CT-guided Percutaneous Catheter Drainage Research Articles

Usefulness of CT-Guided Percutaneous Catheter Drainage Using a Modified Version of the Seldinger Technique for the Treatment of Intra-abdominal Small Abscess and Poorly Depicted Fluid Collection on Sonogram

Purpose: To evaluate the usefulness of CT-guided percutaneous catheter drainage (PCD) using a modified version of the Seldinger technique for deep-seated, small abscesses and poorly depicted fluid collection on abdominal sonogram. Materials and Methods: Fifty-nine cases of CT-guided PCD were performed on 56 patients. Four techniques were applied to secure safe access routes, which include scan postural change, angulation of the gantry, traversal of organs, and using a dissecting needle which can push the intervening bowel. Three landmarks (depth of the front and back wall of the fluid collection and the end point of catheter advancement over the guide wire) were indicated on the drainage catheter for extracorporeal direct observation of moving distance and location of the catheter during the insertion process. The technical success rate, clinical outcome, complications, and instrumental impairments were reviewed. Results: The technical success rate was 100% (59/59), and no grave complications occurred. Four cases (7%) of crooked guide wire insertion were noted. The clinical outcome revealed a 95% (56/59) successful treatment rate and a 5% (3/59) failed treatment rate, which was caused by undissolved hematoma (1/59) and fistula (2/59). Conclusion: The results of this study suggest that CT-guided PCD using a modified version of the Seldinger technique for deep-seated, small abscesses and poorly depicted fluid collections on an abdominal sonogram is useful in terms of accuracy and safety.

CT-Guided Percutaneous Catheter Drainage of Acute Necrotizing Pancreatitis: Clinical Experience and Observations in Patients with Sterile and Infected Necrosis

The purpose of this study was to report on clinical experience with and observations made during primary CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis and to compare results among patients with sterile and those with infected necrosis. We reviewed clinical, radiologic, and bacteriologic data on 35 patients (23 men, 12 women; mean age, 50 years; range, 21-83 years) with acute necrotizing pancreatitis refractory to standard medical care who underwent CT-guided percutaneous catheter drainage with 12- to 22-French catheters. Experiences with two subgroups were compared. One group consisted of 22 patients, 10 with multisystem organ failure, who presented with sterile necrosis (median Atlanta score, 1.3; range, 0-3). The other group consisted of 13 patients, one with multisystem organ failure, who presented with infected necrosis (median Atlanta score, 0.4; range, 0-3). Differences between the group with sterile and the group with infected necrosis were analyzed with the Fisher-Holton exact and Mann-Whitney U tests. Among 35 patients, 17 (49%) were treated successfully with CT-guided percutaneous catheter drainage alone. The effectiveness of CT-guided percutaneous catheter drainage in patients with sterile necrosis (11/22, 50%) was not significantly different from that of drainage in patients with infected necrosis (6/13, 46%). Among 11 patients with multisystem organ failure (10 with sterile necrosis, one with infected necrosis), only four (36%) were treated successfully with CT-guided percutaneous catheter drainage alone; five patients (45%) died. Among 24 patients without multisystem organ failure, 13 (54%) were treated successfully with CT-guided percutaneous catheter drainage alone; one patient died. In our experience, primary CT-guided percutaneous catheter drainage was successful for approximately one half of the patients with acute necrotizing pancreatitis. The presence of multisystem organ failure appears to be a more important indicator of outcome than does the presence of infection.

CT-guided Percutaneous Pigtail Catheter Drainage and Normal Saline Irrigation for Treatment of Loculated Empyema

Empyema is associated with significant morbidity and mortality. For satisfactory outcome, complete drainage is mandated. The appropriate drainage modality of an empyema is not yet established. We report a case of successful computed tomography-guided percutaneous pigtail catheter drainage with daily saline irrigation of a loculated empyema.

CT-guided Percutaneous Catheter Drainage in Necrotizing Pancreatitis: Outcomes among Patients Discharged with Drains in Place

To evaluate the clinical success of discharging patients with persistent drainage from percutaneous pancreatic catheters and to identify factors related to complications and re-admission. The authors identified 15 patients with necrotizing pancreatitis who were discharged with drains after computed tomographic (CT)-guided catheter drainage at their institution from 2000 to 2006. At discharge, all patients were afebrile and were tolerating oral diets but had persistent catheter output. Data reviewed included abdominal CT scans (at admission, before drain placement, and before discharge), microbiologic results, catheter caliber, number of catheters, outpatient follow-up, and re-admission records. Seven of the 15 patients (47%) remained clinically well and underwent successful outpatient catheter removal (median duration of catheter drainage, 94 days). Eight of the 15 patients (53%) were re-admitted because of abdominal pain and/or fever (median time to re-admission, 15 days). Six of the eight re-admitted patients (75%) underwent surgical débridement and two (25%) had catheters manipulated followed by eventual successful outpatient catheter removal. The mean percentage reduction in size of the necrotic collection before discharge was higher in the seven patients who remained clinically well compared to the eight who required re-admission (87.6% vs 49.6%, P = .037). Patients with necrotizing pancreatitis who have persistent drainage from percutaneous catheters at the time of hospital discharge are more likely to be re-admitted if there is CT evidence of inadequate resolution of the necrotic collection.

Multiple Pyogenic Spondylodiscitis with Bilateral Psoas Abscesses Accompanying Osteomyelitis of Lateral Malleolus - A Case Report -

A psoas abscess is a potentially life-threatening infection. Multiple pyogenic spondylodiscitis with bilateral psoas abscesses accompanying an osteomyelitis of the lateral malleolus is an extremely rare event. We present our experience with needle aspiration for the treatment of osteomyelitis of the lateral malleolus and CT-guided percutaneous catheter drainage for a psoas abscess in an elderly patient. Both infections were completely resolved without recurrence. A psoas abscess should be included in the differential diagnosis of a patient with low back pain during musculoskeletal infection. Percutaneous needle aspiration or CT-guided percutaneous catheter drainage is an effective method for treating certain musculoskeletal infections.

Lumbar Pyogenic Spondylodiscitis and Bilateral Psoas Abscesses Extending to the Gluteal Muscles and Intrapelvic Area Treated with CT-guided Percutaneous Drainage - A Case Report -

Bilateral psoas abscesses extending to the gluteal muscle and intrapelvic area are uncommon. We present our experience with computed tomography (CT)-guided percutaneous catheter drainage for the treatment of multiple aggressive abscesses in a diabetic patient. The abscesses completely resolved after the procedures. Psoas abscess should be considered in the differential diagnosis of older diabetic patients with fever, flank or back pain, and flexion contracture of the hip joint. CT scanning is a useful method in diagnosing abscesses, and CT-guided percutaneous catheter drainage is an effective treatment method in selected patients.

Acute necrotizing pancreatitis: role of CT-guided percutaneous catheter drainage

Necrotizing pancreatitis is the most severe form of acute pancreatitis associated with high morbidity and mortality. Percutaneous CT-guided catheter drainage is an important treatment option that can be effective whether used alone, or as an adjunct to operation. Existing literature describing the role of percutaneous catheter drainage of necrotizing pancreatitis is limited. This update reviews techniques, indications, outcomes, and complications of CT-guided percutaneous treatment of acute necrotizing pancreatitis.

Splenic Abscess due to Clostridium perfringens

To the Editor: Splenic abscess is an uncommon clinical entity with an incidence of 0.14% to 0.7%.1 The common causative organisms are aerobic. Anaerobic organisms such as clostridial species are rarely implicated. We present a case of an elderly woman with splenic abscess that grew Clostridium perfringens. CASE REPORT A 64-year-old woman presented with a 2-week history of left upper quadrant abdominal pain associated with fever, nausea, vomiting, and diarrhea. She denied any history of recent antibiotic use, travel, or sick contacts. Patient had a colonoscopy 4 years before presentation which revealed a polypoid leiomyoma in the sigmoid colon; a follow-up colonoscopy a year later revealed hyperplastic polyps in the transverse colon that were removed. History was otherwise noncontributory. On examination, patient was in mild distress because of abdominal pain. Vital signs showed a temperature of 36.4°C and a pulse rate of 110/min. Abdominal examination was significant for left upper quadrant tenderness and splenomegaly. The rest of the physical examination finding was unremarkable. Laboratory data showed marked leukocytosis (white blood cell count of 21.8 × 103/mm3 with 82% neutrophils and 7% bands) and C-reactive protein of 17.5 mg/dL. The rest of the laboratory results were within normal limits. Chest radiograph revealed an elevated left hemidiaphragm. Computed tomography (CT) of the abdomen with contrast revealed an air-fluid level along the posterior part of the spleen consistent with an abscess (Fig. 1). The patient was empirically started on intravenous piperacillin-tazobactam and had a CT-guided percutaneous catheter drainage of the abscess. Abscess drain cultures were positive for C. perfringens, and the antibiotics were changed to ampicillin-sulbactam. Stool was negative for Clostridium difficile toxin. Blood cultures were negative. An echocardiogram of the heart revealed no valvular vegetations. Malignancy workup was negative. Colonoscopy revealed adenomatous polyps in the transverse colon, and she underwent polypectomy. The patient was discharged on intravenous clindamycin for dosage convenience. Her condition improved, and serial abdominal CT scans done over the next few weeks revealed a decrease in the abscess size. The drain was removed after she completed a 6-week course of antibiotics.FIGURE 1: Computed tomography of the abdomen with contrast showing air-fluid level in the spleen.She presented with similar complaints 4 weeks later. A repeat CT of the abdomen revealed recurrence of the splenic abscess. She then underwent splenectomy; dense adhesions were noted along the splenocolic ligament on exploratory laparotomy. She was discharged uneventfully on postoperative day 8. DISCUSSION Splenic abscess is rare with a subtle clinical presentation and requires a high index of suspicion. The most common clinical features are fever, left upper quadrant pain, and splenomegaly.2 Diagnosis is mainly radiological. Ultrasonography is a good noninvasive technique, but CT has the highest sensitivity and specificity.2 Aerobic organisms are the most common organisms isolated and include staphylococcus and streptococcus species, salmonella, and Escherichia coli1-3; anaerobes account for 10% only. Most of the cases reported in the past due to clostridial species had predisposing factors such as malignancy, colitis, hematologic diseases, diabetes, or trauma.4-7 A review of literature revealed 2 reported cases of splenic abscess due to C. perfringens6,8; one had trauma as a predisposing cause, and the other one speculated diabetic microvascular injury as a possible factor. The source of C. perfringens in our patient remained obscure except for the history of diarrhea suggesting colitis and repeated polypectomies with breach in colonic mucosa acting as a possible portal of entry.

Evaluation and selection of different procedures in the treatment of pancreatic pseudocyst

To evaluate the effect of different procedures in the treatment of pancreatic pseudocyst. This retrospective review analyzed the outcome of 114 patients with pancreatic pseudocysts managed in PUMC Hospital from January 1990 to March 2002. There were 25 patients without intervention, the spontaneous resolution of pseudocysts occurred in 23 of these patients during follow up. Twenty-nine cases underwent CT-guided percutaneous catheter drainage; the effective rate of therapy was 67.85%. Surgical procedures performed in 60 cases and the overall mortality was 5% (3/60). The procedures included external drainage (8 cases) with 1 death (12.5%), excision (13 cases), cyst-duodenostomy (1 cases), cyst-gastrostomy (19 cases) with 7 postoperative gastrointestinal bleeding (36.8%) and 1 death (5.26%), Roux-en-Y cyst-jejunostomy (19 cases) with 3 postoperative gastrointestinal bleeding (15.8%) and 1 death (5.26%). CT-guided percutaneous catheter drainage has the advantage of minimal invasive and simple technique; it can be as an effective substitute method of traditional open external drainage. Although minimally invasive techniques offer a variety of treatment options, surgical procedures are still indicated for significant number of patients. The incidence of postoperative gastrointestinal bleeding in cyst-gastrostomy was higher than those patients with Roux-en-Y cyst-jejunostomy, but most of them were not difficult to treatment, so cyst-gastrostomy is still a simple and reasonable procedure for selected patients. Excision is a correct choice for cases in which pseudocysts cannot be differentiated from neoplastic cysts.

Computed Tomography-guided Percutaneous Catheter Drainage of Primary and Secondary Iliopsoas Abscesses

AIM: To report our experience with computed tomography (CT)-guided percutaneous catheter drainage (PCD) of iliopsoas abscesses. MATERIALS AND METHODS: Twenty-two iliopsoas abscesses in 21 patients (11 women, 10 men) aged between 18 and 66 years (mean 36 years) were treated with PCD. Abdominal CT demonstrated the iliopsoas abscesses, which were definitively determined by Gram staining and aspirate cultures. Twenty of the 22 iliopsoas abscesses were primary and two were secondary. All PCD procedures were performed under local anaesthesia using a single-step trocar technique ( n=19) or Seldinger technique ( n=3). RESULTS: PCD was an effective treatment in 21 out of the 22 iliopsoas abscesses. Recurrence was seen in three abscesses as minimal residual collections. Two of them resolved spontaneously with anti-tuberculous regimen. One required percutaneous needle aspiration. The procedure failed in a diabetic patient with a secondary abscess, who died due to sepsis. The length of time that catheters remained in place ranged from 21 to 75 days (mean 59.7 days). Complications included catheter dislocation in four abscesses, which required removal of dislocated catheters and indwelling new ones. CONCLUSION: CT-guided PCD is a safe and effective front-line treatment of iliopsoas abscesses. Surgery should be reserved for failure of PCD and presence of contraindications to PCD.

CT-guided catheter drainage of loculated thoracic air collections in mechanically ventilated patients with acute respiratory distress syndrome.

We report our experience with CT-guided percutaneous catheter drainage of loculated thoracic air collections in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome. Nine critically ill patients had 17 air collections (13 pneumothoraces, three pneumatoceles, one tension pneumomediastinum) that either developed despite the presence of standard surgical chest tubes or were in loculated sites that were difficult to access. All nine patients were ventilated mechanically for a clinical diagnosis of acute respiratory distress syndrome. Catheter size ranged from 7- to 28-French. Response was measured by imaging follow-up, ventilatory parameters, and clinical outcome. On follow-up imaging studies, all 17 air collections were shown to have been evacuated successfully. Catheters remained in place for a mean of 11 days (range, 4-28 days). No major complications occurred. Sixteen air collections were treated successfully with CT-guided catheter placement alone; the remaining air collection, a pneumothorax, was treated with subsequent placement of a chest tube by the surgeon at the patient's bedside. No surgery was undertaken for the air collections. Improvement in gas exchange was documented by increase in the hypoxemia ratio (arterial oxygen pressure divided by the inspired fraction of oxygen) in seven of 12 drainages; the other drainages were accompanied either by no improvement or by deterioration. Eight (89%) of the nine patients eventually were extubated and discharged from the hospital. The ninth patient died. CT-guided percutaneous catheter drainage provided effective treatment for loculated thoracic air collections and obviated surgical intervention in these critically ill, high-surgical-risk patients.

Palliative Sclerosis of Intra-abdominal Cystic Ovarian or Peritoneal Carcinoma

Three patients with platinum- and paclitaxel-resistant predominantly cystic intra-abdominal recurrences of ovarian or peritoneal carcinoma were treated with CT-guided percutaneous catheter drainage and subsequent sclerosis. This relieved colonic or ureteral obstruction and provided significant relief from symptoms. In one case repeated sclerosis was performed. Sclerosis of cystic recurrences may provide additional palliation.

Spondylodiskitic abscesses: CT-guided percutaneous catheter drainage.

To determine whether computed tomographically (CT) guided percutaneous catheter drainage of spondylodiskitic abscesses is an appropriate and effective alternative to surgery. CT-guided percutaneous catheter drainage was performed in 21 patients (16 men, five women; age range, 24-81 years) with 33 spondylodiskitic abscesses. Nine intradiskal, 12 paravertebral, and 12 psoas abscesses were drained with 5.6-14.0-F catheters. In 29 cases, the catheter was inserted by using the Seldinger technique in four cases, a trocar technique was used. All patients underwent follow-up CT or magnetic resonance imaging examinations for 6 months. Successful placement of the drainage catheter was achieved in each patient without procedural complications. The duration of drainage was 4-56 days (average duration, 26.8 days). Three of 33 catheters were changed because of insufficient drainage; one of the 33 catheters had to be reinserted because of dislocation. Two patients underwent surgery for stabilization of the spine with the drainage catheter in place. In 16 of the 21 patients, specific organisms were isolated; thus, definitive medical therapy was possible. Complete evacuation of all abscesses was achieved initially, with no evidence of recurrence during the follow-up. CT-guided percutaneous catheter drainage is an efficient and safe procedure in the management of spondylodiskitic abscesses.

CT-guided percutaneous aspiration and catheter drainage of pyogenic liver abscesses: B. Attar, H. Levendoglu, and N.S. Cuasay. Am J Gastroenterol 81:550–555, (July), 1986

CT-guided percutaneous aspiration and catheter drainage of pyogenic liver abscesses: B. Attar, H. Levendoglu, and N.S. Cuasay. Am J Gastroenterol 81:550–555, (July), 1986

CT guided percutaneous drainage of psoas abscess

Two cases of pyogenic psoas abscess were diagnosed and treated by CT-guided percutaneous catheter drainage. In these 2 patients there was rapid clinical improvement and tomographic disappearance of the masses. Image-guided percutaneous drainage of psoas abscess appears to be a safe and effective alternate to open surgical drainage.

Improved survival in 45 patients with pancreatic abscess.

The reported mortality due to pancreatic abscesses after acute pancreatitis has been 30 to 50%, a statistic that has remained unchanged for decades. This is a report of 45 patients treated over 10 years, showing a dramatic improvement in survival during that period. They represent 2.5% of admissions at the Massachusetts General Hospital for acute pancreatitis. The identifiable antecedents included alcohol (38%), gallstones (11%), and surgical trauma (16%), or were unknown in 24%. Computerized tomography (CT) was clearly the best means of specific diagnosis (unequivocal evidence in 74%, suggestive in 21%). Treatment in 44 patients was surgical debridement and catheter drainage, and in one it was resection of the pancreatic head. Multiple abscesses were present at the first operation in 21 patients. Seven had second drainage procedures for additional abscesses. In the first 5 years (1974-1978), 10 of 26 patients died (38%). In the second 5 years (1979-1983), one of 19 died (5%) (p less than 0.01). Postoperative complications (84%) included wound hemorrhage (9 of 26 vs. 1 of 19), systemic sepsis (7 of 26 vs. 1 of 19), pancreatic fistula (14/45, 13 of which closed spontaneously), colonic perforation (4), duodenal perforation (2), and gastric perforation (1). The causes of death were renal and respiratory failure with sepsis (7), hemorrhage (3), and pulmonary emboli (1). Analysis of the findings shows in the second 5-year period more frequent use of CT to certify the diagnosis of pancreatic abscess earlier, a more aggressive attitude producing earlier surgical intervention, and more extensive drainage and debridement of associated necrotic tissue. Transcatheter arterial embolization was used successfully to control postoperative hemorrhage from the abscess cavity. CT-guided percutaneous catheter drainage was used occasionally for drainage of recurrent abscesses. Neither open packing of major pancreatic abscesses nor lavage of the abscess cavity, as recently advocated, was necessary.

Liver Abscess: Complication of a Ventriculoperitoneal Shunt

Liver abscess is a previously unreported complication of ventriculoperitoneal shunting. We present such a case, which was diagnosed by computed tomography (CT) and managed by CT-guided percutaneous catheter drainage of the liver abscess, appropriate antibiotics, and shunt externalization.

Liver Abscess: Complication of a Ventriculoperitoneal Shunt

Liver abscess is a previously unreported complication of ventriculoperitoneal shunting. We present such a case, which was diagnosed by computed tomography (CT) and managed by CT-guided percutaneous catheter drainage of the liver abscess, appropriate antibiotics, and shunt externalization. (Neurosurgery) 14:480-482, 1984)

Iliopsoas abscess: treatment by CT-guided percutaneous catheter drainage.

Eight cases of iliopsoas abscess were diagnosed and treated by computed tomographic (CT)-guided needle aspiration and percutaneous catheter drainage. The etiology varied but was definitely established in only four of eight cases. Seven of eight were successfully drained and surgery avoided. The eighth patient defervesced satisfactorily but ultimately required surgical debridement of a sacral osteomyelitis. Clinical, anatomic, and technical considerations for percutaneous drainage of iliopsoas abscesses are discussed. CT was essential both in early diagnosis and in guiding diagnostic needle aspiration and catheter placement. Image-guided percutaneous drainage appears to be the treatment of choice for iliopsoas abscess.