PERCUTANEOUS VERSUS OPEN OPERATIVE DRAINAGE OF INTRA-ABDOMINAL ABSCESSES

Intra-Abdominal Abscesses: Emphasis on Image-Guided Diagnosis and Therapy

Infection of the peritoneal cavity can be divided into acute peritonitis and chronic abscess formation. While acute peritonitis is easier to diagnose and treatment is often straightforward, the diagnosis of an intra-abdominal abscess can be subtle and treatment can involve multiple diagnostic and therapeutic modalities. The advent of high-quality computed tomography and ultrasonography has revolutionized the care of these patients, and has allowed for the definitive management of these infections without open operation. We review the current techniques for the diagnosis, localization, and treatment of these serious infections, discuss important factors influencing the decision between percutaneous and operative approaches, and examine several other controversies In this challenging area.

Preoperative Percutaneous Drainage of Spontaneous Intra-Abdominal Abscess in Patients With Crohn's Disease: A Meta-Analysis

GOALS

We aimed to compare clinical outcomes between percutaneous drainage (PD) with or without further elective surgery and initial surgery for patients with Crohn's disease (CD)-related spontaneous intra-abdominal abscess.

BACKGROUND

Intra-abdominal abscess is common in patients with CD leading to significant morbidity. The role of PD before abdominal surgery in patients with CD remains controversial.

STUDY

We performed a meta-analysis comparing PD and surgery as the initial approach to CD-related spontaneous intra-abdominal abscess. Overall complication and recurrent abscess were assessed. Subgroup analyses on initial PD were performed including preoperative PD and PD alone.

RESULTS

A total of 9 studies including 513 patients with CD-related spontaneous intra-abdominal abscesses were included. The overall complication rate was significantly higher in patients undergoing initial surgery compared with those undergoing initial PD [odds ratio (OR)=0.58; 95% confidence interval (CI), 0.35-0.96; P=0.03]. In a subgroup analysis, preoperative PD was associated with a significant reduction in overall complication (OR=0.44; 95% CI, 0.23-0.83; P=0.01) as compared with initial surgery. The risk for recurrent abscess was higher in patients who underwent PD alone than those who underwent initial surgery (OR=2.16; 95% CI, 1.03-4.54; P=0.04). No significance difference in postoperative recurrent abscess was found between preoperative PD group and initial surgery group.

CONCLUSION

Although abdominal surgery appeared to be inevitable in the majority of the patients with CD who develop intra-abdominal abscess, preoperative PD may decrease overall complication after surgery.

Differences in Morbidity and Mortality with Percutaneous versus Open Surgical Drainage of Postoperative Intra-abdominal Infections: A Review of 686 Cases

Intra-abdominal infections following surgical procedures result from organ-space surgical site infections, visceral perforations, or anastomotic leaks. We hypothesized that open surgical drainage is associated with increased patient morbidity and mortality compared with percutaneous drainage. A single-institution, prospectively collected database over a 13-year period revealed 2776 intra-abdominal infections, 686 of which required an intervention after the index operation. Percutaneous procedures (simple aspiration or catheter placement) were compared with all other open procedures by univariate and multivariate analyses. Analysis revealed 327 infections in 240 patients undergoing open surgical drainage and 359 infections in 260 patients receiving percutaneous drainage. Those undergoing open drainage had significantly higher Acute Physiology Score (APS) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and were more likely to be immunosuppressed, require intensive care unit treatment, and have longer hospital stays. Mortality was higher in the open group: 14.6 versus 4.2 per cent ( P = 0.0001). Variables independently associated with death by multivariate analysis were APACHE II, dialysis, intensive care unit (ICU) care, age, immunosuppression, and drainage method. Open intervention for postsurgical intra-abdominal infections is associated with increased mortality compared with percutaneous drainage even after controlling for severity of illness by multivariate analysis. Although some patients are not candidates for percutaneous drainage, it should be considered the preferential treatment in eligible patients.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Percutaneous fluoroscopically guided removal of a deep retroperitoneal foreign body with a laparoscopic trocar and grasping device

Traditionally, soft tissue foreign body removal is performed surgically. Superficial foreign body removal under ultrasonographic and fluoroscopic guidance has been reported. Herein, the authors report a case of percutaneous removal of a retroperitoneal foreign body under fluoroscopic guidance by using a modified laparoscopic trocar device and a laparoscopic grasping device. Iodinated contrast medium administered via the trocar device allowed visualization of the foreign body and distended the retroperitoneal space to allow for manipulation of the foreign body. The procedure was completed in a relatively short time and the patient made an excellent rapid postoperative recovery.

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Computerized tomography (CT)-guided aspiration of abscesses: Outcome of therapy at a tertiary care hospital

OBJECTIVE

To review the experience with percutaneous aspiration of abscesses at a general, tertiary care hospital from 2000 to 2005.

METHODS

Computerized medical records of 90 patients who underwent radiologically guided drainage of 92 fluid collections were reviewed for demographic data, co-morbid conditions, location, radiographic imaging characteristics and culture results and to determine the long-term outcome of the procedure.

RESULTS

Sixty-seven of 92 (73%) abscesses were cured without the need for open surgical drainage; 44 were cured within 14 days, and 23 had delayed resolution requiring prolonged antibiotics and/or a second drainage. Of the abscesses 85% were drained using a catheter in situ, the remaining aspirated using a needle. Twenty-five (27%) of the 92 abscesses failed percutaneous drainage, requiring open surgical drainage or lead to sepsis and death. Neither co-morbid conditions nor the location of abscesses affected the outcome of drainage. Patients who had sterile cultures of aspirated material after receiving antibiotics prior to the procedure had a significantly higher cure rate than otherwise (P<0.05). Catheter drainage was associated with a significantly higher cure rate than was needle aspiration (P<0.05).

CONCLUSION

Percutaneous drainage, along with appropriate antibiotics, is an effective approach to treat deep abscesses. Drainage, itself, is the major determinant of outcome, rather than the location, characteristics of the abscess or condition of the patient prior to the procedure.

Gas Distribution in Intraabdominal and Pelvic Abscesses on CT Is Associated with Drainability

OBJECTIVE

Intraabdominal and pelvic abscesses are treated by percutaneous image-guided drainage, under sedation or general anesthesia. This study attempts to determine if the CT features of gas distribution are associated with "drainability." Our premise was that gas may be trapped deep in a collection as bubbles, if the material is thick. Gas may rise to the surface if the material is thin, forming either an air-fluid level or superficial bubbles.

MATERIALS AND METHODS

Patients with intraabdominal and pelvic abscesses were identified by the interventional radiology database, after research ethics board approval. Patients without prior CT were excluded. The imaging and clinical records were analyzed retrospectively. Intracollection gas distribution was recorded as superficial bubbles, deep bubbles, or air-fluid levels. Collections were classified accordingly: type 1, air-fluid levels; type 2, superficial or deep bubbles and air-fluid levels; type 3, superficial bubbles; type 4, deep bubbles; and type 5, no gas.

RESULTS

One hundred five abscesses were examined in 61 patients, ranging in age from 2-17 years. Eight of 8 of type 1, 16 of 16 of type 2, 19 of 21 of type 3, 8 of 13 of type 4, and 43 of 47 of type 5 were drainable. The abscesses of all patients with an air-fluid level were drainable. Of abscesses with deep bubbles, 61.5% were drainable, versus 90.5% of those with superficial bubbles. Of those with superficial gas (superficial bubbles or air-fluid levels), 95.6% were drainable. In comparison with superficial gas, abscesses with deep trapped gas were associated with a longer duration of drainage, longer hospital stay, lower percentage of successful drainage, and higher percentage of residual collections. The difference is significant for drainability (p = 0.0048; p = 0.0331 after statistical adjustment for multiple testing).

CONCLUSION

Distribution of gas in an intraabdominal or pelvic abscess is associated with drainability. Abscesses with superficial gas (superficial bubbles or air-fluid levels) have a greater chance of being drained successfully than do abscesses with deep trapped gas.

Cecal ligation and puncture versus colon ascendens stent peritonitis: two distinct animal models for polymicrobial sepsis

Colon ascendens stent peritonitis (CASP) and cecal ligation and puncture (CLP), two animal models designed to closely mimic the clinical course of intra-abdominal sepsis, were compared. In the past, immunomodulatory therapies developed in animal studies failed to be successful in humans. As a consequence, the established animal sepsis models were criticized. It has been proposed that present models had to be reevaluated, and new, clinically more relevant models should be evolved. CLP procedure was performed puncturing once (CLP[1]) or twice (CLP[2]) the ligated cecum of C57BL/6 mice. In the CASP model, a stent with defined diameter was surgically inserted into the ascending colon. Survival, bacterial load, immunohistochemistry, and serum cytokine levels were analyzed in the groups. Survival after CASP procedure correlated strongly with the stent diameter, whereas the number of punctures in CLP did not significantly change survival rate. Bacterial loads of peritoneal lavage, liver, and lung, as well as serum cytokine levels (tumor necrosis factor, interleukin 1 beta, interleukin 10) steadily increased from 6 to 24 h after the CASP procedure. In contrast, continuously low amounts of bacteria and cytokines were found in CLP mice at any point of time. Twenty-four hours after CLP surgery, the ligated cecum was covered by adhesive small bowel loops, whereas in CASP mice, the intestinal leakage was then still present. The CASP model mimics closely the clinical course of diffuse peritonitis with early and steadily increasing systemic infection and inflammation (systemic inflammatory response syndrome). In contrast, CLP reveals a model of intra-abdominal abscess formation with sustained and minor signs of systemic inflammation.

Estudo comparativo dos procedimentos percutâneos orientados por métodos de imagem no tratamento das coleções intraperitoneais

OBJETIVO: Verificar e comparar a eficácia da aspiração percutânea (AP) e da drenagem percutânea (DP), orientadas por métodos de imagem, no tratamento das coleções intraperitoneais. MATERIAIS E MÉTODOS: Foram encaminhados ao nosso setor 52 pacientes para tratamento percutâneo de coleções abdominais. Destes, 16 apresentavam coleções intraperitoneais, sendo dez complexas (multiloculadas ou múltiplas) e seis, simples. O volume das coleções variou de 40 a 1.200 ml, com mediana de 200 ml. Foram submetidas a AP seis coleções (37,5%) e a DP, dez (62,5%). Considerou-se como sucesso do método a resolução completa da coleção, com melhora clínico-laboratorial do paciente. RESULTADOS: O sucesso do procedimento ocorreu em 75% dos casos. Nas coleções submetidas a AP houve sucesso em 100%, e nas submetidas a DP o sucesso foi de 60%. O índice de sucesso no grupo submetido a DP foi de 50% nas coleções menores ou iguais a 200 ml e de 75% nas de maior volume. Obteve-se sucesso com a DP em 33,3% das coleções complexas, em 42,9% das infectadas e em 100% das não infectadas e simples. Foram observadas apenas duas complicações menores (bacteremia transitória e infecção cutânea) após os procedimentos. CONCLUSÃO: A AP e a DP são métodos eficazes e seguros para tratamento das coleções intraperitoneais. No nosso estudo, a AP foi mais eficaz que a DP, principalmente nas coleções de menor volume.

Can failure of percutaneous drainage of postoperative abdominal abscesses be predicted?

BACKGROUND

Percutaneous drainage (PD) of complex postoperative abscesses associated with a variety of factors such as multiple location or enteric fistula remains a matter of debate. Accordingly, this retrospective study was designed to determine the predictive factors for failure of PD of postoperative abscess, in order to better select the patients who may benefit from PD.

METHODS

From 1992 to 2000, the data of 73 patients who underwent computed tomography (CT)-guided PD for postoperative intra-abdominal abscess, were reviewed. PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. The possible association between failure of PD and 27 patient-, abscess-, surgical-, and drainage-related variables were assessed using univariate and multivariate analysis.

RESULTS

Successful PD was achieved in 59 of 73 (81%) patients. The overall mortality was 3% but no patient died after salvage surgery. Multivariate analysis showed that only an abscess diameter of less than 5 cm (P = 0.042) and absence of antibiotic therapy (P = 0.01) were significant predictive variables for failure of PD.

CONCLUSIONS

CT-guided PD associated with antibiotic therapy could be attempted as the initial treatment of postoperative abdominal abscesses even in complex cases such as loculated abscess or abscess associated with enteric fistula.

Abscesses in Crohn's disease: outcome of medical versus surgical treatment

GOALS

To compare the long-term outcome of medical, percutaneous, and surgical treatment of abdominal and pelvic abscesses complicating Crohn's disease.

STUDY

All patients with Crohn's disease and an abdominal abscess treated at one institution during a 10-year period were retrospectively identified. We reviewed hospital and outpatient records and contacted patients for telephone interviews. Outcome measures included abscess recurrence, subsequent surgery for Crohn's disease, and medications used at the time of most recent follow-up.

RESULTS

Fifty-one subjects were identified, with a mean follow-up of 3.75 years. Fewer patients developed recurrent abscesses after initial surgical drainage and bowel resection (12%) than patients treated with medical therapy only or percutaneous drainage (56%) (p = 0.016). One half of the patients treated nonoperatively ultimately required surgery, whereas only 12% of those treated with initial surgery required reoperation during the follow-up period (p = 0.010). Most failures of nonoperative therapy occurred within 3 months. Medication use was similar between the treatment groups at the time of most recent follow-up.

CONCLUSIONS

In this series, surgical management of abscesses in Crohn's disease was more effective than medical treatment or percutaneous drainage for prevention of abscess recurrence. However, nonoperative therapy prevented subsequent surgery in half of the patients and may be a reasonable treatment option for some patients.

Multiple fluid collections: CT- or US-guided aspiration--evaluation of microbiologic results and implications for clinical practice

PURPOSE

To determine if patients with multiple fluid collections need every collection aspirated and if cross-contamination is a risk if separate sterile procedures are not followed for each aspiration.

MATERIALS AND METHODS

Records from 1,076 imaging-guided percutaneous aspirations and drainages over 39 months were retrospectively reviewed; 124 patients had multiple fluid collections drained, which yielded 287 aspirates. The patients were divided into two groups: those (n = 82) with multiple collections aspirated on any 1 day, and those (n = 61) with multiple collections aspirated over 10 days. Nineteen patients were included in both groups. Gram stain microscopy and culture results were compared between sequential aspirates in each patient, and their potential effects on antimicrobial therapy and theoretic risk for cross-contamination were evaluated.

RESULTS

In 82 patients undergoing multiple aspirations on any 1 day, multiple microorganisms differed in 32 patients, which indicated a need for therapy change in 18 (22%) patients. In 61 patients undergoing aspiration on different days, microorganisms differed in 32 patients, which indicated a need for therapy change in 15 (25%) patients. Cross-contamination could have occurred in 28 of 93 (30%) aspirates from patients with a second or subsequent collection if separate sterile procedures had not been undertaken.

CONCLUSION

When multiple fluid collections are identified, aspirates from all collections should be obtained through separate sterile procedures to ensure optimal antimicrobial coverage and avoid cross-contamination.

Aortic graft infection: the value of percutaneous drainage

OBJECTIVE

The goal of this study was to compare patients with aortic graft infection treated by primary percutaneous drainage with patients who initially underwent surgery.

MATERIALS AND METHODS

A retrospective review of 23 consecutive patients treated for aortic graft infection was performed. Eleven patients were initially treated with percutaneous drainage and 12 were treated with surgery. The morbidity, mortality, and postprocedural reintervention rates and clinical outcome were analyzed for each group.

RESULTS

The septic process resolved in nine (82%) of 11 patients treated with percutaneous drainage. Of these nine patients, four were treated with percutaneous drainage alone. Drainage was followed by removal of the infected prosthetic graft in the remaining five patients. In the surgical group, sepsis resolved in only four patients (33%) (p = .036). No periprocedural deaths occurred in the percutaneous drainage group, whereas six patients in the surgical group died in the perioperative period (p = .014).

CONCLUSION

Percutaneous drainage can be used as an initial form of treatment in the management of aortic graft infections. Surgery after percutaneous drainage appears to be safer than surgery alone.

Antibiotics for the acute abdomen

Antibiotics are only an adjunct to proper surgical therapy for the treatment of the acute abdomen associated with bacterial secondary peritonitis. Upon presentation, all patients require a preoperative dose of antibiotics for prophylaxis against infection of remaining sterile tissues. Patients found intraoperatively to have an established peritoneal infection benefit from an immediate postoperative course of therapeutic antibiotics. A regimen that adequately covers facultative and aerobic gram-negative bacilli and anaerobic organisms is essential. The duration of therapeutic antibiotics is probably best decided on an individual patient basis. The goal of antibiotics is to reduce the concentration of bacteria invading tissues. The pathogens of bacterial peritonitis are influenced by such factors as the patient's pre-existing chronic diseases, state of acute physiologic debilitation, immunocompetence, recent antibiotic use, recent hospitalization, and neutralization of gastric acidity. Intraoperative peritoneal cultures are most useful in patients suspected of having impaired local host defenses. In these patients, all identified organisms, such as Enterococcus or Candida, may be potential pathogens. The common practice of administering empiric and prolonged courses of broad-spectrum antibiotics in patients who manifest persistent signs of inflammation may be more harmful than beneficial. These patients warrant an exhaustive search for extra-abdominal and intraperitoneal sources of new infection. Otherwise, such use of antibiotics may continue to promote the selection of bacteria that are highly resistant to conventional antibiotics and permit the overgrowth of organisms commonly seen with tertiary peritonitis. The best chance of resolving bacterial peritonitis is through early, aggressive surgical management complemented by short courses of potent antibiotics and appropriate physiologic support. Through these efforts, the clinician tries to help the systemic inflammatory response to benefit the host and not become unregulated, result in MOFS, and produce a high mortality.

Transrectal drainage of deep pelvic abscesses in children using a combined transrectal sonographic and fluoroscopic guidance

The authors review their experience with transrectal drainage of pelvic abscesses in seven children and adolescents (6-16 years old). Initial access was guided by transrectal ultrasound with an endovaginal transducer followed by fluoroscopy for placement of self-retaining catheters (8.5-10 F) using the Seldinger technique. All abscesses were successfully drained without complications. A transrectal catheter was well tolerated by most patients without spontaneous dislodgment. Catheters were removed after an average of 4 days (range 3-7 days). Transrectal drainage of pelvic abscess with transrectal sonographic and fluoroscopic guidance seems to be a safe and effective procedure in children.

What is needed from imaging? The surgeon's point of view

Abdominal sepsis after surgery is decreasing in incidence but has a high mortality, especially in those with other complicating factors. The most difficult abscesses to localize are those in intermesenteric folds. Pyrexia of unknown origin is much less of a clinical problem since the advent of ultrasound and computerized tomography (CT) scanning. Laparotomy still has an occasional role but laparoscopy should precede it and may be therapeutic using minimally invasive surgical techniques; for example, in appendicitis and cholecystitis. Pancreatitis remains a serious clinical problem in which imaging plays an important role. Percutaneous drainage has a similar morbidity and success rate to open drainage. In certain cases of diverticular disease it may obviate altogether the need for surgical resection. The differentiation between abscess and necrotic tumour is important, and CT is most helpful in this area.