Drainage Of Pancreatic Abscesses Research Articles

Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: Five years of experience with zero mortality

ObjectiveThe aim of this study is to perform a comprehensive evaluation of 5 years of experience with the technique of isolated pancreatic anastomosis reconstruction after pancreatoduodenectomy from the perspective of safety and surgical efficacy using a prospective database. MethodsThe study included all consecutive patients undergoing pancreatoduodenectomy from April 2009 to April 2014 at a single referral center for hepato-pancreato-biliary diseases. The primary endpoint was the safety of the procedures, which was assessed as the occurrence of complications during hospitalization. Ninety-day mortality was also assessed. Postoperative pancreatic fistulas were classified as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification. ResultsThe study group included 214 consecutive patients with a median age of 60 years who underwent pancreatoduodenectomy. Portal vein resection was performed on 41 patients. Indications for resection were 165 pancreatic head tumors, 33 ampullary tumors, 7 chronic pancreatitis, 3 distal bile duct tumors, and 6 duodenal tumors. There was no perioperative or 90-day mortality in this series. Complications occurred in 68 patients (32%), and 42 patients presented with pancreatic fistulas (19.6%). Grade A fistulas were present in 38 patients. Three patients presented persistent pancreatic fistula and were treated with percutaneous drainage. One patient developed combined pancreatic and biliary fistulas and was reoperated on for pancreatic abscess drainage. ConclusionsThe technique of isolated pancreatic anastomosis by diverting the pancreatic from biliary secretion may contribute to reducing the severity of pancreatic fistulas and therefore the severity of this complication.

Laparoscopic approach in gastrointestinal emergencies.

This review focuses on the laparoscopic approach to gastrointestinal emergencies and its more recent indications. Laparoscopic surgery has a specific place in elective procedures, but that does not apply in emergency situations. In specific emergencies, there is a huge range of indications and different techniques to apply, and not all of them are equally settle. We consider that the most controversial points in minimally invasive procedures are indications in emergency situations due to technical difficulties. Some pathologies, such as oesophageal emergencies, obstruction due to colon cancer, abdominal hernias or incarcerated postsurgical hernias, are nearly always resolved by conventional surgery, that is, an open approach due to limited intraabdominal cavity space or due to the vulnerability of the bowel. These technical problems have been solved in many diseases, such as for perforated peptic ulcer or acute appendectomy for which a laparoscopic approach has become a well-known and globally supported procedure. On the other hand, endoscopic procedures have acquired further indications, relegating surgical solutions to a second place; this happens in cholangitis or pancreatic abscess drainage. This endoluminal approach avoids the need for laparoscopic development in these diseases. Nevertheless, new instruments and new technologies could extend the laparoscopic approach to a broader array of potentials procedures. There remains, however, a long way to go.

CT Guided Percutaneous Drainage of Pancreatic Abscess: A Case Report and Mini Review

CT Guided Percutaneous Drainage of Pancreatic Abscess: A Case Report and Mini Review

Could Transgastric Endoscopic Ultrasound-Guided Aspiration Alone Be Effective for the Treatment of Pancreatic Abscesses?

Drainage of pancreatic abscesses is required for effective control of sepsis. Endoscopic ultrasound (EUS)-guided endoscopic drainage is less invasive than surgery and prevents local complications related to percutaneous drainage. Endoscopic drainage with stent placement in the uncinate process of the pancreas is a technically difficult procedure. We report a case of pancreatic abscess treated by repeated EUS-guided aspiration and intravenous antibiotics without an indwelling drainage catheter or surgical intervention.

Samoistny drenaż ropnia trzustki do światła przewodu pokarmowego

Samoistny drenaż ropnia trzustki do światła przewodu pokarmowego

Interventional endoscopic ultrasonography: an overview of safety and complications

In recent years, endoscopic ultrasonography (EUS)-guided techniques have been developed as alternatives to surgical, radiologic, or conventional endoscopic approaches for the treatment or palliation of several digestive diseases. The use of EUS guidance allows the therapeutic area to be targeting more precisely, with a possible clinical benefit and less morbidity. Nevertheless, the risks persist and must be taken into consideration. This review gives an overview of the complications observed with the most established procedures of therapeutic EUS. The PubMed and Embase databases were used to search English language articles on interventional EUS. The studies considered for inclusion were those reporting on complications of EUS-guided celiac plexus block (EUS-CPB), EUS-guided celiac plexus neurolysis (EUS-CPN), drainage of fluid pancreatic and pelvic collections, and EUS-guided biliary and pancreatic drainage (EUS-BD and EUS-PD). Variations in methodology and design in most studies made a thorough statistical analysis difficult. Instead, a frequency analysis of complications and a critical discussion were performed. Although EUS-guided celiac plexus injection causes mainly mild and transient complications, growing experience shows that EUS-CPN is not as benign a procedure as previously thought. Most of the major complications have been observed in patients with chronic pancreatitis. The findings show that EUS-guided drainage of fluid collections is a safe procedure. Complications occur more often after the drainage of pancreatic abscesses and necrosis. Although the heterogeneity of studies dealing with pancreatobiliary drainage makes the evaluation of risks after these procedures difficult, complications after EUS-BD and EUS-PD are relatively frequent and can be severe. The technical complexity and the lack of specifically designed devices may account for their complication rates. Clinicians can consider EUS-guided celiac injection and EUS-guided drainage of fluid collections to be safe alternatives to surgical and radiologic interventions. Well-designed prospective trials are needed to assess the risks of EUS-BD and EUS-PD accurately before they are broadly advocated after a failed endoscopic retrograde cholangiopancreatography (ERCP).

Evolving management of pancreatic injury

In this study we present a concise review of the evolving management of traumatic injury to the pancreas, including diagnostic approaches and options for operative and nonoperative intervention. New diagnostic adjuncts can be used for the evaluation of injury to the pancreas and pancreatic duct. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) are used as diagnostic modalities for duct evaluation. ERCP can be therapeutic with sphincterotomy and/or stenting for duct disruption. Computed tomography scan is the initial imaging study of choice for pancreatic injury, but is also used for drainage of pancreatic abscesses or pseudocysts. Nonoperative management of solid organ injuries is the recommended treatment in hemodynamically stable patients. This strategy is now being successfully applied to pancreatic injuries in specific situations. However, the mainstays of pancreatic injury remain the same. The identification of pancreatic duct injury is the top priority. Management includes distal resection, debridement, and closed suction drainage of pancreatic injuries.

Successful EUS-guided drainage of the abscess in the abdominal cavity consequent to the gastric surgery: Report of a case

EUS-guided drainage has been known to be useful for drainage of pancreatic abscess. Little is described about the drainage for postoperative abscess. We report a successful EUS-guided drainage of the abscess in the abdominal cavity consequent to the gastric surgery. The patient was a 42 years old Japanese female who had been noted to have a submucosal tumor in the stomach close to the gastroesophageal junction. EUS-guided fine needle aspiration was performed and the pathological specimen revealed the GIST (gastrointestinal stromal tumor). Laparoscopic surgery was performed and the submucosal tumor was completely removed. Six days after the surgery the patient developed a high fever and the CT scan revealed an abscess formation in the left subphrenic space. Antibiotic treatment was carried out but the abscess had not been changed in size and the inflammation was not improved. Fourteen days after the surgery, EUS-guided abscess drainage was performed. EG530UT linear EUS scope (Fujifilm, Tokyo) was used. The hypoechoic lesion was recognized closed to the gastric wall, which was measured 7cm in maximal diameter. 19G Echo Tip Ultra endoscopic ultrasound needle (Cook Medical Endoscopy, IN, USA) was used to puncture the lesion, which was followed by the guide wire insertion (0.035 Jagwire, Boston Scientific Japan, Tokyo). Yellowish thick fluid came out from the lesion. Olympus KD-441Q needle knife (Olympus, Tokyo) was inserted over the guide wire and small incision was made. Once the needle knife was removed, a double pigtail tube (PBD-203–0703, Olympus, Tokyo) was inserted over the guide wire and placed into the lesion. Two days after the drainage, the fever had been lowered and the patient could discharge the hospital after seven days of the drainage procedure. Since the abscess became reduced in size, the stent was removed endoscopically after two months of the drainage procedure. The abscess disappeared on the endoscopic examination and the CT scan half a year later. EUS-guided drainage is also a promising procedure for the drainage of the abscess in the abdominal cavity consequent to the gastric surgery.

Potentially fatal tricuspid valve aspergilloma detected after laparoscopic abdominal surgery

Fungal endocarditis accounts for 1.3-6% of all cases of infective endocarditis. The most common causative organism is Candida, followed by Aspergillus and other mould fungi. Aspergillus endocarditis is usually associated with high morbidity and mortality. Establishing a definitive and timely diagnosis remains difficult and there are many reports of undetected aspergillomas leading to fatalities in the perioperative period. We present a case report of preoperatively undiagnosed large mobile tricuspid valve aspergilloma obstructing the right ventricular inlet, diagnosed incidentally on the second postoperative day after laparoscopic pancreatic abscess drainage. The patient was successfully managed with emergency open-heart surgery and systemic antifungal agents in the postoperative period.

Imaging Evaluation of Post-Pancreatitis Infection

Acute pancreatitis affects around 40 per 100.000 of the general population and 20-30% of attacks are severe. Mortality is usually associated to septic multiorgan dysfunction syndrome caused by secondary infection of pancreatic or peripancreatic necrosis. The diagnosis of acute pancreatitis is generally based on clinical and laboratory findings. However CT is the imaging technique of choice for detecting complications. Patients with complicated pancreatitis require multiple follow-up examinations. Substitution of US or MRI for CT in certain cases would reduce the radiation dose considerably. Complicated pseudocysts and other pancreatic collections may contain solid debris, which is best depicted by MRI. Abscesses are suggested when gas is present in a pancreatic or peripancreatic collection. MRI can reveal air-fluid levels or large pockets of gas, but CT is more sensitive for small gas collections. US or CT-guided percutaneous drainage of pancreatic abscesses or infected collections is a useful therapeutic approach in acute cases obviating the need for unnecessary surgery. On the other hand infected necrosis can not be successfully treated percutaneously due to its thicker consistency. In this review, the role of different imaging modalities in the evaluation of post-pancreatitis infection as well as in the treatment planning will be discussed.

Natural orifice translumenal endoscopic drainage for pancreatic abscesses

Few series describe endoscopic drainage of pancreatic abscesses. Abscesses are complications of pancreatitis, presenting with sepsis, peritonitis, or both. This report describes the feasibility and efficacy of natural orifice translumenal endoscopic surgery for pancreatic abscesses. This study reviewed 35 consecutively treated patients for the period 1994-2007. The approaches alone or in combination were transmural (transgastric or transduodenal) and transpapillary. The criteria for abscesses were two or more of the following: fever, abdominal pain, elevated white blood count (WBC), and positive fluid cultures. The 35 patients (19 men and 16 women) had a mean age of 49 years. The abscesses had idiopathic (37%), gallstone (32%), alcohol (20%), and divisum (11%) etiologies. The presenting signs were abdominal pain (80%), positive cultures (69%), fever (57%), elevated WBC (51%), and nausea/vomiting (39%). The approaches for abscess drainage were as follows: transgastric (n = 15, 43%), transduodenal (n = 4, 11%), transgastric combined with transpapillary (n = 8, 23%), transduodenal combined with transpapillary (n = 1, 3%), and transpapillary alone (n = 7, 20%). A total of 28 patients (80%) achieved successful endoscopic pancreatic abscess drainage, whereas 7 (20%) required surgery. Of these seven patients, two (6%) required emergent laparotomy to control bleeding, and the remaining five (14%) were explored after failure to demonstrate clinical improvement from endoscopic drainage. Three patients required internal drainage, and two patients required distal pancreatectomy. The mean follow-up period was 15 months, and the complication rate was 6%. No one died from the procedure. Endoscopic surgery for pancreatic abscess is feasible and effective. It is an alternative to surgery that currently can be considered a primary treatment option for selected pancreatic abscesses.

Endoscopic necrosectomy as primary treatment for infected peripancreatic fluid collections (with video)

The success of endoscopic intervention in the management of uncomplicated pancreatic pseudocysts has allowed endoscopists to be more aggressive in managing complicated pancreatic fluid collections. Surgery is considered the mainstay of therapy once pancreatic abscesses develop. As a second-line treatment, endoscopic drainage of pancreatic abscess has been performed in those who are not candidates for surgery. Our purpose was to report our experience with single-session endoscopic necrosectomy and drainage as the primary mode of treatment of infected pancreatic necrosis or abscesses. This was a case series. A single endoscopy unit based at a university medical center. Six consecutive patients who underwent endoscopic necrosectomy as the primary treatment modality for pancreatic abscess or necrosis between May 2006 and February 2007. Resolution of the infected pancreatic fluid collection and avoidance of surgery. Successful single-session endoscopic necrosectomy was performed in all 6 patients with impressive and immediate symptom relief. None needed surgery or other endoscopic or percutaneous interventions. Patients were discharged from the hospital in a median of 8.5 days. Complete resolution of pancreatic lesions were noted in 5 of 6 patients (1 patient had a small residual cyst) in median follow-up of 3.5 months (range 3-11 months). Endoscopic necrosectomy can be performed safely and efficiently for the primary treatment of pancreatic necrosis and abscess. Our data suggest that aggressive single-session necrosectomy can be adequate for the complete removal of infected and necrotic debris.

Drainage of Pancreatic Abscesses and Cysts Under Ultrasound Control

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Pancreatic abscess drainage by gastric biopsy

Pancreatic abscess drainage by gastric biopsy

Endoscopic transpapillary drainage of pancreatic abscess: technique and results

Background: Pancreatic abscess is one of the serious complications of acute pancreatitis. Traditionally, pancreatic abscess has been treated by operative drainage. Based on experience with endoscopic transpapillary drainage of pseudocysts, a similar technique was used in patients with pancreatic abscess. Method: Patients were evaluated by endoscopic retrograde cholangiopancreatography. In those with pancreatic abscess communicating with the main pancreatic duct, pancreatic sphincterotomy, saline irrigation of the abscess cavity, and catheter dilation followed by 10F pancreatic stent placement were done. Instillation of gentamicin and nasopancreatic catheter drainage were used in difficult cases. Results: Of 22 patients with pancreatic abscess, 11 underwent endoscopic transpapillary drainage with technical success in 10 patients (90%); 8 patients (74%) had resolution of pancreatic abscess, clinically and radiographically. Intracavitary instillation of gentamicin and nasopancreatic catheter drainage were used in 2 patients. Two patients in whom endoscopic transpapillary drainage failed underwent operative drainage with a favorable outcome, and the one patient in whom endoscopic treatment was technically unsuccessful underwent successful percutaneous drainage. One patient had mild pancreatitis. Conclusion: Endoscopic transpapillary drainage is an effective nonoperative therapy for selected cases of pancreatic abscess and is associated with minimal morbidity and no mortality. (Gastrointest Endosc 2000;51:391-5.)

3396 Endoscopic drainage of pancreatic abscess with endoscopic fistulization and transgastro-duodenal stenting.

Background: Recently, pancreatic endotherapy is increasingly used even for the treatment of infectious complication of acute pancreatitis and successful endoscopic drainage of infected organized pancreatic nectrosis has been reported (Monkemuller et al, Gastrointest Endosc 1999). Although endoscopic internal drainage of pancreatic abscess has been successfully employed (Messmann, Endoscopy 1995), experience is limited and role of endoscopic drainage in the treatment of pancreatic abscess complicating acute pancreatitis is less well defined. Aim: To determine feasibility, effectiveness and safety of endoscopic drainage for the treatment of pacreatic abscess. Methods: In 6 patients (3M, 3F, mean age 56.1, range 49-67), 8 pancreatic abscesses compressing gut lumen (duodenal compression in 3 cases, stomach compression in 1 case, both duodenum and stomach compressing in 2 cases, mean size 5.3×6.8 cm) were drained endoscopically by means of endoscopic fistulization and subsequent stent(s) placement. Endoscopic fistulization was performed through the gastroduodenal wall using needle-knife (HPC-2, Wilson-Cook Medical Co, NC). Single, 7-10 Fr, biliary stent (pigtail in 6, straight in 2) was placed into the abscess cavity after an aspirate was taken for bacterial culture and irrigation with sterile saline through the evacuated needle-knife sheath or cannulation cathter. In one patient with largest abscess with thick pus, a 7 Fr nasobiliary catheter was placed concurrently with the 10 Fr stent to improve drainage after dilation of fistulous tract using a 10 Fr biliary dilation catheter. Follow-up was done by contrast enhanced CT. Results: Endoscopic drainage with endoscopic fistulization and placement of stent across the gastro-duodenal wall into the abscess cavity was successful in all cases. The mean duration of stent placement was 32.3 days (range 14-42). Complete drainge was achieved in 7 of 8 abscess cavities (87.5%). The complication was 1 case of bleeding (12.5%) requiring surgery which occurred during the repeated attempt of endoscopic transgastric drainage due to incomplete drainage. There was no mortality. Conclusion: These results suggest that endoscopic drainage with endoscopic fistulization followed by transgastro-duodenal stenting is a feasible, effective, and relatively safe non-surgical therapy in selective patients with pancreatic abscess compressing gastro-duodenal lumen. Background: Recently, pancreatic endotherapy is increasingly used even for the treatment of infectious complication of acute pancreatitis and successful endoscopic drainage of infected organized pancreatic nectrosis has been reported (Monkemuller et al, Gastrointest Endosc 1999). Although endoscopic internal drainage of pancreatic abscess has been successfully employed (Messmann, Endoscopy 1995), experience is limited and role of endoscopic drainage in the treatment of pancreatic abscess complicating acute pancreatitis is less well defined. Aim: To determine feasibility, effectiveness and safety of endoscopic drainage for the treatment of pacreatic abscess. Methods: In 6 patients (3M, 3F, mean age 56.1, range 49-67), 8 pancreatic abscesses compressing gut lumen (duodenal compression in 3 cases, stomach compression in 1 case, both duodenum and stomach compressing in 2 cases, mean size 5.3×6.8 cm) were drained endoscopically by means of endoscopic fistulization and subsequent stent(s) placement. Endoscopic fistulization was performed through the gastroduodenal wall using needle-knife (HPC-2, Wilson-Cook Medical Co, NC). Single, 7-10 Fr, biliary stent (pigtail in 6, straight in 2) was placed into the abscess cavity after an aspirate was taken for bacterial culture and irrigation with sterile saline through the evacuated needle-knife sheath or cannulation cathter. In one patient with largest abscess with thick pus, a 7 Fr nasobiliary catheter was placed concurrently with the 10 Fr stent to improve drainage after dilation of fistulous tract using a 10 Fr biliary dilation catheter. Follow-up was done by contrast enhanced CT. Results: Endoscopic drainage with endoscopic fistulization and placement of stent across the gastro-duodenal wall into the abscess cavity was successful in all cases. The mean duration of stent placement was 32.3 days (range 14-42). Complete drainge was achieved in 7 of 8 abscess cavities (87.5%). The complication was 1 case of bleeding (12.5%) requiring surgery which occurred during the repeated attempt of endoscopic transgastric drainage due to incomplete drainage. There was no mortality. Conclusion: These results suggest that endoscopic drainage with endoscopic fistulization followed by transgastro-duodenal stenting is a feasible, effective, and relatively safe non-surgical therapy in selective patients with pancreatic abscess compressing gastro-duodenal lumen.

Complete Recovery after Spontaneous Drainage of Pancreatic Abscess into the Stomach

Pancreatic abscess is a dreaded complication of acute pancreatitis, with a high death rate even with aggressive surgical treatment. We report two cases in which recovery followed spontaneous drainage into the stomach. A 75-year-old woman with biliary pancreatitis and a 63-year-old man with ethanol-induced pancreatitis both developed pancreatic abscess, diagnosed by computed tomography scans and ultrasound. The spontaneous gastric fistula was heralded by a large emesis of purulent and necrotic material in one case and copious nasogastric tube secretions of a similar material in the other. Defervescence was immediate, and both patients went on to complete recovery without any further interventions. Contrast studies showed the fistulae. It is concluded that in the event that a pancreatic pseudocyst spontaneously drains into the stomach a `wait and see' policy should be adopted, and a favorable outcome can be expected.

Percutaneous intervention in acute pancreatitis.

Interventional radiology has an important role to play in the management of local complications of acute pancreatitis, such as necrosis, pseudocyst, and abscess. Computed tomography (CT) is preferred for guiding pancreatic interventional procedures, with the most common access routes being through the left anterior pararenal space for pancreatic tail collections and through the gastrocolic ligament for pancreatic head and body collections. Pancreatic necrosis has a high mortality if infected, and the presence of infection must be determined with CT-guided needle aspiration. Careful planning of the access route is important to avoid the colon. Catheters of 8-12 F are usually sufficient for pseudocyst drainage. An average of 2-3 weeks drainage is required if there is no communication of the pseudocyst with the pancreatic duct and many weeks to months for pseudocysts with pancreatic duct communication. Percutaneous drainage of pseudocysts is associated with success rates of 80%-90%. Pancreatic abscess drainage has quoted success rates varying between 32% (infected necrosis) and 90% (pancreatic abscess). Use of large or multiple catheters is often required for complete drainage. The management of patients with severe acute pancreatitis is time-consuming and labor intensive for interventional radiologists, and a team approach with close communication with surgical personnel is required.

Factors that have resulted in the reduced mortality of acute pancreatitis from 1978–1997

A Prospective study of 4 time periods, i.e. 1978-82, 1983-87, 1988-92, 1993-97 showed a steady decline in the mortality of acute pancreatitis from 13.5% to 8%, to 7% and lastly, to 5% respectively. During this time, the incidence of pancreatitis has escalated so that the overall mortality has increased despite the reduction of percentage terms. The increase of acute cases in the later periods is almost totally due to an exponential rise in gallstone pancreatitis and a few miscellaneous forms such as ERCP, etc. The most impressive decrease in mortality has been in the patients with severe acute pancreatitis (SAP) from about 50% in the early period to between 12-17% over the last 4 yrs. The factors contributing to this decrease were: 1983-87 the introduction of the common signs of severity, i.e. Ranson's and Bank's signs leading to immediate ICU therapy, improved ICU care, particularly for cardiac, pulmonary and renal complications. 1988-92 CT scan became included in the severity score especially with regard to intrapancreatic necrosis, ICU techniques advanced and prolonged drainage of pancreatic abscess or necrotic tissue was introduced. In the middle of this period, skinny needle aspiration for the diagnosis of infection became popular. From 1992-97 the value of early antibiotics in pancreatic necrosis became established, multiple organ system failure was treated intensively with the return to use of Dextran in some centers, octreotide, somatostatin and PAF. Selective bacterial decontamination of the gut was introduced and newer antibiotics which penetrated the necrotic tissue were introduced. The place of emergency ERCP in non-alcohol induced pancreatitis became established particularly in cholangitis. Treatment of complications took great strides with both endoscopic and radiologic nonsurgical techniques taking a quantum leap for the treatment of cysts, persistent necrosis, ascites. Trials of newer agents, i.e. platelet activating factor antagonist have yet to be shown conclusively to decrease the early mortality. Conclusion: This 20 year personal prospective study has shown an impressive decline in the mortality of acute pancreatitis from 13.5-5% especially SAP. Early markers of severity and cytokine antagonists have yet to prove efficacy in reducing the mortality further.

Percutaneous radiologic drainage of pancreatic abscesses.

The purpose of our study was to review and report the patient selection, techniques, and results of percutaneous drainage of pancreatic abscesses by retrospective review. Fifty-nine patients (46 men and 13 women) with a mean age of 44 years old had 80 pancreatic abscesses that were drained percutaneously under radiologic guidance (CT, n = 77; sonography, n = 2; and fluoroscopy, n = 1). Abscesses had a wide spectrum of causes, with alcoholic pancreatitis being most common, trauma second most common, and gallstones third. Ten patients had undergone surgery for pancreatic necrosis or abscess. Patients with pancreatic pseudocysts, necrosis, or acute fluid collections were excluded from this study. Of the 59 patients, 51 (86%) were cured with percutaneous drainage and antibiotic therapy. Of the patients who were not cured with percutaneous drainage, seven required surgery and one underwent repeat percutaneous drainage. In the 59 patients, complications included non-life-threatening bleeding in three patients. Ten of 59 patients (17%) had fistulas that spontaneously formed into the gastrointestinal tract. The duration of catheterization ranged from 4 to 119 days, with a mean duration of 33 days. The rate of mortality at 30 days after completion of percutaneous drainage was 8% (5 of 59). Percutaneous drainage was an effective therapy for this defined group of patients with pancreatic abscesses. Factors leading to the relatively high success rate described in this study likely included selection of patients; catheters of adequate size, number, and location; careful follow-up with appropriate catheter manipulations; and an integrated, cooperative approach whereby surgeons were willing to permit drainage to effect its benefits, rather than operating prematurely.