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     

The clinical impact of preoperative percutaneous drainage of abdominopelvic abscesses in patients with Crohn’s disease

Purpose

Although image-guided percutaneous drainage is increasingly being used to treat Crohn’s disease-related abdominopelvic abscesses, surgery is seldom avoided. The aim of this study was to compare outcomes following the treatment of intra-abdominal Crohn’s abscesses with percutaneous drainage followed by surgery to those after surgery alone.

Methods

We retrospectively reviewed the charts of patients treated for Crohn’s-related abdominopelvic abscesses at Mount Sinai Medical Center between April 2001 and June 2010. Patients who underwent drainage followed by surgery were compared to those who underwent surgery alone. Differences in operative and postoperative outcomes were compared.

Results

Seventy patients with Crohn’s disease-related abdominopelvic abscesses were identified, 38 (54%) of whom underwent drainage before surgery. Percutaneous drainage was technically successful in 92% of patients and clinically successful in 74% of patients. No differences in rate of septic complications (p?=?0.14) or need for stoma creation (p?=?0.78) were found. Patients who underwent percutaneous drainage had greater overall hospital lengths of stay (mean 15.8 versus 12.2?days, p?=?0.007); 8.6% of patients had long-term postponement of surgery after percutaneous drainage.

Conclusions

In our series, the treatment of Crohn’s abscesses with percutaneous drainage prior to surgery did not decrease the rate of postoperative septic complications.     

Percutaneous drainage of liver and splenic abscess

42 patients with solitary (n = 34) and multiple (n = 8) abscesses of the liver (n = 36) and the spleen (n = 6) were treated with ultrasound guided percutaneous interventions. 38 patients (90%) underwent a total of 97 closed abscess aspirations using needles of 0.9 and 1.3 mm in diameter. In 4 cases (10%) percutaneous catheter drainage was performed. Intravenous antibiotics were used in all cases. Those patients with closed abscess aspiration additionally received local injection of aminoglycosides into the cavity. 40 out of the 42 patients could be treated successfully by percutaneous methods for a cure rate of 95.2%. Percutaneous drainage failure occurred in 2.4%. One patient with multiple liver abscesses and catheter drainage died from myocardial infarction (hospital mortality 2.4%). Complications of ultrasound-guided interventions included two minor bleedings, requiring no therapy, and one pleural empyema (complication rate 7.1%). There were no treatment related lethal complications. These results indicate that abscesses of the liver and the spleen up to 10 cm in diameter can be effectively treated by closed (repetitive) needle aspiration and antibiotic therapy with a relatively low rate of complications. About half of our patients with abscesses of more than 10 cm received percutaneous catheter drainage. On the basis of our experience surgical drainage of liver abscesses and splenectomy in splenic abscesses should be restricted to those cases with percutaneous drainage failure.     

Infections associated with biliary drainage procedures in patients with cancer

A total of 170 therapeutic biliary drainage procedures were carried out in 90 patients with cancer over a 1-year period (January-December 1988). There were 129 percutaneous transhepatic biliary drainage procedures done in 61 patients and 41 endoprostheses were placed in 29 patients. The overall infection rate related to these procedures was 60.6%, the rate being similar for the two procedures. Infectious complications were experienced by 50% of patients undergoing a biliary drainage procedure. The most common manifestation was cholangitis followed by bacteremia. Other infections included liver abscess, gallbladder abscess, and subphrenic abscess. The most common isolates were enteric gram-negative bacilli, followed by Enterococcus species, Candida species, and Staphylococcus epidermidis. The use of prophylactic antibiotics in 76% of infected patients failed to prevent biliary catheter-related infections. Two patients died of complications related to biliary sepsis. All other infected patients responded to antimicrobial therapy, which included various regimens of beta-lactam agents (third-generation cephalosporin, extended-spectrum penicillin, imipenem-cilastatin, and aztreonam) that were used in combination with an aminoglycoside in 15 patients.     

Liver abscess: What determines the prognosis?

Records of all patients with liver abscess who presented to a teaching hospital between 1979 and 1986 were reviewed in order to determine prognostic factors and optimal treatment. Of 32 patients, the diagnosis was made ante-mortem in 30, and 24 patients survived. Patients who died tended to be older and more likely to exhibit confusion and other features of systemic toxicity at presentation. Fine needle aspiration, guided by computerized tomography, provided the correct diagnosis in 18 of 19 patients. Of 24 patients with isolated abscesses (1 or 2) 22 survived, whereas six of eight patients with multiple (more than 2) abscesses died ( P < 0.001). Aspirates from patients who survived appeared to grow anaerobes more commonly (NS), whereas those from non-survivors more often grew multiple organisms which usually included Gram-negative bacilli ( P < 0.01). All patients received broad spectrum antibiotics and a drainage procedure was carried out in 26. Of 19 patients treated by percutaneous drainage, 12 recovered, one required hepatic resection before recovering, and six died (four with multiple abscesses). Of nine patients (all with 1–2 abscesses) treated by open drainage, all eventually recovered, but three needed additional procedures. Six of eight non-survivors compared with four of 24 survivors had predisposing biliary sepsis ( P < 0.01). It is concluded that isolated liver abscesses are relatively benign, commonly grow anaerobes, and are usually resolved with antibiotics and drainage (closed or open), whereas multiple abscesses occur in sicker, older patients who are usually jaundiced with uncontrolled biliary sepsis. The prognosis in patients with multiple liver abscesses is poor irrespective of treatment.     

Infectious complications of hepatic artery catheterization procedures in patients with cancer

A total of 353 hepatic artery catheterization procedures were carried out in 211 patients with cancer over a 1-year period (January-December 1988). The procedures included 49 embolizations in 32 patients, 123 chemoembolizations in 73 patients, and 181 chemoinfusions in 106 patients. The overall infection rate was 3.4%. Infectious complications occurred in 3.1% of patients undergoing hepatic artery embolization alone, 1.9% of patients undergoing hepatic artery chemoinfusion, and 4.1% of patients undergoing hepatic artery embolization followed by chemoinfusion. Four patients had infectious complications that included four episodes each of cholangitis, liver abscess, and septicemia. One patient developed a subphrenic abscess in addition to a liver abscess. Enteric gram-negative bacilli (aerobic and anaerobic) were isolated from all four patients. None of the patients had received prophylactic antibiotics. All patients responded to antimicrobial therapy and percutaneous drainage of abscesses.     

Management of abdominal and pelvic abscess in Crohn's disease

Patients with Crohn’s disease may develop an abdominal or pelvic abscess during the course of their illness.This process results from transmural in ammation and penetration of the bowel wall,which in turn leads to a contained perforation and subsequent abscess formation.Management of patients with Crohn’s related intra-abdominal and pelvic abscesses is challenging and requires the expertise of multiple specialties working in concert.Treatment usually consists of percutaneous abscess drainage(PAD)under guidance of computed tomography in addition to antibiotics.PAD allows for drainage of infection and avoidance of a two-stage surgical procedure in most cases.It is unclear if PAD can be considered a definitive treatment without the need for future surgery.The use of immune suppressive agents such as anti-tumor necrosis factor-α in this setting may be hazardous and their appropriate use is controversial.This article discusses the management of spontaneous abdominal and pelvic abscesses in Crohn’s disease.     

2 Imaging and intervention in patients with acute right upper quadrant disease

Because of the high diagnostic yield, its widespread availability and the possibility of bedside examinations, US has become the imaging modality of choice in patients with acute right upper quadrant pain caused by inflammatory disorders such as liver abscesses, acute cholangitis and acute cholecystitis. Computed tomography (CT) can be reserved for more complex cases. US, often in combination with fluoroscopy, is also widely used to control interventions. In patients with liver abscesses the therapeutic strategy is determined by the size of the abscess, its uni- or multifocal presentation and the causative micro-organisms cultured after diagnostic percutaneous aspiration. Small-sized pyogenic abscesses (<3 cm), most fungal and amoebic abscesses can be treated medically. Large-sized pyogenic abscesses should be drained percutaneously and can be cured in 75–90%. Surgery should be restricted to patients with prolonged sepsis after percutaneous drainage and patients with infected pre-existing hepatic lesions.In patients with acute cholangitis drainage of the infected bile is essential. Invasive imaging such as percutaneous or endoscopic cholangiography should only be done with the intention to drain. The use of endoscopic procedures such as nasobiliary drainage, stent placement and sphincterotomy has decreased mortality rates dramatically. Percutaneous drainage should be considered in patients in whom endoscopic procedures fail. Surgery may have a place in the treatment of bile duct obstruction which causes cholangitis.In patients with suspected acute cholecystitis, imaging modalities such as cholescintigraphy and CT can be reserved for patients with inconclusive sonographic studies and more complex cases. The contribution of percutaneous gallbladder aspiration and culture to diagnose acute cholecystitis seems limited. Percutaneous cholecystostomy is an effective procedure with a low morbidity and mortality for high-risk patients. The drainage catheter in the gallbladder does not interfere with cholecystectomy at a later stage in patients with calculous cholecystitis. In most patients with acalculous cholecystitis, percutaneous cholecystectomy provides a definitive treatment.     

Ultrasound guided percutaneous treatment for splenic abscesses： The significance in treatment of critically ill patients

INTRODUCTION Splenic abscess is an uncommon entity with a reported frequency in autopsy series between 0.14% and 0.7%, and with high mortality rates because of delayed detection and treatment[1-3]. It often presents with either vague or nonspecific signs,…     

Endoscopic therapy of a splenic abscess: definitive treatment via EUS-guided transgastric drainage

BACKGROUND: Splenic complications of pancreatitis are exceedingly rare, occurring in only 2.2% of cases. Patients typically present in a dramatic fashion and often need an urgent procedure to prevent overwhelming infection or hemorrhage. Historically, the procedures involve surgery (distal pancreatectomy and splenectomy) or percutaneous drainage. SETTING: Walter Reed Army Medical Center. PATIENT: A patient with acute or chronic pancreatitis presented with pleuritic chest pain and fever up to 105 degrees F (40.6 degrees C). A CT of the abdomen and the pelvis demonstrated a splenic abscess. INTERVENTION: Because of the technical inability to perform transpapillary drainage, EUS-guided transgastric drainage resolved the splenic abscess. CONCLUSIONS: This is the first reported case of a splenic abscess treated definitively with endoscopic therapy. In the face of a worsening clinical picture and reported morbidities up to 79% with surgical and percutaneous drainage procedures, endoscopic therapies should be considered in the management of splenic complications of pancreatitis.     

Three cases of pancreatic pseudocyst treated with transpapillary endoscopic management of pancreatic duct disruption after percutaneous drainage as a first-line treatment]

Previously reported series suggested that the morbidity rate of internal surgical drainage procedure alone was about 15% and the mortality rate was less than 5% in patients with pancreatic pseudocysts. Recently, ultrasonography or CT-guided percutaneous drainage and endoscopic drainage techniques have created a new dimension of invasive, non-surgical treatment options for these patients. In the absence of prospective, randomized, controlled studies comparing outcomes of different pseudocysts drainage techniques, the decision as to which method should be employed often lies with local expertise and enthusiasm. In our experience, radiologic percutaneous drainage with subsequent transpapillary endoscopic drainage had a high success rate and was relatively less difficult which resulted in rapid clinical improvement. We report three cases of pancreatic pseudocysts treated with percutaneous drainage as a first-line treatment followed by endoscopic treatment.     

Endoscopic ultrasound (EUS) guided access and therapy of pancreatico-biliary disorders

Endoscopic ultrasound (EUS) has evolved from a purely diagnostic imaging modality to one that allows therapeutic intervention. It now serves as a viable alternative, and at times is preferred, to percutaneous and surgical techniques for obtaining biliary and pancreatic duct access and for providing drainage. EUS guided intervention is usually performed following failed endoscopic retrograde cholangiopancreatography (ERCP) or as an option for patients who decline surgical intervention or in poor operative candidates. Published data demonstrate overall technical success in 83% of patients with 12% experiencing a procedure related complication. New techniques and equipment must be developed to simplify and abbreviate the procedures, to limit complications, and improve outcomes. In addition, longitudinal data are needed to determine the long-term outcomes and role of EUS guided pancreaticobiliary intervention.     

Ultrasonically guided percutaneous drainage of abdominal fluid collections: a long-term study of its therapeutic efficacy

Fifty patients underwent ultrasonically guided percutaneous drainage (US-GPD) either with needle aspiration or catheter drainage. The procedures resulted in 70% complete recovery, 20% partial success and 10% of failures. The same patients were followed with clinical examination and sonography for a mean time of 36.3 months (minimum follow-up: 12 months). During the follow up period, 10 relapses occurred and one patient, considered for surgery after partial percutaneous treatment of a pyogenic liver abscess, recovered completely under conservative treatment. An analysis of the factors potentially related to the recurrence was made. It was found that one-step needle aspiration of abdominal abscesses and percutaneous treatment of chronic pancreatic pseudocysts are more prone to relapses. We conclude that US-GPD is an efficacious therapy for abdominal fluid collections, but an adequate drainage technique and a careful selection of the patients is crucial to avoid the possibility of relapse.     

Percutaneous management of pancreatic abscesses: long term results in a single center

Background

Several authors consider that surgical intervention is the gold standard for treatment of pancreatic abscesses. Recently, considerable interest has been generated in the minimally invasive management of pancreatic abscess with mixed results reported in the literature.

Aim

To evaluate the efficacy of percutaneous aspiration and/or drainage for patients with pancreatic abscesses.

Methods

We performed a retrospective analysis of 62 patients with 87 pancreatic abscesses treated by percutaneous management from 1989 to 2009. All patients received appropriate antibiotic therapy. Patients with pancreatic abscess < 50 mm in diameter were initially treated by ultrasound-guided percutaneous needle aspiration (PNA) and those with abscess ≥ 50 mm were initially treated by ultrasound-guided percutaneous catheter drainage (PCD). Surgery was planned only when there was no clinical improvement after the initial percutaneous treatment. Primary outcome was conversion rate to surgery.

Results

Two patients (3.2%) received supportive treatment only and one of them died. PNA was performed in 16 patients (25.8%), and 8 of them required PCD because of recurrence of abscess. In 44 patients (70.1%), PCD was performed initially. PCD was performed twice in 6 patients and 3 times in 2 patients. There were 5 patients converted to surgery (8.1%) and one of them died. Medians (interquartile ranges) of hospital stay and catheter dwell-time were 17 (12–26) and 12 (9–21) days, respectively. There were no complications related to the procedure.

Conclusions

Percutaneous aspiration and/or drainage are effective and safe for the treatment of pancreatic abscesses.     

Treatment of pyogenic liver abscess: prospective randomized comparison of catheter drainage and needle aspiration

This study aims to compare the therapeutic effectiveness of continuous catheter drainage versus intermittent needle aspiration in the percutaneous treatment of pyogenic liver abscesses. Over a 5-year period, 64 consecutive patients with pyogenic liver abscess were treated with intravenous antibiotics (ampicillin, cefuroxime, and metronidazole) and randomized into two percutaneous treatment groups: continuous catheter drainage (with an 8F multi-sidehole pigtail catheter); and intermittent needle aspiration (18G disposable trocar needle). There was no statistically significant difference between the two groups regarding patient demographics, underlying coexisting disease, abscess size, abscess number, number of loculation of abscess, the presenting clinical symptoms such as fever, abdominal pain, and pretreatment liver function test. Although not statistically significant, the duration of intravenous antibiotics treatment before percutaneous treatment was longer with the catheter group, and the change of antibiotics after the sensitivity test was more frequent with the needle group. The needle group was associated with a higher treatment success rate, a shorter duration of hospital stay, and a lower mortality rate, although this did not reach statistical significance. In conclusion, this study suggests that intermittent needle aspiration is probably as effective as continuous catheter drainage for the treatment of pyogenic liver abscess, although further proof with a large-scale study is necessary. Due to the additional advantages of procedure simplicity, patient comfort, and reduced price, needle aspiration deserves to be considered as a first-line drainage approach.     

Treatment of Intra-Abdominal Abscesses in Crohn’s Disease: A Nationwide Analysis of Patterns and Outcomes of Care

Background

Abdominal abscesses are a common complication in Crohn’s disease (CD). Percutaneous drainage of such abscesses has become increasingly popular and may deliver outcomes comparable to surgical treatment; however, such comparative data are limited from single-center studies. There have been no nationally representative studies comparing different treatment modalities for abdominal abscesses.

Methods

We identified all adult CD-related non-elective hospitalizations from the Nationwide Inpatient Sample 2007 that were complicated by an intra-abdominal abscess. Treatment modality was categorized into 3 strata—medical treatment alone, percutaneous drainage, and surgery. We analyzed the nationwide patterns in the treatment and outcomes of each treatment modality and examined for patient demographic, disease, or hospital-related disparities in treatment and outcome.

Results

There were an estimated 3,296 hospitalizations for abdominal abscesses in patients with CD. Approximately 39 % were treated by medical treatment alone, 29 % with percutaneous drainage, and 32 % with surgery with a significant increase in the use of percutaneous drainage since 1998 (7 %). Comorbidity burden, admission to a teaching hospital, and complicated Crohn’s disease (fistulae, stricture) were associated with non-medical treatment. Use of percutaneous drainage was more common in teaching hospitals. Mean time to percutaneous drainage and surgical treatment were 4.6 and 3.3 days, respectively, and early intervention was associated with significantly shorter hospitalization.

Conclusions

We describe the nationwide pattern in the treatment of abdominal abscesses and demonstrate an increase in the use of percutaneous drainage for the treatment of this subgroup. Early treatment intervention was predictive of shorter hospitalization.     

118例细菌性肝脓肿临床特点分析

目的 探讨近年来细菌性肝脓肿的临床特点、病原学、诊断和治疗的变化.方法 回顾性分析1986年1月-2010年6月北京协和医院118例细菌性肝脓肿住院患者的临床资料.结果 118例平均年龄53.3岁,其中发热(97.5%)、寒战(91.5%)、右上腹痛(44.1%)是最常见的临床表现.糖尿病(41.5%)、胆系疾病(24...     

Video-assisted hepatic abscess debridement

BackgroundPyogenic liver abscesses are currently treated by either percutaneous computer tomography (CT)-guided drainage or by laparoscopic and a conventional liver resection when conservative treatment fails but may be associated with substantial morbidity and mortality.MethodsA minimally invasive technique involving debridement of right liver abscesses was employed using a minimally invasive video-assisted hepatic abscess debridement (VAHD) after unsuccessful percutaneous CT-guided drainage. Clinical data, complication rates and outcomes of patients were recorded retrospectively.ResultsBetween 2011 and 2014, VAHD was performed on 10 patients at two centres with no observed recurrence of a liver abscess. The median age of the patients was 57 years (range 42–78) with a median pre-operative size of a liver abscess of 78 mm (range 40–115). The median operation time was 47 min (range 23–75), and the median postoperative hospital stay was 9 days (range 7–69). One patient developed a subcutaneous abscess that required further surgery. No patient died, and there were no major complications related to the VAHD.ConclusionsVideo-assisted hepatic abscess debridement is a feasible technique that shows promising results for the treatment of a recurrent right liver abscess.     

Endoscopic drainage of lung abscesses: technique and outcome

BACKGROUND: Lung abscesses commonly respond well to antibiotic therapy. In patients in whom conventional therapy fails, either percutaneous catheter drainage or surgical resection are usually considered, but are frequently problematic. This study describes our experience with endoscopic lung abscess drainage in patients in whom antibiotic therapy fails. METHODS: Patients in whom antibiotic therapy for lung abscess (enlarging cavity or lack of improvement of clinical status) was unsuccessful were considered candidates if an airway connection to the cavity was present. Treatment decisions were made in a multidisciplinary chest conference. Pigtail catheters were placed via a guidewire approach into the cavities. The abscesses were flushed twice daily with gentamycin solution. If fungal infection was suspected, once-daily amphotericin B was added to the regimen. RESULTS: Forty-two patients, from January 2000 to May 2002 (17 woman and 25 men) were included in this study (mean age, 48.9 years). Catheter placement was successful in 38 patients and led to successful therapy after a mean of 6.2 days of treatment (range, 3 to 21 days). Two patients required transient ventilation after catheter placement; there were no other complications. CONCLUSIONS: Endoscopic lung abscess drainage in selected patients in whom antibiotic therapy fails is feasible and successful in experienced hands. This treatment represents an additional option for the chest physician other than percutaneous catheter drainage or surgical resection.     

Les abcès et nécroses pulmonaires à germes banals : drainage ou chirurgie ?

Lung abscesses and necrotizing pneumonia are rare complications of community-acquired pneumonia since the advent of antibiotics. Their management leans first of all on the antibiotic treatment adapted on the informed germs. However, in 11 to 20% of the cases of lung abscesses, this treatment is insufficient, and drainage, either endoscopic or percutaneous, must be envisaged. In first intention, we shall go to less invasive techniques: endoscopic or percutaneous radio-controlled. In case of failure of these techniques, a percutaneous surgical drainage by minithoracotomy will be performed. In the necrotizing pneumonia, because of the joint obstruction of the bronchus and blood vessels corresponding to a lung segment, the systemic antibiotic treatment will be poor effective. In case of failure of this one we shall propose, a percutaneous surgical drainage, especially if the necrosis limits itself to a single lobe. The surgical treatment will be reserved: in the failures of the strategy of surgical drainage, in the necroses extending in several lobes.