Abdominal Fluid Collections Research Articles

Combination Dornase and Alteplase for Intra-abdominal Drain, Abscess, and Hematoma Clearance: A Retrospective Case Series

Background: Since the advent of the MIST2 trial, the combined instillation of dornase and alteplase has become an effective nonsurgical treatment option for empyema and pleural fluid collection. Percutaneous drainage of abdominal abscesses and fluid collections, rather than open surgical treatment, also has become commonplace. The are several case reports and studies on the use of fibrinolytics to drain abdominal fluid collections but no literature reporting use of both alteplase and dornase for abdominal administration. Objective: We present a case series from an academic medical center where dornase therapy was added to fibrinolytic therapy to treat intra-abdominal fluid collections, hematoma, and abdominal drainage catheters with low output. Methods: This is an institutional review board-approved retrospective case series of 13 patients who underwent combination use of alteplase and dornase via intra-abdominal route. The primary objective was to assess for increased drain output, reduction in size of the fluid collection, and adverse events. Results: Many patients had improved drain output after dornase-alteplase therapy. One patient had significant bleeding complications. Conclusions: All patients were discharged alive from the hospital. Clinical success was difficult to define due to variable goals of therapy. Further data are needed to establish the safety and efficacy of this practice, especially compared with intra-abdominal alteplase alone. Patients in our series generally received larger doses of alteplase than in prior studies due to use of dosing modeled on the MIST2 trial. Based on the limited experience of our study, we recommend holding therapeutic anticoagulation during the administration of intra-abdominal dornase-alteplase.

S1502 Postoperative Abdominal Fluid Collections Management with EUS-Guided Transmural Drainage: Timing, Efficacy, and Safety Profile

S1502 Postoperative Abdominal Fluid Collections Management with EUS-Guided Transmural Drainage: Timing, Efficacy, and Safety Profile

Risk Factors for Death in Patients with Severe Acute Pancreatitis in Guizhou Province, China.

To compare the clinical characteristics of survival and nonsurvival patients with severe acute pancreatitis (SAP) and explore the risk of mortality in SAP patients. This was a single-center retrospective study performed in a severe acute pancreatitis diagnosis and treatment center. According to the outcome, SAP patients were divided into survival group and nonsurvival group. One-way ANOVA or independent t-test was used to compare the clinical characteristics of two groups of patients. Multivariate retrospective analysis was used to identify risk factors for mortality in SAP patients. A total of 486 SAP patients were included in the study, and the 90-day mortality for SAP patients was 13.58%. The common etiologies of SAP are biliary tract diseases (69.75%) and hyperlipidemia (17.28%). The most common complications caused by SAP were organ failure (55.14%), ARDS (50.62%), AKI (30.45%), sepsis (27.16%), and abdominal fluid collection (27.57%). There were differences in age, complications, and medical intervention between the nonsurvival group and the survival group. The main causes of death were infection (46.97%), abdominal bleeding (28.79%), and organ failure (9.09%). The binary logistic regression analysis showed that there were significant differences in age, AKI, sepsis, abdominal hemorrhage, organ failure, laparotomy, creatinine, and APTT between the nonsurvival group and the survival group. Age, AKI, sepsis, abdominal hemorrhage, and organ failure are risk factors for mortality in SAP patients. SAP patients with high creatinine and prolonged APTT upon admission require doctors to be vigilant. The main cause of death in SAP patients is pancreatitis-related organ failure and secondary infection.

Image-Guided Percutaneous Drainage of Abdominal Abscesses in Pediatric Patients.

Image-guided percutaneous abscess drainage (IPAD) is an effective, minimally invasive technique to manage infected abdominal fluid collections in children. It is the treatment of choice in cases where surgery is not immediately required due to another coexisting indication. The skills and equipment needed for this procedure are widely available. IPAD is typically guided by ultrasound, fluoroscopy, computed tomography, or a combination thereof. Abscesses in hard-to-reach locations can be drained by intercostal, transhepatic, transgluteal, transrectal, or transvaginal approaches. Pediatric IPAD has a success rate of over 80% and a low complication rate.

Technical and Clinical Outcome of Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement in Abdominal Fluid Collections after Liver Transplantation: A 16-Year Retrospective Analysis of 50 Consecutive Patients.

Evaluation of the effectiveness of CT-guided drainage (CTD) placement in managing symptomatic postoperative fluid collections in liver transplant patients. The assessment included technical success, clinical outcomes, and the occurrence of complications during the peri-interventional period. Analysis spanned the years 2005 to 2020 and involved 91 drain placement sessions in 50 patients using percutaneous transabdominal or transhepatic access. Criteria for technical success (TS) included (a) achieving adequate drainage of the fluid collection and (b) the absence of peri-interventional complications necessitating minor or prolonged hospitalization. Clinical success (CS) was characterized by (a) a reduction or normalization of inflammatory blood parameters within 30 days after CTD placement and (b) the absence of a need for surgical revision within 60 days after the intervention. Inflammatory markers in terms of C-reactive protein (CRP), leukocyte count and interleukin-6, were evaluated. The dose length product (DLP) for various intervention steps was calculated. The TS rate was 93.4%. CS rates were 64.3% for CRP, 77.8% for leukocytes, and 54.5% for interleukin-6. Median time until successful decrease was 5.0 days for CRP and 3.0 days for leukocytes and interleukin-6. Surgical revision was not necessary in 94.0% of the cases. During the second half of the observation period, there was a trend (p = 0.328) towards a lower DLP for the entire intervention procedure (median: years 2013 to 2020: 623.0 mGy·cm vs. years 2005 to 2012: 811.5 mGy·cm). DLP for the CT fluoroscopy component was significantly (p = 0.001) lower in the later period (median: years 2013 to 2020: 31.0 mGy·cm vs. years 2005 to 2012: 80.5 mGy·cm). The TS rate of CT-guided drainage (CTD) placement was notably high. The CS rate ranged from fair to good. The reduction in radiation exposure over time can be attributed to advancements in CT technology and the growing expertise of interventional radiologists.

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study).

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications. Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients. Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

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

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. 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. 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. 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.

Result of hepatectomy for hepatolithiasis in Hue University of Medicine and Pharmacy Hospital

Background: Hepatolithiasis is an endemic disease in the Asia-Pacific region with 30 - 50% prevalence. We aimed to evaluate the patient’s characteristics, indications, and short-term outcomes. Method: A cross-sectional descriptive study. Data were analyzed using the Student’s t-test, univariable analysis by SPSS 20.0 software. Results: 33 cases of liver resection due to hepatolithiasis, mean age was 54.2 ± 13.2, 75.6% female, Child-Pugh score (A 97%, B 3%). The top position at the left lobe was 48.5%. ASA1was 36.4%; ASA2 was 54.5%, and ASA3 9.1%. Left lobe hepatectomy was 90.9%. The operative time was 185.2 ± 35 minutes. The hospitalization time was 16.2 ± 4.7 days. Biloma was 3%, the abdominal fluid collection was 15.2%, Wound infection was 3%, pneumonia was 3%, pleural effusion was 6.1%, urinary infection was 3%, and sepsis was 6.1%. The rate of retained and recurrent stones was 24.2%. There was no mortality after surgery. Conclusion: The hepatectomy for hepatolithiasis is safe and feasible. Key words: hepatectomy, hepatolithiasis, treatment, surgery, result.

Evaluation and management of abnormal liver enzymes in the liver transplant recipient: When, why, and what now?

Evaluation and management of abnormal liver enzymes in the liver transplant recipient: When, why, and what now?

Pitfalls of EUS-guided gastrojejunostomy in a patient with history of Roux-en-Y gastric bypass and a frozen abdomen.

Video 1Case of EUS-guided gastrojejunostomy in a patient with a history of Roux-en-Y gastric bypass and a frozen abdomen.

Sonographic Detection of Surgical Site Fluid Collections and Postoperative Maternal Morbidity Following Cesarean Section.

Surgical site infection (SSI) is one of the most commoncomplications after cesarean and causes much burden on the mother as well as the health care system. SSIs are defined as infections of a surgical site up to 30 days after surgery. Ultrasonography of the surgical site may be a helpful tool to detect its complication. With this background, the following study was planned to evaluate the clinical significance of sonographically detected fluid collections and post-operative maternal morbidity following cesarean section (CS) and identify risk factors associated with their formation. This prospective observational study was conducted at the Department of Obstetrics and Gynecology, Lala Lajpat Rai Memorial Medical College, Meerut. A total of 1000 women, who had undergone CS were included. Sonographic examination of the cesarean site was done on the 3rd or 4th postoperative day to look for any fluid collection in the parities or pelvis. All cases were followed on the 8th postoperative day and finally on the 30th postoperative day to look for any SSIs i.e. surgical wound problems like wound infection, induration, and discharge from a surgical wound, or even wound dehiscence and postoperative morbidity. Results: Out of the total cases (1000), abdominal wound fluid collection was noted in 490 (49%) women after CS. Thirty-two patients were lost to follow-up, so 458 patients were followed, of which collection was septated or loculated in 62 (13.6%) and diffused in 396 (86.5%). Out of 62 loculated and 396 diffused cases, 21 (33.87%) and 20 (5.05%) cases reported surgical site abdominal wound infection and needed resuturing, respectively and it was found to be highly significant (p<0.001). Post-operative fluid collections are common after CS. But it is the pattern of the fluid collection that determines post-operative wound infection and morbidity. Thus ultrasound of the cesarean site may be an important tool to detect surgical site wound complications earlier and to decrease postoperative morbidity.

Chronic Ovine Model of Right Ventricular Failure and Functional Tricuspid Regurgitation

The pathophysiology of severe functional tricuspid regurgitation (FTR) associated with right ventricular dysfunction is poorly understood, leading to suboptimal clinical results. We set out to establish a chronic ovine model of FTR and right heart failure to investigate the mechanisms of FTR. Twenty adult male sheep (6-12 months old, 62 ± 7 kg) underwent a left thoracotomy and baseline echocardiography. A pulmonary artery band (PAB) was placed and cinched around the main pulmonary artery (PA) to at least double the systolic pulmonary artery pressure (SPAP), inducing right ventricular (RV) pressure overload and signs of RV dilatation. PAB acutely increased the SPAP from 21 ± 2 mmHg to 62 ± 2 mmHg. The animals were followed for 8 weeks, symptoms of heart failure were treated with diuretics, and surveillance echocardiography was used to assess for pleural and abdominal fluid collection. Three animals died during the follow-up period due to stroke, hemorrhage, and acute heart failure. After 2 months, a median sternotomy and epicardial echocardiography were performed. Of the surviving 17 animals, 3 developed mild tricuspid regurgitation, 3 developed moderate tricuspid regurgitation, and 11 developed severe tricuspid regurgitation. Eight weeks of pulmonary artery banding resulted in a stable chronic ovine model of right ventricular dysfunction and significant FTR. This large animal platform can be used to further investigate the structural and molecular basis of RV failure and functional tricuspid regurgitation.

An Orthotopic Resection Surgical Technique Using an Inferior Infracolic Approach for Laparoscopic Pancreaticoduodenectomy.

The no-touch isolation technique has been widely used in cancer surgery as a strategy to prevent cancer cells from spreading; however, it is difficult to apply in laparoscopic pancreaticoduodenectomy (LPD). Here, we describe an orthotopic resection surgical technique that applies a no-touch principle for LPD and can help with the in situ resection of tumors. In implementing this surgical strategy, Kocher's maneuver was not performed first. Instead, after the exploration of the abdominal cavity, the distal stomach and the pancreatic neck were transected. Then, the dissection of the uncinate process of the pancreas, the duodenum, and the superior mesenteric vein and artery is carried out via an inferior infracolic approach. Finally, the pancreatic head and duodenum were removed in situ. Among the 41 patients who underwent this technique, two (4.9%) required conversion to open surgery due to uncontrolled bleeding. The average operative time was 335 min (248-1055 min). The mean estimated blood loss was 300 mL (50-1250 mL). Two patients (4.9%) underwent combined PV resection and reconstruction; six patients (14.6%) required a blood transfusion; two patients (4.9%) suffered from postoperative bleeding; two patients (4.9%) suffered from Grade B pancreatic fistulas; one patient (2.4%) suffered from bile leakage; and three patients (7.3%) suffered from abdominal fluid collection. No patients died during the perioperative period. Therefore, orthotopic LPD using an inferior infracolic approach is safe and feasible for patients with malignant pancreatic head and periampullary tumors. However, further investigations are required to elucidate its oncological benefits.

Percutaneous Image-Guided Drainage of Abdominal Fluid Collections in Children: Technical Considerations and Clinical Scenarios

AbstractWhile initially conceived and designed for adults, percutaneous image-guided drainage of abdominal pelvic and fluid collections has revolutionized the management of several pediatric pathologies. Interventional radiology procedures markedly reduce morbidity and mortality by offering a definitive minimally invasive approach or allowing a cleaner and less challenging subsequent open approach. These procedures are associated with improved patient comfort and rapid recovery. While similar techniques apply to children and adults, successful adaptation of image-guided interventional techniques in children requires consideration of several critical differences. This review aims to discuss the indications, contraindications, and technical aspects of percutaneous image-guided drainage of abdominal and pelvic fluid collections in children.

A Recurring Burden: Examining Readmission and Related Cost in the Months after Pancreaticoduodenectomy

Introduction: Readmission after pancreaticoduodenectomy (PD) is common and serves to escalate cost of an already challenging and expensive procedure. Existing literature on discrete cost after PD admission is limited. Methods: A prospectively maintained PD cost database, which includes cost [divided into operating room, postoperative/ward, radiology, interventional radiology (IR)] for index hospitalization and episodes-of-care within 90 days of surgery, was queried for readmission. Baseline characteristics, reasons for readmission, and intervention were studied, and index and 90-day cost compared within the same group. Results: A total of 1284 patients underwent PD from 2010-2019. 90-day cost were available for 460 patients, of which 88 readmitted patients with complete data were analyzed. Patients were readmitted 1.3±0.7 times on average. Mean readmission length of stay (LoS) was 9.7±9.1 days, which was not significantly shorter (p = 0.549) than index LoS (10.4±7.8 days). Median total 90-day cost was $15,780 ($1,237-102,913), which was significantly lower (p < 0.001) than cost of index hospitalization [$27,212 ($15,573-155,042)]. Common reasons for readmission were food intolerance and/or failure to thrive (n = 17, 19.3%), abdominal fluid collection (n = 13, 14.8%), and postsurgical abdominal pain (n = 13, 14.8%). Patients were treated by surgery (eg exploratory laparotomy, PEG tube placement) (n = 13, 14.8%) or IR (eg CT guided drain placement) (n = 33, 37.5%) while the rest (n = 45, 51.1%) were managed medically. 90-day mortality in this cohort was 2.2% (n = 2). Conclusion: Although patients readmitted after PD incur lower 90-day cost than their index stay, LoS is comparable, and many undergo additional therapeutic intervention. This underscores the complexity of PD, which affects recovery and finances well beyond the operation itself.

RIGHT-SIDED CHYLOTHORAX DUE TO RECURRENT CERVICAL CANCER WITH PLEURAL METASTASIS

RIGHT-SIDED CHYLOTHORAX DUE TO RECURRENT CERVICAL CANCER WITH PLEURAL METASTASIS

Comparison of Outcome between Drain and No Drain after Elective Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) has been established as the gold standard treatment for gallstone disease. However, there is a debate regarding the post-operative placement of a drain in LC. Aim: To compare the outcome of patients undergoing placement of drain versus patients without a drain following elective LC. Methodology: A quasi-experimental study was conducted at Mufti Mehmood Memorial Teaching Hospital, Dera Ismail Khan from September 2017 till August 2019. A total of 136 patients of cholelithiasis were randomly allocated to two groups: A (drain placed) and B (no drain placed). Clinical variables such as age, gender, BMI, duration of surgery, duration of hospital stay, vomiting, abdominal fluid collection and wound infection were recorded for all patients in two groups. Results: The mean age of the patients was 38.6±0.2 years. The mean time of surgery in group A was 44.2±10.3 minutes compared to 45.4±10.3 minutes in group B. The mean time of hospital stay in patients of group A was 2.3±1.0 days compared to 2.3±0.9 days in group B. After surgery, 16(23.5%) patients in group A experienced vomiting compared to 22(32.4%) in group B. Seven (10.3%) patients in group A had abdominal fluid collection compared to 12(17.6%) in group B. Moreover, eight (11.8%) patients in group A developed wound infection compared to 11(16.2%) in group B. Conclusion: There is no need to place a subhepatic drain routinely after laparoscopic cholecystectomy in uncomplicated cases. Keywords: Laparoscopic cholecystectomy; cholelithiasis; wound infection; vomiting; fluid collection; drain.

Computed Tomography for the Diagnosis of Intraperitoneal Infected Fluid Collections after Surgery for Gastric Cancer. Role of Texture Analysis.

Several computed tomographic (CT) imaging features have been proposed to describe the infection of postoperative abdominal fluid collections; however, these features are vague, and there is a significant overlap between infected and non-infected collections. We assessed the role of textural parameters as additional diagnostic tools for distinguishing between infected and non-infected peritoneal collections in patients operated for gastric cancer. From 527 patients operated for gastric cancer, we retrospectively selected 82 cases with intraperitoneal collections who underwent CT exams. The fluid component was analyzed through a novel method (texture analysis); different patterns of pixel intensity and distribution were extracted and processed through a dedicated software (MaZda). A univariate analysis comparing the parameters of texture analysis between the two groups was performed. Afterwards, a multivariate analysis was performed for the univariate statistically significant parameters. The study included 82 patients with bacteriologically verified infected (n=40) and noninfected (n=42) intraperitoneal effusions. The univariate analysis evidenced statistically significant differences between all the parameters involved. The multivariate analysis highlighted 10 parameters as being statistically significant, adjusted to Bonferroni correction. Our evidence supports the fact that textural analysis can be used as a complementary diagnostic tool for the detection of infected fluid collections after gastric cancer surgery. Further studies are required to validate the accuracy of this method.

Efficacy, Feasibility, and Safety of Percutaneous Image-Guided Catheter Drainage of Thoracic, Abdominal, and Pelvic Fluid Collections.

Background – Image-guided percutaneous catheter drainage (PCD) using a pigtail catheter bridges the gap between non-invasive and invasive surgical intervention with minimally invasive, image-guided drainage. This study aims to evaluate the efficacy, feasibility, safety, and relevant clinical outcomes of image guided PCD of thoracic, abdominal, and pelvic fluid collections. It also aims to assess the causes of complications and failure associated with PCD. Methods – This prospective analysis of 83 patients with abdominal, thoracic, or pelvic fluid collections was conducted by categorizing patients into three groups of intervention namely – group A (intermittent needle aspiration (INA) and PCD in the same sitting), group B (INA followed by PCD after a 48-hour interval gap), and group C (INA and PCD followed by open surgical drainage). Outcomes were measured in terms of statistical analysis, complications, residual collection, success, and failure rates of the procedure. Results – Abdomen was the most frequently encountered site of fluid collection (61.45%), CT was the most utilized modality for image guidance (61.45%), and fluid drained was most frequently purulent (57.83%). Majority of the patients were categorized into group B (57.83%), followed by group A (38.53%), and group C (3.61%). Pain at the catheter insertion site was the most commonly reported complication (72.23%). Group A and Group B showed a success rate of 93.7% and 97.9% respectively. Conclusion – In our study, image-guided PCD proved to be a time saving and efficient intervention, making it an intervention of choice in a variety of fluid collections/abscesses. INA should be considered as an initial step of management for fluid drainage, which provides an access pathway for catheter placement for PCD.

Dynamic endoluminal contrast enhanced ultrasound (CEUS) for display of drainages in inflammatory abdominal fluid collections1.

To evaluate the additive clinical value of endoluminal contrast enhanced ultrasound (CEUS) after interventional placement of drainages in abdominal fluid collections. Examination of 30 patients using a 1-6 MHz convex probe (Resona 7, Mindray) to locate the fluid collection in B-Mode. Additionally, dynamic endoluminal CEUS with 1 ml sulphur-hexafluoride microbubbles was performed to measure the extent of the percutaneously drained abscesses. Independent assessment of dynamically stored images in PACS in DICOM format. Correlation to reference imaging using computed tomography (CT). A total of 30 patients were examined (17 m, 19-78 years, mean 56.1 years). Drainages were positioned in the liver in 15 cases, in the pelvis after kidney transplantation in 4 cases, close to the spleen in 1 case, and in the abdomen in 10 cases. In all cases abscesses showed marginal hyperaemia with reactive septations in CEUS. The drainage position was assessed by means of B-mode in all cases first and then by CEUS. In 4 cases CEUS showed a fistula to the pleura, in 5 cases to the peritoneum, in 2 cases to the intestine, in 5 cases to the biliary tract, corresponding to the CT. In 2 cases there was a hint of an anastomotic leakage after intestinal anastomosis, which was reliably detected by CT. The drainage was removed in 11 cases within a period of 2 to 5 days after CEUS control, in 9 cases within a period of 5 to 10 days. Another operation was necessary in 3 cases. A new drainage was placed in 2 cases. The required amount of ultrasound contrast medium is 1 ml endoluminally diluted to 9 ml sodium chloride. CEUS facilitates the exact localization and characterization of inflammatory abdominal fluid collections. Furthermore, possible fistulas can be detected that cannot be seen with conventional ultrasound.