained high.     

Factors Affecting the Successful Management of Intra-Abdominal Abscesses With Antibiotics and the Need for Percutaneous Drainage

Purpose There is no definite consensus on the management of intra-abdominal abscesses in adults. This retrospective study evaluated the use of antibiotic therapy and percutaneous image-guided drainage in adult patients with intra-abdominal abscesses. Methods A retrospective chart review of 114 patients with intra-abdominal abscesses was conducted. Data collected included patient demographics, presenting symptoms, radiographic interpretation, vital signs, antibiotic coverage, laboratory values, and details of the hospital course. Bivariate statistical tests were performed using the Wilcoxon rank-sum test, chi-squared test, or Fisher's exact test, where appropriate. Results Sixty-seven of 114 patients (59 percent) had intra-abdominal abscesses resulting from appendicitis, diverticulitis in 30 patients (26 percent), postoperative in 13 patients (11 percent), and undetermined in 4 patients (4 percent). Three patients (3 percent; 95 percent confidence interval, 1–8 percent) failed conservative management and underwent urgent operation. Sixty-one (54 percent; 95 percent confidence interval, 44–63 percent) patients improved with intravenous antibiotic therapy alone. Fifty patients (44 percent; 95 percent confidence interval, 35–54 percent) underwent image-guided percutaneous drainage after 48 to 72 hours of antibiotic therapy. Patients who improved on antibiotics alone had average abscess diameter of 4 cm, whereas patients who underwent percutaneous drainage had average diameter of 6.5 cm (P < 0.0001). Maximal temperature at time of admission was 100.8°F for antibiotic group and 101.2°F for percutaneous drainage group (P = 0.0067). Conclusions The majority of the patients with intra-abdominal abscesses improved with antibiotic therapy alone. Those patients with an abscess diameter >6.5 cm and temperature at admission >101.2°F have higher likelihood of failing conservative therapy with antibiotics alone and requiring percutaneous drainage. Presented at meeting of The International Society of University Colon and Rectal Surgeons, Budapest, Hungary, June 6 to 10, 2004.     

Twenty-year review of the surgical management of perianal Crohn's disease

PURPOSE: A retrospective analysis of 48 patients treated over a 20-year period (March 1973–April 1993) was undertaken to assess the results of our practice of early surgical intervention in suppurative complications of perianal Crohn's disease. METHODS: All patients were either seen in the office within the last six months or contacted by phone. RESULTS: The average age of our patients was 30 years at initial diagnosis. Thirty-four patients (71 percent) initially presented with intestinal disease and four (8 percent) with only perianal disease. Thirteen patients (27 percent) initially presented with simultaneous intestinal and perianal disease. The various fistulas at initial presentation included 8 intersphincteric (17 percent), 14 transphincteric (29 percent), 11 complex or multiple (23 percent), 5 rectovaginal (10 percent), and 2 unclassified, for a total of 40 patients. Eight patients (17 percent) presented with only an abscess. Eighty five percent of our patients healed after their first procedure, with an average time to heal of 2.8 months. Thirteen (27 percent) patients had recurrences after initial healing of their wounds. The mean time to recurrence after healing was 5.25 years. Fifty-four percent of our recurrences (7 patients) were treated by incision and drainage of an abscess only. Seven of 13 recurrences healed after the second procedure (54 percent), and 5 of 6 healed after a third procedure (83 percent). Only seven (14 percent) of our patients underwent a proctocolectomy during the study period, through September, 1993. Our overall probability of avoiding proctectomy and healing perineal wounds of 86 percent is consistent with published literature. CONCLUSIONS: Early aggressive surgical management of suppurative complications of perianal Crohn's disease before complex management problems ensue results in a high incidence of healing and a low risk of subsequent proctectomy.     

Perinephric abscess. Modern diagnosis and treatment in 47 cases

The records of 47 patients with a perinephric abscess diagnosed from 1975 to 1986 at 8 San Francisco Bay Area hospitals were reviewed. The mean age was 51 years. Fifty-five percent were females and 45%, males. The left kidney was affected in 47% of cases, the right kidney in 40%, both in 4%, and a transplanted pelvic kidney in 9%. Fever (55%), chills or diaphoresis (47%), flank pain (40%), abdominal pain (40%), and nausea or vomiting (32%) were the most common presenting symptoms. About half the patients had symptoms for 1 week or less and 12% had no symptoms. Fever was documented before diagnosis in 88% of patients. Abdominal mass (13%) or tenderness (49%), and flank mass (9%) or tenderness (42%) were seen less frequently, and 11% of patients did not have fever, flank, or abdominal findings. The most frequent underlying conditions included previous urologic surgery (45%), previous urinary tract infection (38%), diabetes mellitus (36%), and urinary tract stones (36%). Cultures of perinephric abscesses yielded gram-negative aerobes in 52% of patients, primarily Escherichia coli. Staphylococcus aureus was isolated in 26% of patients and anaerobes in 17%. A single pathogen was isolated in 71% and multiple isolates in 29%. Of interest and great potential therapeutic importance was culture of anaerobes, primarily Bacteroides spp. in 17%, Enterococcus spp. in 7%, and Candida albicans in 7%. Positive blood and urine cultures identified perinephric abscess organisms exactly in 58% and 37% of cases, respectively. Routine laboratory tests such as the white blood cell count and urinalysis were insensitive and non-specific for perinephric abscess. Leukocytosis and anemia at admission were seen in slightly more than half of the patients. For radiologic diagnosis, computerized tomographic scanning was most helpful. Ultrasound and intravenous pyelography were falsely negative in about one-third of cases. Mortality (13%) was low in this series when compared with earlier studies, and probably reflects modern medical care. Six patients (13%) died during hospitalization, 2 of whom had diagnosis of PNA established only at autopsy. Drainage of the perinephric abscess was carried out by open surgical drainage in 64% of patients, percutaneous drainage in 19%, and both in 13%. The initial procedure, whether open surgical drainage or percutaneous catheter drainage, was usually successful. Late complications included nephrocutaneous fistulas in 3 patients and disseminated candidiasis in 1 patient.     

Percutaneous CT Scan-Guided Drainage vs. Antibiotherapy Alone for Hinchey II Diverticulitis: A Case-Control Study

Purpose CT-scan–guided percutaneous abscess drainage of Hinchey Stage II diverticulitis is considered the best initial approach to treat conservatively the abscess and to subsequently perform an elective sigmoidectomy. However, drainage is not always technically feasible, may expose the patient to additional morbidity, and has not been critically evaluated in this indication. This study was undertaken to compare the results of percutaneous drainage vs. antibiotic therapy alone in patients with Hinchey II diverticulitis. Methods This was a case-control study of all patients who presented in our institution with Hinchey Stage II diverticulitis between 1993 and 2005. Thirty-four patients underwent abscess drainage under CT-scan guidance (Group 1), and 32 patients were treated with antibiotic therapy alone (Group 2), in most cases because CT-scan-guided abscess drainage was considered technically unfeasible by the interventional radiology team. Initial conservative treatment was considered a failure when: 1) emergency surgery had to be performed, 2) signs of worsening sepsis developed, and 3) abscess recurred within four weeks of drainage. Results The median size of abscess was 6 (range, 3–18) cm in Group 1 and 4 (range, 3–10) cm in Group 2 (P = 0.002). Median duration of drainage was 8 (range, 1–18) days. Conservative treatment failed in 11 patients (33 percent) of Group 1, and in 6 patients (19 percent) of Group 2 (P = 0.26). Ten patients (29 percent) in Group 1 and five patients (16 percent) in Group 2 underwent emergency surgery (P = 0.24); there were four postoperative deaths (26.6 percent) in this subgroup. Twelve patients (35 percent) in Group 1 and 16 patients (50 percent) in Group 2 subsequently underwent an elective sigmoid resection (P = 0.31). In this subgroup of patients, there was neither anastomotic leakage nor postoperative death. Conclusions Emergency surgery for Hinchey Stage II diverticulitis carries a high mortality rate and should be avoided. To achieve this, antibiotic therapy alone seems to be a safe alternative, whenever percutaneous drainage is technically difficult or hazardous. Actually, our data did not demonstrate any benefit of CT scan-guided percutaneous abscess drainage, suggesting that the role of interventional radiology techniques in this indication deserves further critical evaluation. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006. Reprints are not available.     

A clinical study of liver abscesses at the Critical Care and Emergency Center of Iwate Medical University]

We studied 13 emergency cases of liver abscess. Five cases of septic shock or clouding of consciousness were identified on admission. Six patients had diabetes mellitus. Twelve patients met the diagnostic criteria for systemic inflammatory response syndrome, and nine met the criteria for disseminated intravascular coagulation. Plasma endotoxin levels improved rapidly after drainage. Causative organisms were isolated in all patients, and the most common organism was Klebsiella pneumoniae (seven cases). Percutaneous transhepatic abscess drainage (PTAD) was performed not only in single cases but also in multiple cases with main huge abscesses. Surgical treatment was performed in the following three cases: a ruptured abscess, an ineffective PTAD, and a case of peritonitis after PTAD. Irrigation of abscesses with strong acidic electrolyzed water revealed a significant decrease in treatment duration. In the majority of our cases, severe conditions were identified on admission. Strong acidic electrolyzed water was useful for management of PTAD.     

Flexible fiberoptic bronchoscopy in children on extracorporeal membrane oxygenation

Bleeding is one of the most feared complications of veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO), and is also a potential complication of flexible fiberoptic bronchoscopy (FFB). We retrospectively reviewed 14 patients who underwent FFB procedures with bronchial washings (BW) and bronchoalveolar lavage (BAL) to evaluate the safety of this procedure in children on ECMO. Standard FFB with BAUBW technique was used after stabilization on ECMO. Three patients underwent two procedures each, and one patient underwent three, for a total of 19 procedures. No significant complications, such as bleeding have occurred. Three patients required additional ECMO support shortly after FFB. After the 16 procedures done for atelectasis, seven patients improved radiographically, three had increased opacifications, and six were unchanged. The remaining three patients had suspected pulmonary infections, and in each, therapeutic decisions were guided by the BAL results. Lung compliance was unchanged or improved after 11 of 13 procedures. We conclude that FFB with BAUBW in children on ECMO is safe and may benefit certain patients. Pediatr Pulmonol. 1993; 16:215–218. © 1993 Wiley-Liss, Inc.     

Incidence,outcome, and proposed management of isolated abscesses complicating acute left-sided colonic diverticulitis

In a prospective evaluation of 140 consecutive patients with acute left-sided colonic diverticulitis demonstrated by computerized tomography (CT) in all cases, 22 (16 percent) were found to have an associated abscess without peritonitis. Thirteen of these 22 required surgery (seven during the first stay and six from 2 to 11 months after the acute episode; median, three months). Nine patients were treated conservatively, eight of whom are now totally asymptomatic 24 months after the initial attack (range, 10-47 months). There were 10 mesocolic abscesses (seven treated with antibiotics alone), nine pelvic abscesses (seven requiring surgery), and three intra-abdominal abscesses, all operated upon. These results suggest that mesocolic abscesses can usually be managed conservatively without drainage; should surgery be necessary, en bloc resection with immediate anastomosis can usually be safely performed. Pelvic and intraabdominal abscesses behave more aggressively and usually require a two-stage surgical procedure when initial percutaneous drainage cannot be performed or is felt to be hazardous.     

Definitive treatment of pancreatic abscess by endoscopic transmural drainage

BACKGROUND: Experience with endoscopic transmural drainage of pancreatic pseudocysts prompted the use of a similar technique for the primary treatment of pancreatic abscess. The aim of this study was to assess the feasibility, safety, and effectiveness of endoscopic transmural drainage for the treatment of pancreatic abscesses compressing the gut lumen. METHODS: In 9 patients, a total of 11 pancreatic abscesses compressing the stomach, duodenum, or both organs were drained endoscopically by means of endoscopic fistulization followed by saline solution irrigation and subsequent stent(s) placement. Complete resolution of the pancreatic abscess was defined as the absence of symptoms and no residual collection on follow-up CT. OBSERVATIONS: Endoscopic transmural drainage was technically successful in all cases. Ten abscess cavities (91%) resolved completely after stent placement for a mean duration of 32 days. In 2 patients, insertion of a nasopancreatic catheter was required to irrigate thick pus or necrotic debris. Bleeding occurred in 1 case (11%) but there was no mortality. The relapse rate was 13% over a mean follow-up of 18 months. CONCLUSION: Endoscopic transmural drainage is an effective therapy with minimal morbidity for pancreatic abscess compressing the gut lumen and is a valuable alternative to surgical drainage.     

Intracavitary contrast-enhanced ultrasound in abscess drainage – feasibility and clinical value

Objective. To evaluate the usefulness of intracavitary-applied contrast-enhanced ultrasound (ICCEUS) with BR1 in ultrasound-guided puncture and drainage of abdominal and pelvic abscesses. Material and methods. A total of 71 consecutive patients received ICCEUS after placement of a drainage catheter or a needle in abdominal or pelvic abscesses. Portions of 0.1 ml of BR1 and 20 ml of saline were injected through the drainage catheter or needle. Ultrasound recordings were evaluated to answer the following questions: correct placement of the catheter by showing enhancement in the cavity and the drain – ICCEUS findings suggesting incomplete enhancement in all abscess cavities – enhancement in non-abscess structures. Results. About 52% of patients had liver, 14% of patients had intraperitoneal, 11% had subphrenic, 14% had retroperitoneal, 6% had splenic, and 4% had pelvic abscesses. The majority of the patients received drain placement with 10-F using trocar technique. Enhancement in the drain or needle was seen in all patients. In 2% of patients, during the initial approach, a dislodgment of the catheter from the abscess cavity was diagnosed. Due to non-enhancing abscess compartments, in 36% of the patients more than one drainage treatment was necessary at the time of the first approach. In 14% of the patients communication with surrounding structures was diagnosed. Additional treatment resulted in 4% of cases. Conclusion. ICCEUS was helpful in all patients to confirm correct placement of drain or puncture needle. In 40% of patients, as a consequence of ICCEUS, additional therapy was scheduled, either additional drainage or abscess puncture, endoscopic retrograde drainage of the biliary or pancreatic duct or thoracic intervention.