Complications of percutaneous fluid drainage

Prophylactic surgical drain placement with irrigation reduces abscess formation in patients with severe, uncontained, perforated appendicitis

BACKGROUND

20-25% of perforated appendicitis cases are complicated by abscess formation. This study assesses whether prophylactic closed-suction surgical drain (SD) placement after irrigation can decrease postoperative abscess formation in patients with extensively contaminated, perforated appendicitis.Affiliations: Journal instruction requires country for affiliations; however, these are missing in all affiliations. Please verify if the provided country names are correct and amend if necessary.They're correct METHODS: A multicenter retrospective review was performed on pediatric patients with uncontained perforated appendicitis from January 1, 2020 to August 1, 2023. Limited irrigation was performed. All SDs were oriented towards the pelvis. Data were analyzed in four groups: (G1) SD and irrigation, (G2) only SD, (G3) only irrigation, (G4) neither SD nor irrigation.

RESULTS

One hundred and fifteen patients (44 in G1, 3 in G2, 21 in G3, 47 in G4) were included. The abscess rate was 5.1% (G1), 33.3% (G2), 33.3% (G3), and 37.0% (G4) (p = 0.001). No interventional radiology (IR) drains were placed in G1 and G2. SD duration was 4.1 ± 2.1 days in G1 and 2.7 ± 0.6 days in G2. IR drain duration was 14 ± 10.7 days in G3 and 8.3 ± 3.9 days in G4 (p < 0.001). There were no significant differences in total length of stay and antibiotic duration.

CONCLUSIONS

Irrigation with prophylactic SD placement may prevent postoperative abscesses in patients with severe, uncontained, perforated appendicitis, but prospective data are needed.

Percutaneous Biopsy and Drainage of the Pancreas

Percutaneous biopsy and drainage of pancreatic lesions, though less frequent due to advancements in endoscopic techniques, remain vital skills for interventional radiologists. This review details the indications, options, approaches, and technical considerations for pancreatic biopsy and (peri)pancreatic fluid drainage by examining a comprehensive range of literature. The importance of a multidisciplinary approach is emphasized to ensure optimal patient care and outcomes, highlighting current best practices and recent advancements.

Prophylactic Peri-Nephric Drain Placement in Renal Transplant Surgery: A Systematic Review and Meta-Analysis

Renal transplantation is common worldwide, with >25,000 procedures performed in 2022. Usage of prophylactic perinephric drains is variable in renal transplantation; drains are associated with risks, and there is a lack of consensus regarding benefit of routine drain placement in these patients. This meta-analysis assessed whether prophylactic drainage reduced need for reintervention postoperatively. This systematic review and meta-analysis was carried out using the Preferred Reporting Items in Systematic Reviews and Meta-Analysis, and prospectively registered on PROSPERO. Summary statistics for outcomes of interest underwent meta-analyses to a confidence interval (CI) of 95% and are presented as Forest Plots for Odds Ratio (OR). A systematic literature search in June 2023 revealed 1,540 unique articles across four databases. Of these, four retrospective cohort studies were selected. Meta-analysis of three studies showed no significant reduction in reintervention rate with pre-emptive drain placement, OR = 0.59 (95% CI: 0.16-2.23), p = 0.44. Meta-analysis did not show a significant reduction in perinephric collections with prophylactic drain insertion OR = 0.55 (95% CI: 0.13-2.37), p = 0.42. Finally, there is not good evidence that drain placement reduces superficial wound complications or improves 12-month graft survival. Further work is needed, including well-designed, prospective studies to assess the risks and benefits of drain placement in these patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023422685, Identifier PROSPERO CRD42021255795.

Post-intervention complications and management: Following percutaneous catheter drainage

The role of an interventional radiologist in the care of the patent with pancreatitis is twofold - as a diagnostician and as an interventionalist. The diagnostic part includes the role in the diagnosis of pancreatitis, the possible etiology, and associated complications if any. From the therapeutic point of view it includes the management of the various vascular and non-vascular complications of pancreatitis. With increase in the percutaneous management of pancreatitis associated collections, it is prudent to be well versed with the complications that may be encountered. This article focusses on the various complications secondary to percutaneous management of collections in pancreatitis and the management options that are available at the interventional radiologist's disposal. The complications are discussed under different sections including access-related, catheter-related and other non-vascular complications.

Pilot Study on the Influence of Incentive Spirometry on Percutaneous Image-Guided Intra-Abdominal Drainage Catheter Pressure: A Potential Method to Enhance Drainage

Background

To report the evaluation of incentive spirometry (IS)-induced pressure changes in intra-abdominal drainage catheters and consider its use for maintaining catheter patency and enhancing drainage.

Methods

Prospective study of patients with indwelling intra-abdominal drainage catheters for abdominal fluid collections who had their intra-abdominal pressures measured while performing incentive spirometry. Patients were instructed in the use of an incentive spirometer. Within a week after initial drainage, pressure changes with IS were evaluated three times at 1500 cc and three times at maximum inspiratory effort. Intra-abdominal pressure (IAP) was measured using a pressure monitor connected to the drainage catheter.

Results

Twenty patients (men, 12; women, 8). Fluid collection locations were pelvis, Right-upper quadrant (RUQ), Left-upper quadrant (LUQ), Left-lower quadrant (LLQ), and Right-lower quadrant (RLQ). A total of 16 of 20 patients showed an elevation of IAP with IS. At 1500 cc, the pressure increased by an average of 41.24 mmH2O. At maximal inspiratory effort, the pressure increased by an average of 48.26 mmH2O. Pressure increase was greater in upper abdomen catheters. Four patients with lower abdominal and pelvic collections showed minimal pressure changes with IS.

Conclusion

IS increases IAP and fluid flow through abdominal drainage catheters. Future studies are warranted to determine whether the use of IS enhances catheter performance and facilitates drainage via its effect on IAP.

Safety and clinical efficacy of EUS-guided pelvic abscess drainage

Background and Objectives

EUS is a potential alternative for the drainage of abscesses. The aim of this study was to determine if EUS-guided pelvic abscess drainage is technically feasible, safe, and a valid option for abscess resolution.

Methods

We conducted a retrospective review from 2002 to 2020 at a single quaternary institution. EUS-guided pelvic abscess drainage via the transrectal route was performed in all patients with or without drain/stent placement. Technical and clinical success of EUS-guided pelvic abscess drainage was analyzed. Descriptive analyses and Fisher exact test were performed.

Results

Sixty consecutive patients were included in the study (53.5% male; mean age, 53.8 ± 17.9 years). Pelvic abscesses occurred mainly postoperatively (33 cases; 60.0%) and from complicated diverticulitis (14 cases; 23.3%). Mean diameter was 6.5 ± 2.4 cm (80% unilocular). Drainage was performed with EUS-guided stent placement (double-pigtail plastic or lumen-apposing metal) in 74.5% of cases and with aspiration alone for the remainder. Technical success occurred in 58 cases (97%). Of those with long-term follow-up after EUS-guided pelvic abscess drainage (n = 55; 91.7%), complete abscess resolution occurred in 72.7% of all cases. Recurrence occurred in 8 cases (14.5%) and persisted in 7 patients (12.5%), 7 of which were successfully retreated with EUS-guided pelvic abscess drainage. Accounting for these successful reinterventions, the overall rate of abscess resolution was 85.5%. Abscess resolution rate improved with drain placement (83%). Accounting for 7 repeat EUS-guided pelvic abscess drainages, overall abscess resolution improved. Two deaths occurred (3.4%) because of sepsis from failed source control in patients who had previously failed medical, radiological, and surgical treatment.

Conclusions

EUS-guided pelvic abscess drainage is technically feasible, safe, and an effective alternative to radiological or open surgical drainage. It also offers favorable clinical outcomes in different clinical situations.

A novel technique for the non-surgical management of inadvertent bowel catheterization during percutaneous abscess drainage: a technical note

Percutaneous abscess drainage-related inadvertent bowel catheterization is an undesired complication that requires treatment. In two cases without signs of peritonitis that we examined, it was possible to achieve successful abscess drainage, and to treat abscess-related inadvertent bowel catheterization by using a novel technique without surgery.

Design of a High-Flow Catheter Connector to Enhance Fluid Transfer

PURPOSE

To compare the performance of a prototype high-flow catheter connector, the Lamprey Lock, with that of a conventional Luer connector.

MATERIALS AND METHODS

The Lamprey Lock was created to eliminate the choke point resulting from Luer connections by achieving a cross-sectional area approximately 2.5 times larger than that achieved by a conventional Luer connector. A Lamprey Lock 3-way connector was also created by expanding the inner channels of a traditional Luer 3-way connector and exchanging the male Luer connection with a Lamprey Lock connection. These were tested against unaltered Luer and Luer 3-way connectors to compare flow rates using in vitro models of serous and purulent fluid. Each experimental condition was repeated 5 times.

RESULTS

In the serous model, the mean drainage rate was 4.4 mL/s (95% CI, 4.3-4.6) and 3.3 mL/s (95% CI, 3.3-3.5) for the Lamprey Lock and Luer connector, respectively (P < .001). The mean drainage rate was 4.2 mL/s (95% CI, 3.9-4.5) and 2.7 mL/s (95% CI, 2.5-2.8) for the Lamprey Lock 3-way and Luer 3-way connector, respectively (P < .001). In the purulent model, the mean drainage rate was 1.4 mL/min (95% CI, 1.3-1.6) and 0.75 mL/min (95% CI, 0.68-0.82) for the Lamprey Lock and Luer connector, respectively (P < .001). The mean drainage rate was 1.5 mL/min (95% CI, 1.3-1.7) and 0.74 mL/min (95% CI, 0.70-0.78) for the Lamprey Lock 3-way and Luer 3-way connector, respectively (P < .001).

CONCLUSIONS

The proposed high-flow catheter connector, the Lamprey Lock, demonstrated higher flow rates than those demonstrated by a conventional Luer connector in vitro.

Retrospective evaluation of the use of small-bore wire-guided catheters for the management of peritoneal effusion in cats and dogs

OBJECTIVE

To describe the use of small-bore wire-guided catheters in the management of peritoneal effusion in cats and dogs and to detail any associated adverse events.

DESIGN

Retrospective study.

SETTING

University teaching hospital ANIMALS: Forty-five client-owned animals that had peritoneal catheters placed for management of peritoneal effusion between July 2010 and June 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-five cases were included (25 dogs and 20 cats). Twenty-eight animals had the catheter placed to aid management of a uroabdomen, 8 of which recovered without surgical management, 11 had the catheter placed to allow autotransfusion of hemoabdomen, 3 had peritonitis, and 3 had ascites secondary to cardiac disease. Twenty-seven cases (15 dogs and 12 cats) received sedation (n = 24) or local anesthesia alone (n = 3) to facilitate catheter placement, and 6 cases had the catheter placed while under general anesthesia. Median length of catheter persistence was 24 hours (range: 2-144 h). The most common adverse events reported were impaired drainage (n = 7) and leakage at the insertion site (n = 4).

CONCLUSIONS

Peritoneal catheters can be inserted percutaneously for management of peritoneal effusion. Indications include stabilization and conservative management of uroabdomen, and autotransfusion. They can often be placed with minimal or no sedation and adverse events appear infrequent in occurrence.

Just-in-time Training with Remote Guidance for Ultrasound-Guided Percutaneous Intervention

BACKGROUND: Management of surgical emergencies in spaceflight will pose a challenge as the era of exploration class missions dawns, requiring increased crew autonomy at a time when training and supplies will be limited. Ultrasound-guided percutaneous intervention would allow for the management of a variety of pathologies with largely shared equipment and training. This proof-of-concept work attempts to determine the feasibility of "just-in-time" remote teaching and guidance of a sample procedure of this type.METHODS: Subjects naïve to ultrasound-guided intervention were instructed via a short video regarding the technique for placement of a percutaneous drain into a simulated abscess within a gel phantom. Subjects were then guided through the performance of the procedure via two-way audiovisual communication with an experienced remote assistant. Technical success was determined by the successful aspiration or expression of fluid from the simulated abscess following drain placement. This was then performed by and compared with staff experienced with such procedures. Time to completion and number of needle redirections required were also measured.RESULTS: All 29 subjects naïve to interventional work and the 4 experienced control subjects achieved technical success. There was a statistically significant difference in the time to completion between the two groups, with the experienced subjects averaging 2 min to completion and the inexperienced 5.8 min. There was no statistically significant difference in the number of redirections.DISCUSSION: This proof-of-concept work demonstrates high rates of technical success of percutaneous ultrasound-guided intervention in previously inexperienced personnel when provided with brief just-in-time training and live two-way audiovisual guidance.Lerner DJ, Pohlen MS, Apland RC, Parivash SN. Just-in-time training with remote guidance for ultrasound-guided percutaneous intervention. Aerosp Med Hum Perform. 2022; 93(12):882-886.

Safety and Efficiency of Prostatic Abscess Transgluteal Drainage: A Case Report and Review of the Literature

Prostatic abscess (PA) is an uncommon disorder that mainly affects diabetic and immunocompromised patients. It requires a high index of suspicion for diagnosis since it can clinically mimic acute prostatitis. Historically, transurethral drainage along with antimicrobial therapy has been the gold standard therapy. However, advances in imaging modalities have shifted the management of PA to less invasive approaches. Here, we present a case of a large PA drained by the percutaneous transgluteal approach. This access route is a safe, effective, and well tolerated alternative for PA drainage, done under local anesthesia and providing a relatively cleaner approach than transrectal or transperineal drainage, allowing easier and better catheter fixation as well. This article illustrates the different steps of the procedure and reviews the literature on PA management.

Value of spectral detector computed tomography to differentiate infected from noninfected thoracoabominal fluid collections

PURPOSE

To investigate the diagnostic value of spectral detector CT (SDCT)-derived virtual non-contrast (VNC), virtual monoenergetic images (VMI) and iodine overlays (IO) for distinguishing infected from noninfected fluid collections (FC) in the chest or abdomen.

METHOD

This retrospective study included 58 patients with venous phase SDCT with 77 FC. For all included FC, microbiological analysis of aspirated fluid served as reference. For quantitative analysis, wall thickness was measured, and (ROI)-based analysis performed within the fluid, the FC's wall (if any) and the aorta. Two radiologists qualitatively evaluated visibility of wall enhancement, diagnostic confidence regarding infection of fluid collection, confidence of CT-guided drainage catheter placement and visibility of anatomical landmarks in conventional images (CI) and VNC, VMI_40keV, IO.

RESULTS

Wall thickness significantly differed between infected (n = 46) and noninfected (n = 31) FC (3.5 ± 1.8 mm vs. 1.4 ± 1.8 mm, AUC = 0.81; p < 0.05). Fluid attenuation and wall enhancement was significantly higher in infected as compared to noninfected FC in all reconstructions (p < 0.05, respectively). Highest AUC regarding A) attenuation in fluid was yielded in CI and VMI_70,80keV (0.75); B) wall enhancement in CI (0.88) followed by iodine concentration (0.86). Contrast-to-noise ratio of wall vs. fluid was highest in VMI_40keV (p < 0.05). All assessed qualitative parameters received significantly higher ratings when using spectral reconstructions vs. CI (p for all <0.05), except for visibility of wall enhancement.

CONCLUSION

Spectral reconstructions improve the assessment of infected from noninfected thoracoabdominal fluid collections and depiction of wall enhancement. Diagnostic performance of the quantitative measurements in spectral reconstructions were comparable with measurements in conventional images.

Ultrasound-Guided Percutaneous Drainage of Abdominal Collections—An Analysis over 5 Years

Introduction. Ultrasound-guided (US-guided) percutaneous drainage (PD) of abdominal collections represents the first-choice alternative to surgical intervention. The aim of our study was to assess the efficacy and safety of PD of visceral and non-visceral abdominal collections by reviewing our personal experience over a period of 5 years. Material and methods. The present study included 66 patients who underwent PD under ultrasound guidance. We analyzed clinical variables (collection size, catheter diameter, collection type, microbiological analysis, antibiotic regimens) along with the outcomes of the procedure. Results. Visceral collections were predominant, encompassing 38 hepatic abscesses and 1 splenic hematoma. Microbiological analysis showed that the majority (54%) were monomicrobial. The most encountered pathogens were Klebsiella pneumoniae and Escherichia coli. Technical success was achieved in all cases and clinical success was observed in 84.6% of the cases. No immediate procedural complications were detected. There were 6 patients who needed reinterventions, either by catheter replacement or by surgical treatment. The mortality rate was 4.5%, due to patients’ poor overall status and oncological comorbidities. Conclusions. Percutaneous drainage under ultrasound guidance is a safe and effective procedure in the management of abdominal collections.

Narrative review of vascular iatrogenic trauma and endovascular treatment

Iatrogenic injury is unfortunately a leading cause of morbidity and mortality for patients worldwide. The etiology of iatrogenic injury is broad, and can be seen with both diagnostic and therapeutic interventions. While steps can be taken to reduce the occurrence of iatrogenic injury, it is often not completely avoidable. Once iatrogenic injury has occurred, prompt recognition and appropriate management can help reduce further harm. The objective of this narrative review it to help reader better understand the risk factors associated with, and treatment options for a broad range of potential iatrogenic injuries by presenting a series of iatrogenic injury cases. This review also discusses rates, risk factors, as well as imaging and clinical signs of iatrogenic injury with an emphasis on endovascular and minimally invasive treatments. While iatrogenic vascular injury once required surgical intervention, now minimally invasive endovascular treatment is a potential option for certain patients. Further research is needed to help identify patients that are at the highest risk for iatrogenic injury, allowing patients and providers to reconsider or avoid interventions where the risk of iatrogenic injury may outweigh the benefit. Further research is also needed to better define outcomes for patients with iatrogenic vascular injury treated with minimally invasive endovascular techniques verses conservative management or surgical intervention.

Intermittent quick-check CT fluoroscopy-guided percutaneous drainage placement in patients with infected renal and perirenal fluid collections: 11-year experience

PURPOSE

We aimed to evaluate technical and clinical success and safety of computed tomography fluoroscopy (CTF)-guided percutaneous pigtail drainage (PPD) placement in patients with infected renal and perirenal fluid collections.

METHODS

This retrospective analysis comprised 44 patients (52.27% men; age, 57.1±18.5 years) undergoing low-milliampere (10-20 mA) CTF-guided PPD placement in 61 sessions under local anesthesia from August 2005 to November 2016. Infected fluid collections (n=71) included infected renal cysts (12.68%), renal and perirenal abscesses due to comorbidities (23.94%), or fluid collections after renal surgery or urological intervention (63.38%). Technical success was defined as PPD placement with consecutive fluid aspiration, clinical success as normalization or marked improvement of clinical symptoms (e.g., flank pain, fever) and inflammatory parameters (leukocyte count, C-reactive protein) after minimally invasive combination therapy (intravenous broad-spectrum antibiotics and drainage). Complications were classified according to the CIRSE classification.

RESULTS

Overall, 73 single lumen PPD (7.5-12 F) were utilized (1 PPD per session, 69.86%; 2 PPD per session, 15.07%). In 4 cases, PPD could not be inserted into the fluid collection (4.11%) or could not be aspirated (1.37%), yielding overall 94.5% primary technical success. Mean duration of functioning PPD before removal was 10.9 days. Adverse events within 30 days comprised PPD failure (2.27%) or secondary dislocation (Grade 3, 11.36%) and one death (Grade 6, unrelated to intervention, 2.27%). Additional invasive measures after primary CTF-guided PPD were required in 5 patients (nephrectomy 6.82%, partial nephrectomy 2.27%, surgical drainage 2.27%). Thus, clinical success using only minimally invasive measures was achieved in 39 of 44 patients (88.64%).

CONCLUSION

Given a minor proportion of patients requiring surgical revision, combined antibiotics and CTF-guided PPD of infected renal and perirenal fluid collections provides an excellent technical and clinical outcome.

Novel Dual-Lumen Drainage Catheter to Enhance the Active Evacuation of Complex Fluid Collections

PURPOSE

To compare the performance of a dual-lumen flushable drainage catheter to a conventional catheter for complex fluid collection drainage.

METHODS

Two prototype catheters (20- and 28-F) were created by incorporating a customized infusion lumen within the wall of a large-bore conventional drainage catheter, which facilitated simultaneous irrigation of the drainage lumen and the targeted collection via inward- and outward-facing infusion side holes. These were tested against unaltered 20- and 28-F conventional catheters to determine if the injection of a dedicated flush lumen improved rapidity and completeness of gravity drainage. In vitro models were created to simulate serous fluid, purulent/exudative fluid, particulate debris, and acute hematoma.

RESULTS

In the purulent model, mean drainage rate was 19.9 ± 8.0 and 9.5±1.4 mL/min for the 20-F prototype and control (P < .001) and 63.9 ± 4.3 and 35.4 ± 3.4 mL/min for the 28-F prototype and control (P = .006), respectively, with complete drainage achieved in all trials. In the particulate model, mean drainage rate was 24.5 ± 9.7 and 12.0 ± 12.5 mL/min for the 28-F prototype and control (P = .003), respectively, with 69.0% versus 41.1% total drainage achieved over 24 minutes (P = .029). In the hematoma model, mean drainage rate was 22.7 ± 4.6 and 4.8 ± 4.3 mL/min for the 28-F prototype and control (P = .022), respectively, with 80.3% versus 20.1% drainage achieved over 15 minutes (P = .003). Particulate and hematoma 20-F prototypes and conventional trials failed due to immediate occlusion.

CONCLUSIONS

The proposed dual-lumen drainage catheter with irrigation of a dedicated flush lumen improved evacuation of complex fluid collections in vitro.

Treating Porcine Abscesses with Histotripsy: A Pilot Study

Infected abscesses are walled-off collections of pus and bacteria. They are a common sequela of complications in the setting of surgery, trauma, systemic infections and other disease states. Current treatment is typically limited to antibiotics with long-term catheter drainage, or surgical washout when inaccessible to percutaneous drainage or unresponsive to initial care efforts. Antibiotic resistance is also a growing concern. Although bacteria can develop drug resistance, they remain susceptible to thermal and mechanical damage. In particular, short pulses of focused ultrasound (i.e., histotripsy) generate mechanical damage through localized cavitation, representing a potential new paradigm for treating abscesses non-invasively, without the need for long-term catheterization and antibiotics. In this pilot study, boiling and cavitation histotripsy treatments were applied to subcutaneous and intramuscular abscesses developed in a novel porcine model. Ultrasound imaging was used to evaluate abscess maturity for treatment monitoring and assessment of post-treatment outcomes. Disinfection was quantified by counting bacteria colonies from samples aspirated before and after treatment. Histopathological evaluation of the abscesses was performed to identify changes resulting from histotripsy treatment and potential collateral damage. Cavitation histotripsy was more successful in reducing the bacterial load while having a smaller treatment volume compared with boiling histotripsy. The results of this pilot study suggest focused ultrasound may lead to a technology for in situ treatment of acoustically accessible abscesses.

Pseudoaneurysm of the Mesenteric Artery Status Post Drain Placement for Complicated Diverticulitis

Perforated diverticulitis presents a challenging clinical scenario for the surgeon. Development of an abscess in those without an acute abdomen may be amendable to non-operative drainage. Furthermore, early intervention can dramatically alter the hospital course let alone the overall outcome. While relatively safe as a procedure, image-guided drainage does carry risk that needs to be calculated relative to benefit gained. One rare albeit possibly serious risk is pseudoaneurysm formation.

Outcomes of a single-step endoscopic ultrasound-guided drainage of pancreatic-fluid collections using an electrocautery-enhanced coaxial lumen-apposing, self-expanding metal stent with and without fluoroscopy

Background

Fluoroscopy is often used during the endoscopic drainage of pancreatic-fluid collections (PFCs). An electrocautery-enhanced coaxial lumen-apposing, self-expanding metal stent (ELAMS) facilitates a single-step procedure and may avoid the need for fluoroscopy. This study compares the treatment outcomes using ELAMS with and without fluoroscopy.

Methods

Patients with PFCs who had cystogastrostomy from January 2014 to February 2017 were enrolled. Two groups were studied based on fluoroscopy use. Technical success was defined as uneventful insertion of ELAMS at time of procedure. Clinical success was defined as (i) clinical resolution of symptoms after the procedure and (ii) >75% reduction in cyst size on computed tomography 8 weeks after stent placement. Adverse events including bleeding, stent migration, and infection were recorded.

Results

A total of 21 patients (13 males) had PFCs drainage with ELAMS in the study period. The mean age was 51.6 ± 14.2 years. Thirteen patients had walled-off necrosis while eight had a pancreatic pseudocyst. The mean size of the PFCs was 11.3 ± 3.3 cm. Fluoroscopy was used in seven cases (33%) and was associated with a longer procedure time compared to non-fluoroscopy (43.1 ± 10.4 vs 33.3 ± 10.5 min, P = 0.025). This association was independent of the size, location, or type of PFCs. Fluoroscopy had no effect on the technical success rates. In fluoroless procedures, the clinical resolution was 91% as compared to 71% in fluoroscopy procedures (P = 0.52) and the radiologic resolution was 57% as compared to 71% in fluoroscopy procedures (P = 0. 65). Three cases of stent migration/displacement occurred in the fluoroless procedures.

Conclusions

ELAMS may avoid the need for fluoroscopy during cystogastrostomy. Procedures without fluoroscopy were significantly shorter and fluoroscopy use had no impact on the technical or clinical success rates.

ACR Appropriateness Criteria® Left Lower Quadrant Pain-Suspected Diverticulitis

This review summarizes the relevant literature regarding imaging of suspected diverticulitis as an etiology for left lower quadrant pain, and imaging of complications of acute diverticulitis. The most common cause of left lower quadrant pain in adults is acute sigmoid or descending colonic diverticulitis. Appropriate imaging triage for patients with suspected diverticulitis should address the differential diagnostic possibilities and what information is necessary to make a definitive management decision. Patients with diverticulitis may require surgery or interventional radiology procedures because of associated complications, including abscesses, fistulas, obstruction, or perforation. As a result, there has been a trend toward greater use of imaging to confirm the diagnosis of diverticulitis, evaluate the extent of disease, and detect complications before deciding on appropriate treatment. Additionally, in the era of bundled payments and minimizing health care costs, patients with acute diverticulitis are being managed on an outpatient basis and rapid diagnostic imaging at the time of initial symptoms helps to streamline and triage patients to the appropriate treatment pathway. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Duodenal perforation after percutaneous fluid drainage, a rare event: a case report

Duodenal perforations can be caused by surgical instruments during operations. These injuries can go initially unnoticed and lead to problematic complications. While uncommon, bowel perforation after percutaneous fluid drainage can severely impact the patient's outcome. These can occur from equipment used for image-guided percutaneous drainage, a technique that has changed the way surgeons handle postoperative fluid collections and has become daily practice. Prompt recognition and timely treatment of these types of complications can minimize the consequences of this dreaded scenario. We present the case of a 29-year-old male, for whom an intra-abdominal collection was detected after laparoscopic cholecystectomy. CT-guided percutaneous drainage was performed, during which the catheter inadvertently punctured the duodenum. Surgical consultation was required and, since the patient remained asymptomatic, conservative management of the duodenal perforation was accomplished without complications. On follow-ups, the patient is doing well.

Complications of Percutaneous Drainage in Step-Up Approach for Management of Pancreatic Necrosis: Experience of 10 Years from a Tertiary Care Center

INTRODUCTION

Percutaneous catheter drainage (PCD) as initial intervention in necrotizing pancreatitis has led to improved outcomes and obviated need for surgery in a significant proportion. However, there can be difficulty in accessing deep-seated necrotic collections by percutaneous catheter and complications are likely.

METHODS

The present study involves a retrospective analysis of a prospectively maintained database of patients with necrotizing pancreatitis managed by a step-up approach. All patients who underwent PCD were studied for catheter-related complications.

RESULTS

A total of 707 PCD catheters were used in 314 patients (median 2, interquartile range IQR 1-3). The total number of interventions were 1194 (median 3, IQR 2-5). Enteric communication was seen in 8.9%, of which colonic fistula occurred in 71.4%, duodenal in 17.8%, and jejunal in 10.7% of patients. Majority (78.5%) of the fistulae were managed conservatively by withdrawal of the drain. Operative management was required in 30% of colonic and 40% of duodenal fistulae. Need for surgery, length of hospital stay, and mortality were not significantly different between patients with and without fistulae. Bleeding complications were seen in 7.3% of patients, out of which 34.7% were managed conservatively, 21.7% required angioembolization of pseudo-aneurysms, and 34.7% needed surgery. Patients with bleeding had significantly higher requirement for surgery and mechanical ventilation compared to those with no bleeding. There was no significant increase in hospital stay, ICU stay, and mortality.

CONCLUSION

Hollow viscus and vascular injuries are important complications seen with catheter drainage of necrotic collections. Majority of patients with enteric communication were managed conservatively, with no added morbidity or mortality. Bleeding complications related to PCD had higher requirement for surgical intervention, but mortality rates remained similar to those of patients with no bleeding complications.

Feline abdominal ultrasonography: what's normal? what's abnormal? The liver

PRACTICAL RELEVANCE

Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. Ultrasound examination of the liver can be key in the diagnosis of diseases such as hepatic lipidosis and hepatic neoplasia.

CLINICAL CHALLENGES

Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even differentiating between normal variation and pathological changes can be challenging for all but the most experienced. When assessing the liver via ultrasound, a diffuse alteration in liver echogenicity may be difficult to detect unless the change is marked and, although comparisons can be made with the spleen and kidneys, this relies on these organs being normal.

EQUIPMENT

Ultrasound facilities are readily available to most practitioners, although use of ultrasonography as a diagnostic tool is highly dependent on operator experience.

AIM

This review, the first in an occasional series on feline abdominal ultrasonography, discusses ultrasonographic examination of the normal and diseased liver, with focus on the liver parenchyma. It is aimed at general practitioners who wish to improve their knowledge of and confidence in feline abdominal ultrasound and is accompanied by high-resolution images. Ultrasound-guided sampling of the liver is also covered. Future articles will discuss the biliary tree and hepatic vascular anomalies.

EVIDENCE BASE

Information provided in this article is drawn from the published literature and the author's own clinical experience.

Successful Endoscopic Management of Double Iatrogenic Perforations Induced by Endoscopic Retrograde Cholangiopancreatography and Computed Tomography-Guided Colon Drainage

Endoscopic retrograde cholangiopancreatography (ERCP) is a high-risk procedure with a significantly high rate of complications, such as pancreatitis, bleeding, perforation, and infection. Pancreatitis is the most common post-ERCP complication with an incidence of approximately 3.5%. Although perforation is a rare complication with an incidence of 0.1–0.6%, it may be associated with a high rate of mortality of 1.0–1.5%. Here, we report a rare case of ERCP-induced double iatrogenic perforations in the duodenum and colon complicated by an intra-abdominal abscess. The post-ERCP perforation was successfully sealed using fibrin glue (Tisseel). The intra-abdominal abscess was treated with a computed tomography-guided pigtail drainage; however, the pigtail spontaneously migrated and perforated the ascending colon. The pigtail was removed, and closure of the colon perforation was successfully achieved with endoscopic clipping. Tisseel spray can be a treatment option for post-ERCP perforations. Careful consideration of procedural complications, early detection of perforations, and prompt treatment can be life-saving.

Preventing Surgical Site Infections Related to Abdominal Drains in the Intensive Care Unit

Surgical site infections are significant contributors to health care-associated infections. Nursing interventions may help decrease the incidence of surgical site infections, particularly in regards to the management of postsurgical abdominal drains. This comprehensive guide, compiled from evidence-based practice literature, is intended for nurses to use to reduce surgical site infections secondary to postsurgical abdominal drains. This article focuses on drain management in intensive care unit patients, who are at risk for infection because of their immunocompromised state.

Fluid Flow Patterns Through Drainage Catheters: Clinical Observations in 99 Patients

PURPOSE

To describe patterns of fluid flow through locking pigtail and biliary catheters in patients that underwent biliary and abdominopelvic fluid drainage.

METHODS

Contrast movement through catheter sideholes in pigtail and biliary catheters was evaluated retrospectively using sinograms and cholangiograms at 7-10 days post insertion. Dilute contrast injected through the catheter was evaluated by following flow through the catheter shaft and exit from side holes within the body cavity. Exit of contrast through side holes was appreciated and recorded. Included patients underwent biliary and abdominopelvic fluid drainage using 10.2-F catheters. Exclusion criteria included masking of contrast flow through sideholes by catheter angulation, contrast pooling or other imaging artifacts.

RESULTS

A total of 99 patients meeting inclusion criteria underwent evaluation of contrast flow through pigtail (n = 81) and biliary (n = 18) catheters. For pigtail and biliary catheters, 91/99 cases (91.9%) showed contrast exiting the catheter from only the sidehole located most proximally to the catheter hub. In 6/99 cases (6.1%) contrast exited no further than the second most proximal sidehole. In 2/99 cases (2.0%) contrast exited no further than the third most proximal sidehole. In no cases was contrast observed exiting from distal sideholes beyond the third most proximal sidehole.

CONCLUSION

Retrograde contrast injection through catheters suggests that the majority of the contribution to total output in drainage catheters comes from the most proximal side hole. Contribution of distal side holes to total drainage is negligible or non-existent, therefore the distal segment of the catheter may be considered non-functional.

Drain Failure in Intra-Abdominal Abscesses Associated with Appendicitis

BACKGROUND

Previous studies have suggested that percutaneous drainage and interval appendectomy is an effective treatment for appendicitis with associated abscess. Few studies to date have analyzed risk factors for failed drain management. We hypothesized that older patients with more co-morbidities would be at higher risk for failing conservative treatment.

METHODS

The 2010-2014 editions of the National Inpatient Sample (NIS) were queried for patients with diagnoses of peri-appendiceal abscesses. Minors and elective admissions were excluded. We identified patients who underwent percutaneous drainage and defined drain failure as undergoing a surgical operation after drainage but during the same inpatient visit to assess for factors associated with failure of drainage alone as a treatment. After univariable analysis, binomial logistic regression was used to assess for independent risk factors. Frequencies were analyzed by χ² and continuous variables by Student's t-test.

RESULTS

A total of 2,209 patients with appendiceal abscesses received drains; 561 patients (25.4%) failed conservative management and underwent operative intervention. On univariable analysis, patients who failed conservative management were younger, more likely to be Hispanic, have more inpatient diagnoses, and to have undergone drainage earlier in the hospital course. Multivariable regression demonstrated that the number of diagnoses, female sex, and Hispanic race were predictive of failure of drainage alone. Older age, West and Midwest census regions, and later drain placement were predictive of successful treatment with drainage alone. Failure was associated with more charges and longer hospital stay but not with a higher mortality rate.

CONCLUSION

Approximately a quarter of patients will fail management of appendiceal abscess with percutaneous drain placement alone. Risk factors for failure are patient complexity, female sex, earlier drainage, and Hispanic race. Failure of drainage is associated with higher total charges and longer hospital stay; however, no change in the mortality rate was noted.

Leakage of Hepaticojejunal Anastomosis: Radiological Interventional Therapy

BACKGROUND

Hepaticojejunostomy is an established procedure accompanying liver resection as well as hepatobiliary and pancreatic surgery. Typical complications requiring radiological intervention are abscesses and anastomosis leakage. Biliary obstruction and strictures are less frequent indications for interventional radiology since many of them can be treated endoscopically.

METHODS

Depending on anatomic location, underlying etiology, and complication of leakage, different procedures of interventional radiology are performed: treating abscesses through percutaneous abscess drainage (PAD), handling biliary leakage by percutaneous transhepatic biliary drainage (PTBD) after percutaneous transhepatic cholangiography (PTC), or rarely performed percutaneous stent implantation and internalization after PTC and PAD to treat biliary strictures or to cover the leak. A selective literature search was performed, taking into account recent papers of radiological interventions concerning leakage of hepaticojejunostomy.

RESULTS

Different radiological interventions for the treatment of potentially devastating complications after hepaticojejunostomy are recommended. PAD and PTBD serve either as a definite treatment or as bridging therapy until re-surgery is performed. Complications mainly concern uncontrollable bleeding during the intervention.

CONCLUSION

Radiological interventions are safe and usable if the indication is meticulously chosen. PAD is one of the most commonly performed procedures by interventional radiologists and a well-established and safe procedure. PTC, PTBD, and biliary stent implantation are important procedures which are required if endoscopic interventions failed or cannot be performed due to postoperatively changed anatomical structures.

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.

The evolving management of the appendix mass in the era of laparoscopy and interventional radiology

AIM

An appendix mass is the result of a walled-off perforation of the appendix which localises, resulting in a mass and it is encountered in up to 7% of patients presenting with acute appendicitis. However, its management is controversial due to the lack of high level evidence. This review article sets out a rationale diagnostic and therapeutic strategy for the appendix mass based upon up-to-date available evidence.

METHODS

A literature review of the investigation and management of appendix mass/complicated appendicitis was undertaken using PubMed, EMBASE and Google Scholar.

RESULTS/CONCLUSION

No prospective studies were identified. The great majority of recent evidence supports a conservative management approach avoiding urgent appendicectomy because of the high risk of major complications and bowel resection. Appendix abscesses over 5 cm in diameter and persistent abscesses should be drained percutaneously along with antibiotics. Appendix phlegmon should be treated with antibiotics alone. Surgery is reserved for patients who fail conservative treatment. Routine interval appendicectomy is not recommended, but should be considered in the context of persistent faecolith, ongoing right iliac fossa pain, recurrent appendicitis and appendix mass persistent beyond 2 weeks. Clinicians should be particularly wary of patients with appendix mass aged over 40 and those with features suggesting malignancy.

Xanthogranulomatous Pyelonephritis with Staghorn Calculus, Acute Gangrenous Appendicitis and Enterocolitis: A Multidisciplinary Challenge of Kidney-Preserving Conservative Therapy

Xanthogranulomatous pyelonephritis (XP) is a rare form of pyelonephritis and without treatment destructive to the kidney. We describe a 74-year-old Caucasian immunocompetent female patient with XP and multiple abscesses on the upper pole of the right kidney and several impacted obstructing renal calculi in the middle calyx that developed severe colitis and gangrenous appendicitis during therapy. Proteus mirabilis was detected as the major pathogen in the urine culture. Kidney preserving therapy was carried out by intensive parenteral bacterial eradication, CT-guided abscess drainage and stone destruction by 3 sessions of extracorporeal shock wave lithotripsy under ureteral stenting. Large tumor masses in XP are often daunting and may lead to a nephrectomy. However, kidney-preserving therapy is possible and should be considered in non-septic patients or in case of a solitary kidney.

Number and location of drainage catheter side holes: in vitro evaluation

AIM

To evaluate the influence of number and location of catheter shaft side holes regarding drainage efficiency in an in vitro model.

MATERIALS AND METHODS

Three different drainage catheter models were constructed: open-ended model with no side holes (one catheter), unilateral side hole model (six catheters with one to six unilateral side holes), and bilateral side hole model (six catheters with one to six bilateral side holes). Catheters were inserted into a drainage output-measuring device with a constant-pressure reservoir of water. The volume of water evacuated by each of the catheters at 10-second intervals was measured. A total of five trials were performed for each catheter. Data were analysed using one-way analysis of variance.

RESULTS

The open-ended catheter had a mean drainage volume comparable to the unilateral model catheters with three, four, and five side holes. Unilateral model catheters had significant drainage volume increases up to three side holes; unilateral model catheters with more than three side holes had no significant improvement in drainage volume. All bilateral model catheters had significantly higher mean drainage volumes than their unilateral counterparts. There was no significant difference between the mean drainage volume with one, two, or three pairs of bilateral side holes. Further, there was no drainage improvement by adding additional bilateral side holes.

CONCLUSION

The present in vitro study suggests that beyond a critical side hole number threshold, adding more distal side holes does not improve catheter drainage efficiency. These results may be used to enhance catheter design towards improving their drainage efficiency.

Diagnosis and management of hemorrhagic complications of interventional radiology procedures

Image-guided interventions have allowed for minimally invasive treatment of many common diseases, obviating the need for open surgery. While percutaneous interventions usually represent a safer approach than traditional surgical alternatives, complications do arise nonetheless. Inadvertent injury to blood vessels represents one of the most common types of complications, and its affect can range from inconsequential to catastrophic. The interventional radiologist must be prepared to manage hemorrhagic risks from percutaneous interventions. This manuscript discusses this type of iatrogenic injury, as well as preventative measures and treatments for postintervention bleeding.

Laparoscopy may have a role in the drainage of liver abscess: Early experience at Owerri, Nigeria

Background:

Image-guided percutaneous drainage with antimicrobial agents is the standard modality of treatment of liver abscess. Open surgical drainage, and lately laparoscopic drainage becomes useful in selected patients. Nigeria is awakening late to the laparoscopic surgery revolution. Public health institutions have started making enormous investments in minimal access surgery, which can augment deficient diagnostic capacities.

Objective:

To describe the outcomes of the patients who underwent laparoscopic liver abscess drainage at the Federal Medical Centre, Owerri.

Materials and Methods:

A retrospective analysis of the laparoscopic liver abscess drainage procedures done between the period September 2007 and December 2012 was done.

Results:

A total of eight patients in the study period were worked up for abscess surgical drainage based on ultrasound (seven cases) and computed tomography (one case) supported localized collection in the liver. Intraoperatively, one patient was noticed to have nodules on the liver that was later confirmed as hepatocellular carcinoma. Operating time ranged from 37 to 126 min. There was no conversion to open surgery. On the follow-up, one patient had residual abscess of 45 mm diameter size, after 6 weeks, and in whose aspirate acid-fast bacilli were identified.

Conclusion:

Laparoscopic drainage should be considered in the management of liver abscess.

Selective transperitoneal aspiration of a distended bowel with a small-caliber needle during laparoscopic Nissen fundoplication: a prospective randomized controlled trial

INTRODUCTION

Anecdotal reports have demonstrated the feasibility of needle aspiration to deflate a distended bowel, but we do not know of any prospective study that has evaluated this technique. We designed a controlled study to evaluate the use of the selective transperitoneal needle aspiration of a bowel loop (STAB) in infants.

MATERIALS AND METHODS

Candidates were patients of less than 6 months of age, scheduled for laparoscopic Nissen fundoplication, in whom severe colonic distension was observed. We randomized the patients to the study drug or placebo in a 1:1 mode. The treatment group received STAB, whereas the control group was subject to conventional maneuvers. We performed 403 Nissen procedures laparoscopically: 102 were in infants ≤ 6 months old, but only 44 presented severe transverse colonic distension.

RESULTS

STAB facilitated the surgical procedure and drastically reduced surgical time. Thus, we calculated our sample size with use of the following inputs: 90% power, a critical P value of .05, and 50% reduction in surgical time. This resulted in a necessary sample size of 21 subjects per group, for a total required sample size of 42 subjects. STAB procedures were done in 23 patients, and conventional measures were used in 21. STAB was attempted a total of 45 times. Mean operative time was shorter in the STAB group.

CONCLUSIONS

We propose the use of STAB as alternative therapy to decompress a dilated large-bowel loop during laparoscopic surgery. This maneuver is simple and efficient and has no clinical complications. Future studies are required to evaluate its role in the subset of other patients or procedures.

Fatal liver injury complicated by percutaneous catheter drainage after distal pancreatosplenectomy in a patient with pancreatic cancer

Postoperative pancreatic fistula (POPF) combined with postoperative fluid collection, bleeding and abscess formation is one of the most critical morbidities after distal pancreatectomy or pancreaticoduodenectomy. Percutaneous catheter drainage has been commonly used for managing for the postoperative management of abnormal fluid collection. Removal of the catheter is rarely associated with occurrence of life-threatening complication such as serious liver damage. Herein, we report a case of unexpected fatal liver injury complicated by percutaneous catheter drainage treatment after distal pancreatosplenectomy in a patient with pancreatic cancer. We suggest that prudent decision for timing of catheter removal and meticulous care during procedure can reduce the possibility of major liver injury in patients with percutaneous transhepatic catheter drainage.

Empyema necessitans: very late complication of pulmonary tuberculosis

Empyema necessitans is a rare clinical finding nowadays. We report the case of a patient admitted in our ward for investigation of an unknown onset anterior chest wall mass, with no accompanying signs or symptoms. It is noteworthy that the patient had had pulmonary tuberculosis submitted to thoracoplasty more than 60 years before. Thoracic MRI showed a large heterogeneous mass, with a thick wall and internal septations located at the right anterior chest wall, as well as a heterogeneous content inside the right pleural cavity, with direct communication between both. An aspirative puncture of both masses was performed, with positive cultures for Mycobacterium tuberculosis, thus leading to the diagnosis of pleural tuberculosis with anterior chest wall empyema necessitans. A drain was inserted and antibiotics started. This case draws our attention to a very rare complication of pulmonary tuberculosis and its surgical treatment, though it aroused many decades after primary infection.

In vitro evaluation of the insertion force for different dilator tip configurations

The purpose of this study was to evaluate the tissue penetration insertion force of different dilator tip geometries in simulated tissue. Four different dilator tip designs-conical (control), triangular, diamond, and biconvex-were appraised. The penetration force for each dilator was measured by using an ad hoc device. Each modified dilator required significantly less force necessary for "tissue" insertion compared with the conical control (P < .05 for all designs). These data suggest that angled dilator tips may facilitate insertion and may contribute to new dilator and catheter tip design.

Klebsiella pneumoniae liver abscess in an immunocompetent child

Klebsiella pneumoniae has emerged as a leading pathogen that causes pyogenic liver abscesses (PLAs) in Korea. K. pneumoniae liver abscess (KLA) is potentially life threatening, and the diagnosis is difficult. In developed countries, PLA is rarely observed in children and is frequently associated with disorders of granulocyte function and previous abdominal infection. We observed a case of KLA in a healthy 12-year-old boy. To our knowledge, this is the first reported case of KLA in an immunocompetent child without an underlying disease in Korea. The patient was treated with percutaneous catheter drainage and antibiotics. The catheter was placed in the intrahepatic abscess for 3 weeks and parenteral antibiotics (ceftriaxone and amikacin) were administered for 4 weeks, followed by oral antibiotics (cefixime) for 2 weeks. We reported this case to raise awareness of KLA in immunocompetent children among physicians, and to review the diagnosis, risk factors, potential complications, and appropriate treatment of KLA.