Approaches to the difficult drainage and biopsy

Pelvic abscess - to drain or not to drain?

PURPOSE OF REVIEW

Pelvic abscess is a common gynaecological condition, particularly during and after the Covid-19 pandemic, possibly resulting from obstacles to accessing care during this time. To date, no consensus guideline on management exists with a lack of applicable randomized controlled trials (RCTs) comparing medical management with antibiotics alone, image-guided drainage and surgical management, despite this being a potentially life-threatening condition.

RECENT FINDINGS

We present the current literature assessing risks, which contribute to failure of medical therapy, predictive models to guide management and reports of long-term sequelae. Consideration for early laparoscopic or image-guided drainage should be given to women in whom fertility is a priority, pelvic abscess at least 7 cm, white blood cell count on admission more than 16 x 1000/μl, bilateral pelvic abscess, intrauterine device in situ for more than 5.5 years and preexisting endometrioma. Pelvic abscess rupture or severe sepsis should always trigger timely drainage.

SUMMARY

We present the current knowledge on management of pelvic abscesses to help guide clinical practice supported by the most recent evidence. We report the lack of high-quality evidence for many aspects of pelvic abscess treatment and call for well designed large multicentre RCTs to answer the question of which treatment yields the best outcomes.

Percutaneous biopsy of musculoskeletal tumors and the potential for needle tract seeding: technical considerations, current controversies, and outcomes

Multidisciplinary communication and planning between the musculoskeletal radiologist and orthopedic oncologist are essential for proper biopsy planning when a primary musculoskeletal malignancy is suspected. Image-guided percutaneous biopsy allows for real-time visualization of the biopsy needle and surrounding structures, combining high diagnostic accuracy with safety and cost-effectiveness. However, determining a surgically optimal biopsy trajectory for a mass can be technically challenging due to critical surrounding anatomy or challenging needle approach angles. Inappropriately placed biopsies can have serious repercussions on patient function and oncological survival. The potential for needle tract seeding and local recurrence after biopsy of sarcoma has been central to the debate regarding the need for excision of the biopsy tract. This multidisciplinary review highlights current controversies in the field, including the issue of core needle biopsy tracts and their excision, technical considerations and advances in image-guidance in the setting of challenging biopsies, advances in histopathological diagnostics with implications for targeted therapy in sarcoma, as well as surgical and oncological outcomes after needle tract biopsy.

CT-Guided Transhepatic Catheter Drainage of Deep Postoperative Collections: Initial Experience

Introduction This article assesses the safety and utility of transhepatic drainage of deep seated postoperative intra-abdominal collections under computed tomography (CT) guidance in a short series.

Materials and Methods This retrospective study included five patients (mean age: 45.8 years; 3 males, 2 females) who underwent CT-guided transhepatic drainage of postoperative abdominal abscess in our department between April 2019 and December 2020. The clinical and surgical details and the details of the transhepatic drainage procedure were evaluated along with success rates and complications.

Results The surgical procedures were Whipple's pancreaticoduodenectomy in four patients and gastrectomy in one patient. Four out of five abscesses were drained through the right lobe of liver, while one was through the left lobe with a technical success rate of 100%. The mean total time for catheter drainage procedure including patient positioning and preparation was 29.2 minutes. None of the patients had procedure-related complications. Mean duration of catheter drainage was 12 days. All patients had complete resolution of symptoms after drainage and the clinical success rate was 100%.

Conclusion Transhepatic approach is safe and effective for the drainage of inaccessible postoperative abdominal collections or abscesses where a standard percutaneous approach is not possible.

High presacral collection approached through the perineal route: A novel computed tomography-guided technique

For a definitive diagnosis of abdomino-pelvic lesions, percutaneous aspiration or biopsy is often necessary; however, finding a safe 'window' for access is challenging. This case report discusses a novel method to approach a deep pelvic collection and also briefly reviews the various approaches to access such lesions. A sample was obtained from a non-resolving presacral collection using a CT-guided percutaneous, trans-perineal approach with repeated sessions of hydro-dissection. Successful aspiration and analysis revealed multi-drug resistant tuberculosis, thus guiding appropriate management.

Percutaneous Transhepatic Biopsy for Extrahepatic Lesions

Purpose The purpose was to assess the diagnostic accuracy and safety of percutaneous transhepatic biopsy for extrahepatic lesions.

Materials and Methods Between January 2008 and December 2019, 26 patients (17 men and 9 women; median age, 60 years) underwent percutaneous transhepatic needle biopsy for extrahepatic lesions at our institution. Transhepatic biopsy was deemed appropriate compared with other biopsy routes or methods (i.e., endoscopic or surgical). The lesions were in the porta hepatis (n = 9), retroperitoneum (n = 6), right adrenal gland (n = 4), right kidney (n = 3), lesser omentum (n = 2), duodenum (n = 1), pleura (n = 1), and inferior vena cava (n = 1). The median maximal diameter of the lesions was 45.5 mm (range, 18–148 mm). Core-needle biopsy was performed in all patients. Eighteen-gauge and 21-G needles were used in 25 and one patient, respectively. Ultrasound was used for biopsy in 21 patients, and CT fluoroscopy was used in five patients. Postbiopsy tract embolization was performed in three patients. Technical success and diagnostic accuracy of the biopsy were evaluated. Complications were recorded using the systemic inflammation response (SIR) criteria.

Results The pathological results of biopsy were carcinoma (n = 10), lymphoma (n = 9), and other diagnoses (n = 7). Technical success was obtained in all patients. The accurate diagnosis was achieved in 24 of the 26 patients (92.3%). A major complication, a bladder tamponade, was observed in one patient (3.8%) after biopsy of a right kidney lesion. A hematoma caused by iatrogenic renal injury likely obstructed the bladder outlet. Minor complications were observed in three patients (11.5%).

Conclusions Percutaneous transhepatic biopsy for extrahepatic lesions is feasible with acceptable safety.

Celiac Plexus Block and Neurolysis in the Management of Chronic Upper Abdominal Pain

Chronic upper abdominal pain occurs as a complication of various malignant and benign diseases including pancreatic cancer and chronic pancreatitis, and when present may contribute to lower quality of life and higher mortality. Though various pain management strategies are available as part of a multimodal approach, they are often incompletely effective and accompanied by side effects. Pain originating in upper abdominal viscera is transmitted through the celiac plexus, which is an autonomic plexus located in the retroperitoneum at the root of the celiac trunk. Direct intervention at the level of the plexus, referred to as celiac plexus block or neurolysis depending on the injectate, is a minimally invasive therapeutic strategy which has been demonstrated to decrease pain, improve function, and reduce opiate dependence. Various percutaneous techniques have been reported, but, with appropriate preprocedural planning, use of image guidance (usually computed tomography), and postprocedural care, the frequency and severity of complications is low and the success rate high regardless of approach. The main benefit of the intervention may be in reduced opiate dependence and opiate-associated side effects, which in turn improves quality of life. Celiac plexus block and neurolysis are safe and effective treatments for chronic upper abdominal pain and should be considered early in patients experiencing such symptoms.

Bending percutaneous drainage catheters to facilitate CT-guided insertion using curved trocar technique

PURPOSE

To assess the safety and efficacy of placing thoraco-abdominal drainage catheters under CT-guidance using a curved trocar technique.

METHODS

A retrospective study of 182 CT/CT-fluoroscopy-guided thoraco-abdominal catheter drainages was conducted; half were performed by residents or fellows under the supervision of one radiologist (Group 1) and the other half under the supervision of 10 other radiologists (Group 2). Group 1 procedures employed a curved catheter assembly placed using trocar technique (n = 44) or straight catheters placed with Seldinger technique (n = 47). Group 2 procedures employed a straight catheter placed using trocar technique (n = 16) or straight catheters placed with Seldinger technique (n = 75). Technical success, procedure time, radiation dose (CT Dose Index CTDI_vol), and adverse events (Common Terminology Criteria for Adverse Events, 4.0) were compared between techniques and groups using Student's t test, Fisher's exact test or Chi-square analysis.

RESULTS

All procedures in groups 1 and 2 were technically successful. Mean procedure time for Group 1 curved trocar technique (28 ± 8 min) was shorter than groups 1 and 2 Seldinger technique (37 ± 11 min, p = .00002). Mean CTDI_vol for Group 1 curved trocar technique (107.8 ± 54.2 mGy) was lower than groups 1 and 2 Seldinger technique (136.1 ± 99.7 mGy, p = 0.032). Adverse event rates for curved trocar, straight trocar, and Seldinger techniques were 2.3% (1/44), 0% (0/16), and 3.3% (4/122), respectively (p = 1); all were grade 1 or 2, and no catheter malfunctions occurred.

CONCLUSIONS

The curved catheter trocar technique is a safe and effective modification of the standard trocar technique that may facilitate CT-guided procedures impeded by CT gantry size limitations.

A New CT-Guided Modified Trocar Technique for Drainage of Difficult Locations Abscesses

PURPOSE

Computed tomography (CT) is commonly used to guide drainage of deep-seated abdominal fluid collections. However, in some cases, these collections seem to be inaccessible due to surrounding organs or their being in difficult locations. The aim of this study is to describe a modified Trocar technique to drain collections in difficult locations, especially those in the subphrenic space, without passing through intervening organs.

MATERIALS AND METHODS

This retrospective case series study describes seven inpatients who underwent CT-guided drainage using a modified Trocar technique for abscesses that are difficult to access percutaneously. All patients provided written informed consent prior to the procedure. After placement of a 12-14F catheter inside the peritoneum, the Trocar stylet was removed so that the tip of the catheter became blunt and flexible to avoid injury to organs and structures in the catheter route, and the catheter was slowly advanced towards the collection using CT guidance and tactile sensation. After reaching the target, the stylet was reintroduced to enter the abscess wall.

RESULTS

All procedures were performed using an anterior abdominal wall access with adequate catheter positioning and resulted in clinical status improvement in the days after the drainage. No complications related to the procedure were identified in any of the patients.

CONCLUSIONS

The modified Trocar technique for percutaneous CT-guided drainage of abdominal abscesses may be feasible for lesions that are difficult to access with conventional methods.

Percutaneous image-guided pelvic procedures in women with gynecologic cancers: utilization, complications, and impact on patient management

PURPOSE

Image-guided percutaneous pelvic procedures often play an important role in the management of women with gynecologic cancers. The purpose of this study is to evaluate the utilization of and indications for these procedures, and quantify their impact on patient management.

METHODS

IRB-approved retrospective record review of percutaneous pelvic procedures requested by gynecologic oncology, 2005 to 2015. Descriptive statistics and logistic regression were performed.

RESULTS

392 pelvic procedures, including fluid aspiration, core biopsy, and fine needle aspiration, were performed in 225 women. Procedures were performed under sonographic guidance (303/392, 77.30%), CT guidance (87/392, 22.19%), or both (2/392, 0.51%). Pathology results included: no specimen sent (157/392, 40.05%), new cancer diagnosis (55/392, 14.03%), recurrence or metastasis of known primary cancer (107/392, 27.30%), benign tissue (67/392, 17.09%), and nondiagnostic (6/392, 1.53%). In terms of management, some procedures led to oncologic surgery, radiation, or chemotherapy (158/392, 40.31%), cessation of oncologic treatment (36/392, 9.18%), or treatment of infection (10/392, 2.55%). Many procedures were therapeutic (178/392, 45.41%), while a minority were performed for genomics (1/392, 0.26%) or did not impact clinical management (9/392, 2.30%). The number of procedures per year increased over time during the period of data collection. Date of service was a significant positive predictor of a purely therapeutic procedure (OR 1.69 [95 % CI 1.44-1.98], p < 0.0001) and a significant negative predictor of a malignant diagnosis (OR 0.72 [95 % CI 0.64-0.81], p < 0.0001), for each year later in the 10-year cycle.

CONCLUSION

In this single institution study, we identified a trend toward increased utilization of image-guided percutaneous pelvic interventions in women with gynecologic cancers. The case mix has shifted over the past 10 years, with procedures for symptom management constituting a larger proportion and diagnostic procedures constituting a smaller proportion of procedures over time.

Midline extraperitoneal approach for bilateral widespread retroperitoneal abscess originating from anorectal infection

INTRODUCTION

Anorectal abscess is one of the most common anorectal conditions encountered in practice. However, such abscesses may rarely extend upward and cause life-threatening medical conditions.

PRESENTATION OF CASE

A 53-year-old woman presented with symptoms of anorectal abscess and evidence of severe inflammatory response and acute kidney injury. Computed tomography revealed a widespread abscess extending to the bilateral retroperitoneal spaces. Surgical drainage was performed via a totally extraperitoneal approach through a lower midline abdominal incision, and the patient had a rapid and uncomplicated recovery.

DISCUSSION

Although retroperitoneal abscesses originating from the anorectal region are rare, they are life-threating events that require immediate treatment. Percutaneous abscess drainage has been recently evolved; however, surgical drainage is required sometimes that may be challenging, particularly in the case of widespread abscesses, as in our case.

CONCLUSION

The midline extraperitoneal approach reported here might be an effective surgical option for patients with bilateral widespread retroperitoneal abscesses.

Hydrodissection-assisted image-guided percutaneous biopsy of abdominal and pelvic lesions: experience with seven patients

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of retroperitoneal organ displacement for image-guided percutaneous biopsy.

CONCLUSION

Organ displacement using 0.9% saline or 5% dextrose in water (D5W) can create safe access routes for targeted abdominal and pelvic biopsies.