Trends in Use of Percutaneous Versus Open Surgical Drainage of Abdominal Abscesses

PURPOSE

To compare recent trends in the use of percutaneous and surgical approaches to treating abdominal abscesses in a large population.

METHODS

The nationwide Medicare Physician/Supplier Procedure Summary Master Files for 2001 through 2013 were searched. Current Procedural Terminology-4 codes were selected for the four types of abdominal abscesses that had distinct codes for both open surgical and percutaneous drainage-appendiceal, peritoneal, subphrenic, and liver. Medicare specialty codes were used to determine if the procedures were performed by radiologists or other nonradiologist physicians. Trends in use of the two approaches were compared.

RESULTS

In 2001, a total of 14,068 abdominal abscesses were drained percutaneously. This volume increased progressively every year thereafter, reaching 28,486 in 2013 (+102%). Open surgical drainage volume was 8,146 in 2001, decreasing progressively to 6,397 in 2013 (-21%). In 2001, 63% of all abdominal abscesses had been drained percutaneously; by 2013, this figure had risen to 82%. In 2001, radiologists had performed 90% of all percutaneous abdominal abscess drainages; this percentage share increased to 97% in 2013. Of all abdominal abscesses treated in 2013 in Medicare patients, 79% were treated by radiologists.

CONCLUSIONS

Use of percutaneous drainage of abdominal abscesses has steadily increased, whereas use of open surgical drainage has declined. The vast majority of these abscesses are now treated percutaneously. Radiologists are a strong majority of those performing the procedures. Although this database does not provide information on outcomes, percutaneous drainage is another good example of radiology-related value.

The use of a covered stent in carotid blowout syndrome

Rupture of the extracranial carotid arteries or their major branches is known as carotid blowout syndrome (CBS). CBS is a well-recognized complication of cancer of the head and neck and subsequent radiation therapy. A few treatment modalities are available, including open ligation and different endovascular techniques, but questions regarding both the immediate and delayed complications of these procedures persist. In this case report, we describe the management of acute CBS in a 54-year-old man who had previously been treated for follicular thyroid carcinoma. The patient was hemorrhaging from a pseudoaneurysm of the left common carotid artery. A self-expanding polytetrafluoroethylene (Teflon) -covered stent was successfully deployed endovascularly, and this resulted in cessation of the bleeding and restoration of flow through the vessel. We examine the covered-stent approach to treating acute CBS, and we discuss other treatment approaches that have been described in the literature.

Prognostic factors for survival after embolization of hepatic metastases in uveal melanoma

8562

Background: Liver is the most common site of metastasis (>80%) in patients with uveal melanoma. Embolization of the hepatic artery has been used to control hepatic metastases. Methods: Uveal melanoma patients with hepatic metastases embolized with iodized poppy seed oil and gelatin sponge, and either BCNU (chemoembolization, CE) or GM-CSF (immunoembolization, IE) during periods when each of these drugs was the agent of first choice, were evaluated. Prognostic factors that predict OS and progression free survival (PFS) in the liver (PFS-L) and in the extra-hepatic systemic organs (PFS-S) were analyzed univariately using the log-rank test and multivariately using Cox proportional hazards model. The following parameters were evaluated: age, gender, pre-existing extrahepatic metastases (EHM), LDH, AST, ALP, and treatment modality (CE or IE). Results: A total of 53 uveal melanoma patients with < 50% liver involvement with melanoma were analyzed. In comparison to the 19 patients (14 males/5 females) who underwent CE, the 34 patients who underwent IE (12 males/22 females) have significantly better OS (14.1 vs. 9.7 months, p=0.012) and PFS-S (10.2 vs. 4.8 months, P=0.013) in univariate analyses. Female patients outlived male patients (14.2 vs. 9.7 months, p=0.005). In Cox model, the shorter OS was associated with male gender (hazard ratio (HR)=2.1; 95% CI, 1.1–4.0; p=0.020), and marginally related to EHM (HR=1.8; 95% CI, 1.0–3.4; p=0.052). Independent predictors of shorter PFS-S included older age (HR=1.04 per year; 95% CI: 1.01–1.06; p=0.007), EHM (HR=2.1; 95% CI, 1.1–3.8; p=0.017), and CE (HR=2.1; 95% CI, 1.2–3.8; p=0.012). The gender-by-treatment interaction was also considered in all Cox models, but it was not significant. None of the covariates was a predictor of PFS-L in univariate or multivariate analyses. Conclusions: IE and female gender were found to be positive prognostic factors for survival after embolization of hepatic metastases.

No significant financial relationships to disclose.

Treatment of biliary calculi using holmium: yttrium aluminum garnet laser

BACKGROUND

The holmium: yttrium aluminum garnet laser (Ho: YAG) has been shown to be effective and safe for the treatment of urinary calculi. Its effectiveness for the treatment of biliary calculi was investigated.

METHODS

Endoscopic Ho: YAG lithotripsy of biliary stones was performed 7 times in 4 patients. Two patients had biliary duct calculi, and the other two patients had gall bladder calculi. All patients had multiple calculi that ranged in size from 4 mm to 5 cm. All procedures were performed percutaneously under intravenous sedation and local anesthesia. Rigid and flexible endoscopes were used to access the biliary calculi. Postoperative cholangiograms were performed on all patients.

RESULTS

All calculi were successfully fragmented with the Ho: YAG laser. The most common settings on the laser were 1.0 J and 10 Hz. Average total laser energy used was 12.24 kJ. Two patients required multiple procedures for the resolution of the biliary calculi. No vascular or biliary injuries were encountered. Three patients were free of biliary calculi on their postoperative cholangiogram. One patient with multiple gallbladder stones refused further treatment after two percutaneous procedures.

CONCLUSION

The holmium: yttrium aluminum garnet laser can be used safely and effectively in the endoscopic treatment of biliary calculi. This treatment maybe a suitable option in patients who are not candidates for more invasive procedures.