CT-guided Drainage Research Articles

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment

In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23). Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.

Strict adherence to bsg guidelines required forcholecystectomy following pancreatitis toprevent high readmission rates

Strict adherence to bsg guidelines required forcholecystectomy following pancreatitis toprevent high readmission rates

Antibiotics and Drainage for Treating Stent-Graft Infection after EVAR

The patient was a 64-year-old man. He developed fever and lumbago 6 months after the EVAR. Because CT showed an abscess in the aortic aneurysm surrounding the stent graft, stent-graft infection was diagnosed, and treatment with intravenous antibiotics was initiated. However, the fever and inflammatory markers persisted; therefore, CT-guided drainage catheter placement was performed. After all the pus had been discharged, the fever subsided, and the inflammatory reaction was also suppressed. One year has elapsed since the treatment, and the patient continues to visit with no complaints. We report that stent-graft infection was relieved with antibiotics and drainage.

Retroperitoneal Abscess Formation as a Result of Spilled Gallstones during Laparoscopic Cholecystectomy: An Unusual Case Report

One of the complications of laparoscopic cholecystectomy for gallstone disease that seems to exceed that of the traditional open method is the gallbladder perforation and gallstone spillage. Its incidence can occur in up to 40% of patients, and in most cases its course is uneventful. However in few cases an abdominal abscess can develop, which may lead to significant morbidity. Rarely an abscess formation due to spilled and lost gallstones may occur in the retroperitoneal space. We herein report the case of a female patient who presented with clinical symptoms of sepsis six months following laparoscopic cholecystectomy. Imaging investigations revealed the presence of a retroperitoneal abscess due to retained gallstones. Due to patient's decision to refuse abscess's surgical drainage, she underwent CT-guided drainage. The 24-month followup of the patient has been uneventful, and the patient remains in good general condition.

Multiple sterile liver abscesses: An unusual presentation mimicking metastatic disease

A 57-year-old man with diabetes mellitus and alcohol-related iver disease presented with a 2-day history of nausea, vomitng and reduced appetite. On examination, he was apyrexial with ight upper quadrant tenderness. Laboratory tests revealed microytic anaemia (haemoglobin 8.9 g/dL, MCV 79 fL), and elevated hite blood cell count (15.8 × 109/L), C-reactive protein (248 mg/L), lkaline phosphatase (416 IU/L) and gamma-glutamyltransferase 151 IU/L). Blood cultures were sterile. Abdominal ultrasound scan Fig. 1A) showed multiple, large, mixed echoic lesions (the largest 1 cm in diameter), predominantly within the right lobe of the iver. Hepatic metastases were considered, but staging CT scan Fig. 1B) did not detect a primary neoplasm and tumour markrs were within normal limits. CT-guided drainage yielded sterile us with marked neutrophilia. The patient received intravenous o-amoxiclav and metronidazole, with regression of the hepatic bscesses at one-month follow-up (Fig. 2A and B).

A Retrospective Study of Pancreatic Pseudocyst Management

Purpose: Pancreatic pseudocysts (PP) can be managed by surgery, EUS (endoscopic ultrasound) and CT-guided drainage. There is scant data on the clinical outcomes and the cost of these three procedures. Aim: To study the characteristics of clinical outcomes concerning EUS, Surgical and CT guided techniques of PP drainage, and associated direct cost of hospitalization. Methods: Chart review by searching UMass Memorial Medical Center database between June 2005 and April 2011 was done for all patients with PP who had drainage. Patients were classified on basis of initial procedure. Main outcome is treatment success which was defined as complete resolution or decrease in size of PP to 2 cm, in association with clinical resolution of symptoms at 6 week follow up. Re-intervention was defined as need for repeated procedure because of persistent symptoms with a residual PP more than 4 cm. Direct cost in U.S. dollars included all charges for hospital stay from day of admission to discharge. Results: 58 patients were identified, 19, 31 and 8 patients in EUS, CT and Surgery groups. Clinical characteristics are described in Table 1. CT guided group is slightly older than 2 groups p = 0.02. Albumin level in surgical group is slightly lower than other 2 groups p = 0.03. Mean WBC count is similar for all three groups p = 0.12. Treatment success rate was 74%,54%,62% in EUS, CT and surgical groups respectively p = 0.013. Treatment success rate is highest in PP located in the head and lowest in body there is no statistical difference chi = 7.37 p = .117. Success rate of tail PP drainage in EUS group was 83.3%. Reintervention rate was 36%,33%,50%, in EUS, CT, and surgery groups respectively. Complications were observed in 31%, 12% and 25% in EUS, CT and surgical groups respectively. Total length of stay was significantly different in the three groups 12, 31 and 56 days in EUS, CT and surgery groups respectively. Average cost of hospital stay for patients in EUS group $91186 was less when compared with CT groups $279393 and surgical $458455 p<0.0001.Table 1: . No Caption available.Conclusion: This study shows reasonable success rates in all three modalities when compared to recent studies. EUS guided drainage is increasingly accepted as an initial step in management considering success rate, cost and complications obviating the need for surgery. On average, length of hospital stay and associated cost for patients who were admitted and had PP drainage is very high, which were due to multiple co-morbidities. Major study limitation is lack of stratification based on severity of condition and underlying co-morbidities. A large randomized study is needed to better evaluate and compare costs and outcomes of these three modalities.Table 2: . No Caption available.

Pyogenic Liver Abscess Due to Diverticulitis

Purpose: AIM: Diverticulitis involving the colon can occasionally present with complications, including perforation, obstruction and abscess. This report describes a case of sigmoid diverticulitis which presented with a protracted illness related to a large hepatic abscess. CASE REPORT: A 43 yo male with a history of systemic hypertension and sleep apnea presented in 7/10 with complaints of fever, upper abdominal pain and 12 lb weight loss over the preceding 6 mos. Physical examination revealed signs of dehydration, lowgrade fever and right upper quadrant tenderness. CT scan showed a 12.3 cm x 9.9 cm heterogeneous right liver lobe mass and a 3.5 cm peri-sigmoid soft tissue mass which contained an air locule. Lab tests indicated: serum bilirubin 1.6 mg/dl (N=0.2-1.1), serum transaminase levels 3 X ULN, serum alkaline phosphatase 3X ULN and peripheral leukocyte count 16,100 (N=4,200-10,800). A serum CEA level was 0.2 (N= < 2.5 mg/ml for non-smoker). The patient was admitted to the hospital for hydration and expedited evaluation. Colonoscopy revealed moderate sigmoid diverticulosis and a short segment of mid-sigmoid luminal erythema and edema. A diagnosis of presumptive sigmoid diverticulitis with pericolonic and pyogenic liver abscess was made and broad-spectrum antibiotics (levofloxacin and metronidazole) were instituted. The patient underwent aspiration of the liver lesion under CT-guidance, which yielded ˜750 ml of purulent material. A percutaneous drain was left in the liver and antibiotics were continued. The fluid did not grow any pathogens, although the pyogenic abscess was presumed to be bacterial in etiology. It was believed that bacterial pathogens were not isolated from the abscess as the patient had been receiving antibiotics for ˜ 36 hrs prior to the CT-guided liver drainage procedure. He was discharged home on ertapenem intravenously. The patient was followed on an outpatient basis by serial CT scanning and clinical evaluation, and periodic repositioning of the drain within the liver abscess cavity occurred. The abscess progressively diminished in size and the final CT scan, performed 16 weeks after his initial presentation, revealed collapse and resolution of the liver abscess cavity. The patient then underwent uneventful elective laparoscopic sigmoid resection. The patient ultimately made a full and unremarkable recovery. CONCLUSION: This case describes a patient presenting with sigmoid diverticulitis with localized peri-sigmoid abscess, and large pyogenic liver abscess. Combined prolonged antibiotic therapy and percutaneous liver abscess drainage led to clinical and radiographic resolution of the abscess.

A complication of a dropped appendicolith misdiagnosed as Crohn’s disease

Appendicoliths are formed by calcium salts and faecal debris layered and lodged within the appendix. They are detected on unenhanced x-rays in less than 10% of patients with appendicitis. When an appendicolith is found extraluminally, it is pathognomonic for perforation of the appendix. Moreover, retained appendicoliths act as a nidus for infection and are likely to be the source of a postoperative intraperitoneal abscess. However, this is very rare with only 30 reported cases of intra-abdominal abscess secondary to an appendicolith in the literature over the past 40 years. Retained, or dropped, appendicoliths most commonly present as an area of high attenuation less than 1cm in diameter with an associated abscess close to the caecum or Morrison's pouch on computed tomography (CT). A study published in 2006 showed that although there is initial success with CT-guided drainage of abscesses secondary to faecaliths, all will recur and formal surgical drainage with removal of the appendicolith is required. This case report highlights not only an unusual complication of a retained appendicolith but also the importance of taking a thorough history and interpreting investigations in the context of the patient's past medical history so as to produce a differential diagnosis and prevent treatment of incorrect conditions.

Percutaneous Treatment of an Infected Aneurysmal Sac Secondary to Aortoesophageal Fistula with a History of Stent-Graft Treatment for Thoracic Aortic Aneurysm

A 68-year-old man who was subjected to stent-grafting of a descending thoracic aortic aneurysm (TAA) 4months previously was admitted to our hospital with constitutional symptoms, including high fever, sweating, nausea, vomiting, weight loss, and backache. An infected aneurysmal sac was suspected based on computed tomography (CT) findings, and an aortoesophageal fistula (AEF) was identified during esophagoscopy. CT-guided aspiration was performed using a 20-G Chiba needle, confirming the presence of infection. For treatment of the infected aneurysmal sac, CT-guided percutaneous catheter drainage in a prone position was performed under general anesthesia with left endobronchial intubation. Drainage catheter insertion was successfully performed using the Seldinger technique, which is not a standard treatment of an infected aneurysmal sac. Improvement in the patient's clinical condition was observed at follow-ups, and CT showed total regression of the collection in the aneurysmal sac.

Pelvic abscess associated with anastomotic leak in patients with ileal pouch-anal anastomosis (IPAA): transanastomotic or CT-guided drainage?

Evidence is lacking whether an abscess associated with anastomotic leak after an ileal pouch-anal anastomosis (IPAA) should be drained by transanal or CT-guided drainage. Therefore, the aim of this study was to compare outcomes after the two techniques for drainage. Patients who underwent IPAA (1984-2009) and diagnosed with a pelvic abscess associated with an anastomotic leak were identified. The choice of operative or image-guided drainage was based on surgeon preference. Differences between patients undergoing transanal (group TA) and CT-guided drainage (group CT) were determined. Groups TA (n = 53) and CT (n = 18) had similar age (p = 0.3), gender (p = 0.3), body mass index (p = 0.6), steroid use (p = 0.4), albumin level (p = 0.9), ileostomy (p = 0.6), and follow-up time (p = 0.5). The size of the abscess was greater in group CT (p = 0.012). Two patients developed fistula at the CT-guided drainage site. Both healed after conservative treatment and drainage of associated gluteal abscess, respectively. Thirteen patients in group TA and three patients in group CT (p = 0.6) had failure of drainage and underwent surgery. The success rates for the procedures in terms of long-term pouch retention were 75.5% and 83%, respectively, for TA and CT. Groups TA and CT had similar bowel frequency (p = 0.9), incontinence (p = 0.6), urgency (p = 0.9), seepage (p = 0.6), pad usage (p = 0.1), quality of life (p = 0.9), and happiness with surgery (p = 0.9). There is a risk of fistula at drainage site after a CT-guided drainage of the pelvic abscess associated with anastomotic leak following IPAA. Transanal and CT-guided drainage are equally effective and result in similar long-term pouch-related outcomes.

Frequency, risk factors, and management of perigraft seroma after open abdominal aortic aneurysm repair

Perigraft seroma (PGS) causing enlargement of the native aneurysm sac after open abdominal aortoiliac aneurysm (AAA) repair is a rarely recognized complication with unknown clinical consequences. This study was undertaken to determine the frequency of PGS, identify associated risk factors, and review resulting complications and their management strategies. Charts of all patients who underwent open AAA repair at our institution from 1995 to 2009 and had at least one postoperative abdominal cross-sectional imaging study (the study subjects) were retrospectively reviewed. PGS was defined as a perigraft fluid collection present > 3 months postoperatively, ≥ 3-cm in diameter and having a radiodensity ≤ 25 Hounsfield units on computed tomography (CT). Patient records were reviewed for demographics, comorbidities, operative and postoperative variables, and long-term outcome. Of the 111 study subjects identified, 13 had aortic reconstruction with Dacron grafts and 98 with polytetrafluoroethylene (PTFE) grafts. Twenty patients (18%) had PGS, all of whom had PTFE grafts (20 of 98; 20.4%). Mean age was 68.5 years and mean aneurysm diameter preoperatively was 6.4 cm (range, 4.0-10.9 cm). The average time from AAA repair to PGS detection was 51 months (range, 4-156 months). PGS averaged 6.0-cm in diameter (range, 3.0-11.0 cm). Multivariate analysis revealed that the following factors were associated with PGS development: diabetes (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1-21.2; P = .013), smoking (OR, 5.6; 95% CI, 0.73-33.74; P = .01), anticoagulation (OR, 7.2; 95% CI, 2.6-63.3; P = .003), bifurcated graft reconstruction (OR, 8.0; 95% CI, 2.6-94.1; P = .017), and left flank retroperitoneal approach for repair (OR, 7.1; 95% CI, 1.9-26.5; P = .003). Four patients (4 of 20; 20%) required intervention for PGS-related complications: 3 patients for symptomatic PGS expansion (1 patient with rupture) and 1 patient for acute limb ischemia secondary to graft limb compression and thrombosis. Two patients had open exploration, sac evacuation/reduction, and graft replacement with a Dacron graft: 1 patient for a ruptured aneurysm sac and 1 patient for persistent pain associated with sac enlargement. A third patient underwent a failed CT-guided drainage for abdominal pain and was subsequently treated with partial graft excision. The patient with acute limb ischemia was treated with catheter-directed thrombolysis and graft limb stenting. PGS after open AAA repair occurs more frequently than previously reported. Complications requiring intervention can occur in up to 20% of patients with PGS. A variety of treatment modalities can be used to deal with the complications. Earlier CT surveillance is advised after open AAA repair with a PTFE graft if symptoms are suggestive of PGS development.

Treatment of Deep Intramuscular and Musculoskeletal Abscess: Experience With 99 CT-Guided Percutaneous Catheter Drainage Procedures

The purpose of this article is to describe our experience draining deep muscular and musculoskeletal abscess collections with CT guidance, emphasizing clinicopathologic factors associated with drain failure, and to further analyze patient outcomes according to whether the process involves muscle alone or also involves adjacent bone or joint (skeletal involvement). The details of percutaneous catheter drainage were retrospectively recorded for all drainages performed over a 9-year period. The technical and clinical successes of percutaneous catheter drainage were determined. Multifactor logistic regression analysis was used to identify predictors of drain failure (malignancy, age, chemotherapy, surgery, infection, complexity, size, days in situ, and skeletal involvement). These parameters were assessed in all patients, those with muscle involvement alone and those with musculoskeletal collections. Eighty-nine of 94 patients underwent one percutaneous drainage procedure and 5 of 94 patients underwent two drainages for a total of 99 drainages in 94 patients (one drainage [n = 89] and two drainages [n = 5]). There were 62 men and 32 women with a mean age of 58.5 years (age range [±SD], 22.3-88.0 ± 16 years). The abscess diameters ranged from 1.8 to 13 cm (mean, 5.3 ± 2.5 cm), volume aspirated ranged from 0 to 200 mL (mean, 45 ± 44 mL), and mean duration of drainage was 16.2 days (range, 2-110 ± 18.7 days). The iliopsoas muscle was the most common site of drainage, accounting for 87.8% of the total. Catheter insertion was possible in all patients, with the muscular component successfully drained in 82% (81/99) overall: 85% (46/54) of those with muscle involvement alone and 77% (35/45) of those with musculoskeletal collections. Catheter drainage and antibiotic administration resulted in 65.6% (65/99) not requiring any surgical intervention and resolution of abnormal white cell count or fevers in 98.8% (79/80) of those with abnormal parameters before treatment. Skeletal infection was associated with increased risk of drainage failure (p = 0.0001). Percutaneous imaging-guided musculoskeletal drainage is clinically useful, safe, and effective for draining complex musculoskeletal collections. It is highly effective for draining collections involving muscle alone; however, skeletal infection is associated with a higher risk of drain failure.

Ct-guided percutaneous drainage of lung abscesses: review of 40 cases

To evaluate the safety and effectiveness of CT-guided percutaneous drainage of lung abscesses considering success rate versus complications. This retrospective study was carried out at Computed Tomography and Interventional Radiology Department of Sotiria Hospital, Athens, Greece, from 1/1/2007 to 1/1/2010. Forty patients with lung abscesses in which antibiotic therapy failed and were managed with CT-guided percutaneous drainage were included in the study. Catheter placement was carried out using Trocar technique in the majority of the cases. Lung abscess completely resolved with no residual cavity in thirty three patients. Seven patients had residual cavity and surgery was performed. Thus, the success rate of radiological drainage of the lung abscesses (33/40) was 83%. Five (13%) patients developed pneumothorax. Three developed moderate pneumothorax and chest-tube needed to be inserted and two patients developed mild pneumothorax which was managed with aspiration. These patients were kept under observation and followed-up by chest X-rays. No other complications and no mortality occurred during the procedure for all the forty patients. CT-guided percutaneous catheter drainage is a useful and safe procedure for the treatment of patients with lung abscesses who do not respond to medical therapy and should be considered a valuable alternative to open surgery.

Liver mass with central calcification

A previously healthy 29-year-old woman of Spanish origin presented with a 1-month history of right upper quadrant pain associated with fever and night sweats. The physical examination demonstrated a temperature of 38.5°C, a normal blood pressure, a normal heart rate, and mild right upper quadrant tenderness with no peritoneal signs. Laboratory tests showed a slightly raised white blood cell count of 12,000/mm3 with a normal differential count and a C-reactive protein level of 230 mg/L. Liver function tests were normal. The abdominal computed tomography (CT) scan showed a hypodense lesion in the right hepatic lobe with a central calcified deposit (Fig. 1). The blood culture and serological tests for hydatidosis and amebiasis were negative. A definite diagnosis was made by a positive polymerase chain reaction test for Brucella melitensis in the abscess fluid (the abscess fluid culture was negative). The patient was initially managed by CT-guided percutaneous drainage and a combination of doxycycline (100 mg/day by mouth) and rifampin (600 mg/day by mouth). A laparoscopic liver exploration was subsequently performed to improve drainage and to remove the calcified deposit (Fig. 2). The patient responded well to treatment with 8 weeks of oral antibiotics. Contrast-enhanced CT assessment. Laparoscopic exploration showing the abscess cavity with a calcified deposit (arrow) between the right liver lobe and the abdominal wall. CT, computed tomography. Brucellosis is a zoonosis caused by Brucella, a genus of gram-negative coccobacillary microorganisms. It occurs worldwide, but major endemic areas include countries of the Mediterranean basin (including Spain, to which the patient had been frequently traveling), the Arabian Gulf, the Indian subcontinent, and parts of Central and South America. Humans can acquire brucellosis by the ingestion of infected food (especially unpasteurized milk), by direct contact with an infected animal (sheep, cattle, or pigs), or by aerosols.1 In humans, brucellosis is a chronic granulomatous infection that is associated with nonspecific, mild clinical symptoms such as fever, fatigue, night sweats, anorexia, and weight loss. It is, therefore, difficult to diagnose, and screening for Brucella should be performed in the case of fever of unknown origin. Almost every organ and system can be affected, but osteoarticular complications are the most common, with peripheral arthritis, sacroiliitis, and spondylitis occurring.2 Laboratory studies are nonspecific in patients with brucellosis, and white blood cell counts are usually normal to low. Although the presence of some degree of hepatitis is frequent, the development of a liver abscess (brucelloma) is rare and occurs in only approximately 1% of patients with brucellosis.3 It most commonly represents a chronic form of the disease that has remained latent. The typical CT scan pattern of liver brucelloma is a rounded or ovoid hypodense area with central calcification5 and is similar to the pattern found in this case. Confirmation of the diagnosis of brucellosis can be achieved by various techniques, including blood cultures, serological tests, and real-time polymerase chain reaction with blood or pus.4 The classic treatment for brucellosis is based on doxycycline and rifampin. In the case of liver abscess, surgery is most often required because the risk of recurrence after conservative management is at least 50%.3 After surgery, which can be performed laparoscopically (as in the present case), a patient's chance of being cured is extremely good.

Management of Leak From the Tip of the “J” in Ileal Pouch-Anal Anastomosis

Diagnosis and management of leak from the tip of the J-pouch after IPAA has not been systematically studied. The aim of this study is to report our experience in the diagnosis and management of these leaks following primary IPAA. This study is a retrospective review of prospectively gathered data. Data were obtained from a prospectively maintained single-institution pelvic pouch database. Included in this study were patients with a leak from the tip of the J-pouch after primary IPAA. The main measures of outcomes after salvage surgery were pouch failure, pouch function, and quality of life. There were 27 (14 male) patients. Median age was 37 years (range, 20-73). Underlying disease in these patients was ulcerative colitis in 22 patients. Predominant symptoms were abdominal pain (n = 15) and fever (n = 5). Twenty patients had either a pelvic abscess detected by CT or MRI or a leak demonstrated at gastrografin enema or pouchoscopy. In 6 patients, the diagnosis was only made at salvage surgery. In 1 patient, the leak-associated abscess was detected during emergent laparotomy for acute peritonitis before salvage surgery. Of 27 patients, 1 had successful CT-guided drainage without the need for further surgery. Another patient had pouch resection with end ileostomy. Salvage surgery was performed in 25 patients by means of pouch repair (n = 23) and new pouch creation (n = 2); 8 patients had a repeat anastomosis. Median time from primary IPAA to salvage surgery was 0.9 years (0.13-9.8). Twenty-four patients with salvage surgery have a functioning pouch after a mean follow-up of 3.2 ± 1.9 years. : The study was limited by its retrospective nature. Leak from the tip of the J-pouch is indolent and diagnosis can be difficult. Satisfactory outcomes in terms of pouch retention may be expected after appropriate surgical management.

Computed Tomography–guided Drainage of Mediastinal Abscesses: Clinical Experience with 23 Patients

Purpose To evaluate the technical and clinical success rates of computed tomography (CT)–guided percutaneous drainage of mediastinal abscesses. Materials and Methods An interventional radiology database was used to identify patients who underwent CT-guided percutaneous drainage of mediastinal abscesses. Medical records were reviewed to evaluate abscess etiology, drainage technique, clinical outcome, and complications. Results Over a 10-year period, 23 patients (20 men; average age, 54 y; range, 34–77 y) with 24 mediastinal abscesses underwent 25 CT-guided drainage procedures. Abscess etiologies included esophageal leak after esophagectomy (n = 6), perforated esophageal cancer (n = 4), Nissen fundoplication (n = 3), emetogenic esophageal rupture (n = 3), infectious (n = 2), cardiac surgery (n = 1), iatrogenic (n = 1), gastric strangulation (n = 1), Whipple procedure (n = 1), and thoracotomy for lung cancer (n = 1). Drainages were performed with tandem trocar (n = 14) or Seldinger (n = 11) technique. A total of 25 catheters were used: 8.5 F (n = 9), 10 F (n = 8), 12 F (n = 6), 14 F (n = 1), and 16 F (n = 1). The mean time of catheter drainage was 13.6 days. Technical success was achieved in all 25 attempts (100%). Twenty-two of the 23 patients had complete resolution of the abscess without the need for surgical debridement, for a clinical success rate of 95.6%. One patient underwent technically and clinically successful abscess drainage but required surgical exploration for repair of an anastomotic leak after esophagogastrectomy. There was one complication. One patient had inadvertent placement of a catheter within a pulmonary vein. The catheter was removed after 24 hours without hemodynamic consequences. Conclusions Percutaneous CT-guided drainage of mediastinal abscesses is an uncommon procedure, but the results of this study suggest that it is associated with high technical and clinical success rates.

Chronic, Progressive Back Pain, Fever and a Noticeable Paravertebral Mass

A 46-year-old woman presented with an 8-month history of fever, lumbar pain, and a slowly growing right paravertebral mass. She reported regular consumption of unpasteurized goat cheese. The physical examination revealed a fluctuant right paravertebral mass and marked pain on palpation over the lumbar spine at the L3-L4 level. A computed tomography (CT) scan of the spine revealed erosions of the end plates of L3 and L4 and the antero-superior angle of L3, narrowing of the intervertebral space between L3 and L4, and new bone formation (Figure 1). Widening of the right iliopsoas muscle was also observed on magnetic resonance imaging (MRI) of the spine (Figure 2). A tube agglutination test for brucellosis was positive at 1/640, and a CT-guided percutaneous drainage of the paravertebral mass yielded purulent material from which Brucella melitensis was isolated in culture. Doxycycline, gentamycin, and rifampicin were started with good clinical response. Bacterial vertebral osteomyelitis may be caused by pyogenic bacteria, Mycobacterium tuberculosis, and B. melitensis. Tuberculosis predominantly affects the thoracic spine; paravertebral masses are common, but new bone formation is unusual. Pyogenic vertebral osteomyelitis, mainly caused by Staphylococcus aureus, presents very similarly to brucellosis both clinically and radiographically. Brucellosis caused by B. melitensis is acquired mostly by eating contaminated dairy products. Vertebral osteomyelitis and iliopsoas abscess are recognized complications of untreated brucellosis.1 Triple antibiotic therapy seems to improve clinical outcome.2 Figure 1. (A) CT scan of the spine showing erosions on the antero-superior angle of the vertebral body of L3, narrowing of the intervertebral disc space between L3 and L4, erosions on the end plates of these two vertebral bodies, and new bone formation. (B) Widening ... Figure 2. (A) MRI of the spine. Hypointensity on T1-weighted images at the L3-L4 level and narrowing of the L3-L4 intervertebral disc space. (B) Hyperintesity on T2-weighted images and marked widening of the right iliopsoas muscle.

Abstract No. 27: An ultra-low dose protocol for CT-guided drainge procedures

Abstract No. 27: An ultra-low dose protocol for CT-guided drainge procedures

Gallium-67 SPECT/CT for Abdominal Abscess

An 80-year-old woman, who had suffered from end-stage renal disease under peritoneal dialysis, was presented with intermittent fever, leukocytosis, and elevated C-reactive protein for 4 months. She did not have symptom of abdominal pain. Culture of ascites showed Klebsiella pneumoniae. Abdominal utrasonography was negative. Whole-body gallium-67 imaging showed a segmental uptake mimicking bowels in right abdomen. SPECT/CT revealed the uptake in a soft tissue density beneath the abdominal wall instead of bowels. Contrast-enhanced CT demonstrated a low-density mass with peripheral enhancement at the aforementioned area. Her clinical condition stabilized gradually after CT-guided percutaneous drainage of pus from the abscess.

Percutaneous Management of Postoperative Bile Leaks After Upper Gastrointestinal Surgery

This study was designed to investigate the benefit of percutaneous interventional management of patients with postoperative bile leak on clinical outcome. Primary study endpoints were closure of the bile leak and duration of percutaneous transhepatic biliary drainage (PTBD) treatment. Secondary study endpoints were necessity of additional CT-guided drainage catheter placement, course of serum CRP level as parameter for inflammation, and patients' survival. Between January 2004 and April 2008, all patients who underwent PTBD placement after upper gastrointestinal surgery were analyzed regarding site of bile leak and previous attempt of operative bile leak repair, interval between initial surgery and PTBD placement, procedural interventional management, course of inflammation parameters, duration of PTBD therapy, PTBD-related complications, and patients' survival. Thirty patients underwent PTBD placement for treatment of postoperative bile leaks. In 12 patients (40%), PTBD was performed secondary to a surgical attempt of bile leak repair. Additional percutaneous drainage of bilomas was performed in 14 patients (47%). CRP serum level decreased from 138.1 ± 73.4 mg/l before PTBD placement to 43.5 ± 33.4 mg/l 30 days after PTBD placement. The mean duration of PTBD treatment was 55.2 ± 32.5 days in the surviving patients. In one patient, a delayed stenosis of the bile duct required balloon dilation. Two PTBD-related complications (portobiliary fistula, hepatic artery aneurysm) occurred, which were successfully treated by embolization. Overall survival was 73% (22 patients). PTBD treatment is an effective therapy. PTBD treatment and additional CT-guided drainage of bilomas helped to reduce intraabdominal inflammation, as shown by reduction of inflammation parameters.