Comparative Outcomes of Trocar Puncture With Sump Drain, Percutaneous Drainage, and Surgical Drainage in the Management of Intra-abdominal Abscesses in Crohn’s Disease

Initial Management of Intra-abdominal Abscesses and Preventive Strategies for Abscess Recurrence in Penetrating Crohn's Disease: A National, Multicentre Study Based on ENEIDA Registry

INTRODUCTION

Intra-abdominal abscesses complicating Crohn's disease [CD] are a challenging situation. Their management, during hospitalisation and after resolution, is still unclear.

METHODS

Adult patients with CD complicated with intra-abdominal abscess. who required hospitalisation, were included from the prospectively maintained ENEIDA registry from GETECCU. Initial strategy effectiveness and safety to resolve abscess was assessed. Survival analysis was performed to evaluate recurrence risk. Predictive factors associated with resolution were evaluated by multivariate regression and predictive factors associated with recurrence were assessed by Cox regression.

RESULTS

In all, 520 patients from 37 Spanish hospitals were included; 322 [63%] were initially treated with antibiotics alone, 128 [26%] with percutaneous drainage, and 54 [17%] with surgical drainage. The size of the abscess was critical to the effectiveness of each treatment. In abscesses < 30 mm, the antibiotic was as effective as percutaneous or surgical drainage. However, in larger abscesses, percutaneous or surgical drainage was superior. In abscesses > 50 mm, surgery was superior to percutaneous drainage, although it was associated with a higher complication rate. After abscess resolution, luminal resection was associated with a lower 1-year abscess recurrence risk [HR 0.43, 95% CI 0.24-0.76]. However, those patients who initiated anti-TNF therapy had a similar recurrence risk whether luminal resection had been performed.

CONCLUSIONS

Small abscesses [<30mm] can be managed with antibiotics alone; larger ones require drainage. Percutaneous drainage will be effective and safer than surgery in many cases. After discharge, anti-TNF therapy reduces abscess recurrence risk in a similar way to bowel resection.

Trocar puncture with modified sump drainage for duodenal stump fistula after radical gastrectomy for gastric cancer: A retrospective controlled study

Duodenal stump fistula (DSF) is a serious complication of radical gastrectomy for gastric cancer. Herein, we illustrated an innovative choice for treating duodenal stump fistulas by placing a modified sump drainage through trocar puncture into the DSF-related abscess (DSF-abscess) cavity. We retrospectively analyzed 974 consecutive patients who underwent gastrectomy for gastric cancer between 2011 and 2021. Of these patients, 34 who developed postoperative duodenal stump fistulas postoperatively were enrolled into our study, and their clinical data were retrospectively assessed. From January 2011 to December 2017, 15 patients received conventional treatments (percutaneous catheter drainage, PCD group) known as the traditional percutaneous method, and 19 patients from January 2018 to December 2021 received new treatments (Troca's SD group) consisting of conventional therapies and placement of a modified sump drainage through trocar puncture into DSF-abscess cavity. The demographics, clinical characteristics and treatment outcomes were compared between two groups. Compared with the PCD group, the rates of postoperative complications, duodenostomy creation, subsequent surgery, fistula healing rates of the DSF, and length of postoperative hospital stay were significantly decreased in the Troca SD group. However, there was no significant difference in the abscess recurrence rate and mortality rates. Trocar puncture with a modified sump drainage is an safe, effective, and technically feasible treatment for duodenal stump fistula after radical gastrectomy for gastric cancer. This novel technique should be further investigated using large-scale RCT research.

Trocar Puncture With a Sump Drain for Crohn's Disease With Intra-Abdominal Abscess: A 10-Year Retrospective Cohort Study

Background

Traditional percutaneous catheter drainage (PCD) and surgical intervention could not always achieve satisfactory results for patients with Crohn's disease (CD) who have complications with intra-abdominal abscess. We proposed a trocar puncture with sump drainage for the treatment of CD with intra-abdominal abscess and compared it with the conventional PCD and surgical intervention.

Methods

Crohn's disease patients with intra-abdominal abscess and admitted to our hospital from 2011 to 2020 were identified by reviewing the electronic medical records. We divided them into Trocar, PCD, and fecal diverting (FD) groups, according to the ways of treating an abscess. Outcomes, risk factors for abscess recurrence, and postoperative complications were compared among the three groups.

Results

A total of 69 patients were included and they were divided into Trocar (n = 18), PCD (n = 29), and FD (n = 22) groups. Four patients in the PCD group were transferred to receive the FD surgery due to the failure of initial treatment. The incidence of abscess recurrence was significantly higher in the PCD (48%) and FD (50%) groups compared to the patients using the trocar puncture with the sump drain (Trocar group) (16.7%). There were 8 patients in Trocar, 22 in PCD, and 20 s in the FD group who received enterectomy. None of the patients in the Trocar had an ultimate stoma and the incidence of postoperative complications was statistically lower [0% (Trocar) vs. 31.8% (PCD) vs. 45% (FD), P < 0.05]. The way of initial treating of the abscess was significantly correlated with the abscess recurrence and postoperative complications.

Conclusions

Trocar puncture with a sump drain had a lower incidence of abscess recurrence, abdominal adhesions, postdrainage, and postoperative complications compared to the conventional PCD or surgical intervention.

Risk factors for postoperative surgical site infections in patients with Crohn's disease receiving definitive bowel resection

Surgical site infection presents as a significant problem that limits the potential benefits of surgical interventions. This study is to investigate risk factors for postoperative SSI in patients with Crohn’s disease receiving definitive bowel resection. A case-control study including 49 patients with SSI and 105 patients without SSI was performed. Demographics, clinical characteristics, laboratory information, medical and surgical data were compared between groups. Significant elements were subsequently brought into logistic regression analysis for further identification. Patients with SSI exhibited higher tobacco usage rate (p = 0.03), lower preoperative hemoglobin (p = 0.02) and pre-albumin level (p = 0.02). Bowel penetration instead of stricture was more frequent in patients with SSI (p = 0.04). Longer duration of operation (p = 0.03) and higher intraoperative lactate level (p = 0.02) were observed in patients with SSI. Logistic analysis identified that preoperative pre-albumin (95% CI: 0.2~0.7; OR = 0.5; p = 0.03), duration of operation (95% CI: 2.3~9.5; OR = 3.8; p = 0.03) and intraoperative lactate level (95% CI: 1.7~7.2; OR = 3.4; p = 0.04) were associated with postoperative surgical site outcome. Our data has identified that lower preoperative pre-albumin, longer duration of operation and higher intraoperative lactate level are risk factors for SSI in patients with Crohn’s disease receiving definitive bowel resection.

A Meta-analysis of Percutaneous Drainage Versus Surgery as the Initial Treatment of Crohn's Disease-related Intra-abdominal Abscess

BACKGROUND AND AIMS

Spontaneous intra-abdominal abscess formation is a common complication of Crohn's disease. Percutaneous drainage [PD] may avoid surgery and preserve bowel length, although there is no consensus on its efficacy as the initial treatment and the associated outcomes if unsuccessful. This study uses meta-analytical techniques to compare the outcomes of PD alone versus primary surgery for Crohn's-related intra-abdominal abscess.

METHODS

A comprehensive search for comparative studies examining the use of PD and surgery for spontaneous Crohn's-related intra-abdominal abscess was performed. Each study was reviewed and data extracted. Random-effects methods were used to combine data.

RESULTS

There were six studies including a total of 333 patients that met the inclusion criteria. Surgery was performed initially in 184 patients, PD was performed in 149. Groups were similar in demographics and abscess characteristics. There was a significantly higher risk of abscess recurrence following PD (odds ratio [OR]: 6.544, 95% confidence interval [CI]: 1.783-24.010, p: 0.005]. The pooled proportion of PD patients requiring subsequent surgery was 70.7%. There was no significant difference between approaches in post-procedural complication rate [OR: 0.657, 95% CI: 0.175-2.476, p: 0.535], ultimate permanent stoma requirement [OR: 0.557, 95% CI: 0.147-2.111, p: 0.389] or length of hospital stay [difference in means: -1.006 days, 95% CI: -28.762-26.749, p: 0.943].

CONCLUSIONS

PD can avoid surgery in up to 30% of patients presenting with spontaneous Crohn's-related intra-abdominal abscesses. However, the suggested advantages over surgery in relation to complications and length of stay were not apparent. Further studies in this area are needed.

Outcomes of initial medical compared with surgical strategies in the management of intra-abdominal abscesses in patients with Crohn's disease: a meta-analysis

BACKGROUND

Several studies have also evaluated the efficacy of initial medical management compared with initial surgical management strategies with regard to abscess resolution with variable results.

OBJECTIVE

The aim of this study is to evaluate the efficacy of initial medical management compared with surgical management of Crohn's disease (CD)-related intra-abdominal abscesses.

DATA SOURCES

A comprehensive search of multiple databases (MEDLINE/PubMed, Cochrane databases, CINAHL, Scopus, and Google Scholar) was performed in August 2014.

STUDY SELECTION

All studies on adults comparing initial surgical versus medical approaches to treat CD-related abscesses were included.

MAIN OUTCOMES MEASURED

The durability of abscess resolution and rate of stoma creation between the groups undergoing initial surgical versus medical approaches were compared.

RESULTS

The pooled analysis of the nine studies including a total 603 patients showed an overall rate of abscess resolution were 56.6% in the medical group compared with 80.7% in the surgical group. There was over three-fold higher chance of achieving abscess resolution when an initial surgical strategy was used at the time of abscess diagnosis compared with the medical strategy (odds ratio 3.44, 95% confidence interval: 1.80, 6.58, P<0.001). The number needed to treat using the initial surgical approach to prevent a recurrent abscess was four patients.

LIMITATIONS

All included studies were retrospective case series with potential clinical confounders not fully accounted in the analysis.

CONCLUSION

Initial surgical management appears to be superior to medical management in patients with CD-related intra-abdominal abscesses. Though all the included studies in this meta-analysis were retrospective, this meta-analysis is likely the strongest level of evidence with regard to the management of CD-related abscesses, given that a randomized-control trial may not be feasible given the low rate of abscess development in CD.