Image-guided Catheter Drainage Research Articles

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.

Image-guided catheter drainage in loculated pleural space collections, effectiveness, and complications.

Introduction:Image-guided drainage is an established technique with a multitude of applications. The indications, techniques, and management of image-guided catheter drainage, however, continue to evolve. Image-guided drainage alone is sometimes sufficient for the treatment of a collection, but it can also act as an adjunct or temporizing measure before definitive surgical treatment. Drainage of a symptomatic collection is performed to drain pus from the cavity, working in conjunction with antibiotics. Infected collections accumulate antibiotics to a limited extent, which generally precludes effective treatment with antibiotics alone unless the collection is very small (1–3 cm). There are many indications for image-guided drainage in the chest, including pleural disease, lung parenchymal, pericardial, and mediastinal collections. Pleural collections represent a common clinical problem, for which image-guided drainage is recommended to reduce complications encountered as a result of blind drainage.Aim and Objective:To evaluate the efficacy and complications of ambulatory catheter drainage system for infective and loculated pleural collection.Materials and Methods:The study was conducted in the department of radiodiagnosis and imaging, Sheri Kashmir Institute of Medical Sciences Srinagar 2016 to 2018. It was prospective in nature. All the patients were referred from in patient department as cases of clinically symptomatic pleural collections with image-based evidence of loculations or septations. All 30 patients referred for drainage were imaged using suitable imaging technique (USG or CT) to quantise and document presence of septations and loculations in pleural collections. Mean attenuation of pleural fluid, presence of internal echo's and associated pleural thickening (>2mm) was noted.Results:The overall success rate in our study was 77%, with recurrence in 10 % of patients and failure rate of 13 %. The outcome as per etiology was success rate of 100% in parapneumonic effusion, 70 % in TB, 50 % in malignancy and 100% in pleural collection after recent surgical intervention. The common procedure related complications noted in our study were hemothorax (3%), post procedural pain (23 %), pneumothorax (3%).Conclusion:Image guided percutaneous drainage of loculated pleural space collections is an effective and safe procedure.

Pancreatic necrosis: Complications and changing trend of treatment.

Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.

Nonsurgical management of an enlarging pneumatocele by fibrin sealant injection via pigtail catheter

Most pneumatoceles disappear spontaneously and do not cause severe symptoms. Treatment alternatives include various conventional or surgical methods. However, an enlarging, complicated pneumatocele with cardiorespiratory instability requires imaging-guided catheter drainage or surgery. Here, we report the case of a newborn girl with an enlarging pneumatocele accompanied by pulmonary interstitial emphysema secondary to mechanical ventilation. The pneumatocele was successfully managed by the injection of fibrin sealant via a pigtail catheter.

Image-guided Percutaneous Splenic Interventions

In the spleen, image-guided interventional procedures such as biopsy and catheter drainage have not been widely performed because of the perceived increased risk of complications. The ability of image-guided biopsy to allow tissue diagnosis of a focal splenic mass without the need for splenectomy is the driving force behind use of this procedure in oncology patients. The literature on image-guided splenic biopsy suggests that the highest biopsy yield is achieved with core biopsy and the lowest complication rate is achieved with fine-needle aspiration. Image-guided catheter drainage is an effective alternative to splenectomy for management of infected splenic collections. In clinical practice, image-guided splenic biopsy, fluid aspiration, and catheter drainage have high success rates. Image-guided alcohol ablation is effective in treatment of splenic cysts. The literature on splenic radiofrequency ablation (RFA) is sparse; therefore, further studies are needed to determine the role of RFA in management of splenic neoplasms and hypersplenism. Image-guided percutaneous thrombin injection can be used to treat splenic artery pseudoaneurysms. Awareness of the correct interventional techniques and their limitations is important for safe performance of image-guided percutaneous splenic interventions.

Co-existence of Posttraumatic Empyema Thoracis and Lung Abscess in a Child After Blunt Chest Trauma: A Case Report

Posttraumatic empyema is a rare complication of trauma with an incidence of 1.6-2.4% in trauma patients. However, it is rarely reported in children. We report the case of a 15-year-old boy who was involved in a traffic accident and diagnosed with a pulmonary contusion at a local hospital. Fourteen days after the accident, posttraumatic empyema thoracis and lung abscess developed with clinical presentations of fever, productive cough and right chest pain. He was successfully treated with computed tomography-guided catheter drainage and intravenous cefotaxime. We emphasize that posttraumatic empyema thoracis and lung abscess are very rare in children, and careful follow-up for posttraumatic lung contusion is essential. Image-guided catheter drainage can be an adjunctive tool for treating selected patients, although most complicated cases of posttraumatic empyema thoracis require decortication therapy.

Diagnosis and Management of Parapneumonic Effusions

Parapneumonic effusions affect many patients and are associated with considerable morbidity and mortality. It is necessary to differentiate complicated effusions requiring intervention from uncomplicated effusions. Differentiation is achieved using clinical, pleural fluid, and imaging parameters. Intervention takes the form of blind catheter placement and drainage, image-guided catheter placement and drainage, and surgical decortication [video-assisted thoracoscopic surgery (VATS) or open thoracotomy]. Image-guided drainage and management of complicated effusions in adults and pediatric patients are safe and highly effective in select patients. The use of intrapleural fibrinolytic agents to facilitate resolution of complicated effusions is widespread and considered effective by many despite a lack of conclusive data supporting this method. We propose an algorithmic approach to patients with parapneumonic effusions and advocate image-guided drainage and management in patients likely to benefit from this treatment.

Neumonía complicada con neumatocele en un lactante, caso clínico

Introduction: Pneumatocele is an uncommon complication of pneumonia, most often asymptomatic with spontaneous resolution. Case-report: Female infant with an history of right upper lobe pneumonia, an air filled structure was noted in the chest X-ray. Asymptomatic until admitted for a wheezing episode, where an increase in the size of the structure was evidenced. She had clinical and radiological follow-up as recommended in a recent study, observing that 5 months later the cystic image was completely resolved. Discussion: According to criteria from published studies, this case is a non complicated pneumatocele because it was asymptomatic, compromised less than 50% of the hemithorax and no atelectasia, bronchopleural fistula or signs of infection were observed. Non complicated pneumatoceles can be followed up, and complicated can be treated by image guided catheter drainage or surgical resection. In this case, we confirmed spontaneous resolution after clinical and radiological follow-up.

Experience on the use of a high-pressure water jet system in a Burn Care Unit

We report the results of image-guided catheter drainage with adjunctive enzymatic pleural debridment in the treatment of empyemas and other complicated pleural fluid collections.Retrospective review.One hundred eighteen patients with complicated pleural fluid collections were treated with image-guided drainage. There were 79 empyemas, 27 sterile loculated parapneumonic effusions, 10 sterile hemothoraces, and 2 sterile postoperative exudative effusions. Forty-one patients had failed prior large-bore thoracostomy drainage. The estimated age of the effusions at the time of image-guided drainage ranged from 1 to 175 days with a mean estimated age of 13 days.Patients were treated with image-guided placement of one or more 12F to 16F chest drains. Adjunctive urokinase instillation was used in 98 cases. Urokinase (100,000 to 250,000 U/mL) was instilled in 20 to 240-mL aliquots and reaspirated in 1 to 4 h. One to four instillations were performed per day until drainage was complete.Drainage was successful in 111 cases (94%). Two patients died of sepsis with incomplete drainage. Five patients underwent decortication (three recovered and two died postoperatively). Fifty-three patients (45%) required placement of more than one drain. The mean duration of drainage was 6.3 days. Patients treated with pleurolysis required a mean of five instillations of urokinase. The mean total dose of urokinase used per case was 466,000 U. There were no complications.Image-guided drainage with adjunctive pleural urokinase therapy is a safe and effective method of closed thoracostomy drainage of complicated pleural fluid collections and can obviate surgery in most cases.

Imaging-Guided Catheter Drainage of Abdominal Collections with Fistulous Pancreaticobiliary Communication

Our aim was to study the success of percutaneous imaging-guided catheter drainage of abdominal collections with documented fistulous pancreaticobiliary communication. Fifty-seven patients (age range, 23-88 years) with abdominal collections who underwent imaging-guided catheter drainage were included in this retrospective study. These collections showed communication with either the pancreatic duct (n = 15) or the biliary duct (n = 42) on imaging. The imaging guidance included CT (n = 40), sonography (n = 17), and fluoroscopy (n = 4), either alone or in combination. The success of catheter drainage was described as resolution of the collection on follow-up imaging and clinical improvement. Other treatments directed toward management of leaks or collections were also recorded. The success rates of catheter drainage for abdominal collections with biliary and pancreatic ductal communication were 93% (39/42) and 67% (10/15), respectively. The difference was statistically significant (p = 0.01). The three complications seen in this study were pneumothorax in one patient, bowel perforation in one, and death in one. The drainage catheter was upsized in five patients and an additional catheter was needed in nine patients. Imaging-guided catheter drainage is a clinically useful option for drainage of abdominal collections that have pancreaticobiliary communications. The success rate is significantly better for collections with biliary communication than for those with pancreatic communication.

Radiological catheter drainage of abscesses in children

To assess the efficacy and safety of radiological catheter drainage of fluid collections and abscesses in children, and to review the principles, indications, technique, and possible complications of these procedures. A retrospective analysis was made of all radiologically guided catheter placements performed between March 1999 and April 2003. Patients' age, sex, location of the collection, technical details of the procedure, including modality used for guidance, technique of placement, type of catheter used, catheter indwelling time, and time for temporization were recorded from chart reviews. Success rate was calculated based on the number of curative drainage procedures. 33 children (16 boys and 17 girls) aged between 7 days and 14 years of age (mean 7 years) underwent 37 procedures. Successful drainage was achieved in 31 of 33 patients (94%). The dwell time for catheters ranged between 1 day and 30 days (mean 5.7 days). Mean duration for defervescence was 2 days. There were no major complications. Imaging-guided catheter drainage of fluid collections in children is safe and effective. Newer approaches, better imaging, and improved techniques have resulted in improved cure rates. The basic principles, common indications, various techniques, and the possible complications of these procedures, with special reference to the pediatric population, are reviewed in this article.

Pneumatoceles in postpneumonic empyema: an algorithmic approach

Purpose The aim of the study was to determine the natural course and select appropriate therapy for pneumatocele (PC) in children with postpneumonic empyema. Materials and Methods Records of 134 children treated for postpneumonic empyema between October 1997 and June 2003 were reviewed retrospectively, and 58 (43%) of them were found to have PC. Their chest x-rays and computed tomography scans as well as patient profiles were evaluated to assess the size, location, course, and complications. Clinical course, treatment indications, and results were also reviewed. Results The patients were aged from 14 months to 15 years (mean 3.8 years). There were 36 boys and 22 girls. The PC was located on the right hemithorax in 34 patients and on the left in 24. Staphylococcus aureus was the most common isolated infective agent. Of the 58 children, 37 (63.7%) showed complete resolution with improvement of the infection within 2 months. Thirteen PCs had evidences of gradual decrease in size without any indication for invasive approaches, and they resolved completely, with a mean time of 6.1 (ranging from 1-13) months. One tension PC, 3 large PCs (>50% of hemithorax), 1 case with bad tolerance to follow-up, and 2 persistent PCs had no reduction in size on follow-up; a total of 7 patients underwent image-guided catheter drainage procedure, and 5 of them resolved completely. In the last 2 cases, surgical excision was required because of persistent cystic cavity caused by thickened PC wall. One patient whose PC had not been decreasing in size developed findings of severe lung abscess with thickened wall and directly underwent surgery. In none of these patients recurrences or complaints related to PC were noted on their control visits. Conclusion Most of these PCs are simple PC and show spontaneous resolution with improvement of the infection within the first 2 months. However, some decrease gradually by time, and close follow-up should be continued in case of complicated PC. Persistent features of chest infection, more than 50% involvement of hemithorax and severe atelectasis, development of broncopleural fistulae (tension PC), and bad tolerance to follow-up remind complicated PC, and they are indications of image-guided catheter drainage procedure. Its failure occurs in PC with thickened wall that does not collapse, as was in our cases with persistent PC and severe infected PC, and thus, this is an indication for surgical excision.

Early mediastinal seroma secondary to modified Blalock-Taussig shunts--successful management by percutaneous drainage.

Large symptomatic mediastinal seroma following modified-BT shunts, traditionally required revisional thoracotomy. We describe percutaneous image-guided pigtail catheter drainage in the successful treatment of early mediastinal seroma secondary to PTFE Blalock-Taussig shunt, avoiding thoracotomy. A retrospective review of all relevant clinical and imaging records in five patients was performed. All five presented with intermittent stridor, respiratory distress and/or episodic desaturation within 6 weeks of their surgery. In four of five infants, percutaneous drainage was effective and reoperation was avoided. In one of five, rather than urgent surgical evacuation and BT shunt revision, we were able to perform an elective stage-II bidirectional Glenn SVC-RA anastamosis in a stable infant. There were no complications. Percutaneous image-guided drainage of mediastinal seroma secondary to PTFE-BT shunt is a safe, minimally invasive, and effective treatment. This may avoid BT shunt revision.

Efficacy of Pigtail Catheter Drainage in Patients with Thoracic Empyema or Complicated Parapneumonic Effusion

Background : The management of thoracic empyema and complicated parapneumonic effusion requires adequate antibiotics use and prompt drainage of infected pleural space. Tube thoracostomy for loculated empyema has low success rate and is also an invasive procedure with potential morbidity. Complications include hemothorax, perforation of intra-abdominal or intra-thoracic organs, diaphragmatic laceration, empyema, pulmonary edema, and Horner's syndrome. Given the potential morbidity of traditional chest tube insertion, use of the image-guided pigtail catheter drainage(PCD) of empyema has been employed. We retrospectively analyzed the medical records of patients with empyema or complicated parapneumonic effusion to determine the efficacy of percutaneous pigtail catheter drainage. Materials and Methods : 45 patients with complicated parapneumonic effusions or empyema were treated at Gil medical center from January 1998 to June, 1999. All were initially given PCD procedure and the following data were collected: clinical symptoms at the time of diagnosis, alcohol and smoking

Usefulness of imaging-guided catheter drainage and talc sclerotherapy in patients with metastatic gynecologic malignancies and symptomatic pleural effusions.

The purpose of our study was to assess the usefulness of imaging-guided catheter drainage and talc sclerotherapy in patients with metastatic gynecologic malignancies and symptomatic pleural effusions and to assess the affect of ascites on the success rate of this treatment. Twenty-five patients (mean age, 63 years) with metastatic gynecologic malignancies who had 26 symptomatic effusions treated at our institution over a 4-year period with imaging-guided catheter drainage and talc sclerotherapy were included in this study. Response to treatment was assessed by comparing pre-, immediate post-, and 30-day postsclerotherapy chest radiographs. Response to the treatment was graded as complete (no reaccumulation), partial (accumulation above immediate post- but below presclerotherapy level), or no response (reaccumulation to or above the presclerotherapy level). The presence of ascites on CT (n = 23), sonography (n = 1), direct intraoperative visualization (n = 1), or at physical examination (n = 1) was also noted. Of the 25 patients, 13 patients with 14 treated malignant effusions survived at least 30 days after sclerotherapy and formed the final study group. The remaining patients either died (n = 11) or were lost to follow-up (n = 1). At 30 days, 12 of the 14 treated effusions showed complete responses and one showed a partial response. The overall response rate was 86%. Abdominal ascites was present at the time of treatment in 11 patients (79%) and did not affect the success rate (p > 0.999). Imaging-guided catheter drainage and talc sclerotherapy are an effective treatment for symptomatic pleural effusions in patients with metastatic gynecologic malignancies. Ascites does not adversely affect the response to pleurodesis.

IMAGE-GUIDED MANAGEMENT OF COMPLICATED PLEURAL FLUID COLLECTIONS

Percutaneous image-guided catheter drainage with adjunctive ICFT has become the mainstay in the treatment of complicated pleural fluid collections. There are six basic principles of image-guided drainage and ICFT that must be understood to maximize the efficacy and safety of the procedure. 1. There must be a basic understanding of why traditional nonguided thoracostomy drainage fails in a significant percentage of patients. Tube malposition relative to fluid loculations, fluid debris and viscosity, and the presence of a stage 3 pleural peel are the primary reasons for failure. Image-guided placement of drains addresses the issue of tube malposition and ICFT greatly facilitates drainage of fibrinous fluid. 2. Proper use of cross-sectional imaging is one of the keys to ultimate success. CT and ultrasound allow very accurate assessment of the underlying pathologic process and are crucial in planning the drainage procedure, guiding the actual placement of drains, and following the course and outcome of treatment. The added costs of cross-sectional imaging are more than compensated by the increase in success of the drainage procedure. 3. Aggressive catheter management is the single most important factor in success. Multiple loculations require multiple catheters for adequate drainage. Pleural adhesions may form quickly as drainage progresses leading to the formation of undrained loculations. Frequent cross-sectional imaging is needed to detect undrained loculations so that additional drainage catheters may be placed if needed. It is crucial that the drainage catheter always be properly positioned in relation to fluid loculations. 4. Intracavitary fibrinolytic therapy is a very powerful adjunctive therapy to aid in complete evacuation of fluid collections that contain fibrin nets and debris. It can also partially débride the pleural surfaces of fibrinous debris and facilitate complete re-expansion of the underlying lung. Intracavitary fibrinolytic therapy should not be used in an attempt to salvage success by a malpositioned chest tube. 5. The ultimate success of closed drainage for complicated pleural fluid collections is closely related to the age of the effusion at the time of drainage. A very high rate of clinical success may be expected when these techniques are used in the treatment of stage 2 fibrinopurulent effusions. If drainage is delayed until the third stage (fibrous pleural peel formation) then closed drainage likely will fail and a formal thoracotomy and decortication will be necessary. Experience in the literature suggests that effusions up to 4 to 6 weeks in duration may be drained successfully but those older than 6 weeks likely will have an associated pleural peel. Effective pleural drainage must be instituted early in the course of the disease process. 6. There may be significant residual pleural and parenchymal inflammatory changes after complete drainage of a stage 2 effusion. If the fluid in the pleural space has been adequately drained and the visceral and parietal pleural surfaces apposed, then the residual inflammatory pleural thickening and associated lung consolidation resolve over 2 to 4 months and pulmonary function returns to baseline. Imaging studies immediately after complete pleural drainage are not normal. These residual abnormalities should not be interpreted as evidence that open surgical drainage should have been performed. Effective closed drainage carries lower morbidity, mortality, and cost than does open surgical drainage. For radiologists and clinicians alike it does not suffice simply to place one or more thoracostomy tubes, round daily, and hope that the occasional use of fibrinolytic agents does the rest. Without a more aggressive approach to catheter position and management the efficacy is no greater than that historically seen with nonguided closed drainage and surgeons will continue to plead for earlier effective open drainage.

Effects of Intracavitary Urokinase Instillation in Complicated Pleural Effusion

Background : Complicated exudative pleural fluid collections have traditionally been treated by either closed tube thoracostomy drainage or by open surgical drainage. Complete drainage is important in order to control pleural sepsis, restore pulmonary function, and entrapment. Recently intracavitary fibrinolytic therapy has been advocated as a method to facillitate drainage of complicated exudative pleural effusion and to allow enzymatic debridemant of the restrictive fibrinous sheets covering the pleural surface. The purpose of this study is to prospectively evaluate the effects of image-guided catheter drainage with high dose urokinase(UK) instillation in the treatment of complicated pleural effusions. Patients : Twenty complicated pleural effusion patients that poorly respond to image-guided drainage were allocated to receive UK. There were 8 pneumonia and 12 tuberculosis. Methods : Drugs were diluted in 250 mL normal saline and were infused intrapleurally through the chest tube or pig-tail catheter in a daily dose of 250,000 IU of UK. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasound and/or computed tomography. Results : The mean UK instillation time was . The mean volume drained UK instillation was , and post-UK was . The follow up duration after UK therapy was mean days. We had successful results in 19 cases (95.0%). There were 12 pleural thickenings (60.0%), 2 markedly decreased effusions (10.0%) and 5 cases of no thickening or effusion. There was recurrence after treatment in only one patient(5%) with complicated pleural effusiondue to tuberculosis. Conclusions : Image-guided drainage with high dose UK instillation (250,000 U/day) in complicated pleural effusion is a safe and more effective method than closed thoracostomy drainage. And this management, in turn, can obviate surgery in most cases.

Outcome of primary empyema thoracis: therapeutic and microbiologic aspects

Background. This study was undertaken to determine whether all adult patients with primary empyema thoracis need decortication. Methods. A management algorithm was developed and analyzed in a prospective, longitudinal, nonblinded study of 179 consecutive adult patients. The treatment options included thoracentesis, closed (tube) thoracostomy, image-guided catheter drainage, and decortication. We reviewed the outcomes of these procedures as they related to the pleural fluid cultures isolated and the antibiotic regimens used. Results. Of the 179 patients, 20 had thoracentesis as the primary procedure, and 18 (90%) were cured. Ninety patients underwent closed thoracostomy as the primary procedure with a cure rate of 62% (56 patients) and a mortality rate of 11% (10 patients), and 24 patients required a secondary procedure. Seventy-six patients underwent decortication as either the primary or the secondary procedure with a cure rate of 88% (67 patients) and a mortality rate of 1.3% (1 patient); 8 patients required conversion to open thoracostomy. Hospital stay for decortication was 14 ± 1 days and for closed thoracostomy, 17 ± 1 days ( p < 0.05). Decortication was necessary in 55% of patients with anaerobic infections and in 50% with aerobic infections. Clindamycin in combination with gentamicin sulfate was the most efficacious regimen with a success rate of 82% (51 of 62 patients); only 33% (17 of 52) were cured with penicillin. The overall mortality rate in this study was 6.7% (12 of 179 patients). Conclusions. Forty-two percent of patients with primary empyema thoracis ultimately require decortication. Decortication is more frequently necessary for anaerobic, tuberculous, staphylococcal, and pneumococcal infections. Although the overall mortality in this study was low, mortality remains high in elderly patients and patients with comorbid disease.

Posttraumatic empyema thoracis: a 24-year experience at a major trauma center.

The purpose of this paper is to review the outcome of patients with posttraumatic empyema thoracis. Between April 1972 and March 1996, the Division of Cardiothoracic Surgery at the King-Drew Medical Center managed or was consulted on 5,474 trauma patients (4,584 patients with penetrating injuries and 890 with blunt injuries) who were admitted emergently for thoracic and thoracoabdominal injuries and who underwent tube thoracostomy. Patients were not given routine prophylactic antibiotics merely because they had a chest tube placed. Based on our previous reports on thoracic trauma, our criteria for empiric antibiotic administration included (1) emergent or urgent thoracotomy, (2) soft-tissue destruction of the chest wall by shotgun injuries, (3) lung contusion with hemoptysis, (4) associated abdominal trauma requiring exploratory laparotomy, or (5) associated open long-bone fractures. Eighty-seven of these 5,474 patients developed posttraumatic empyema thoracis, for an incidence of 1.6%. These 87 patients were treated with tube thoracostomy, image-guided catheter drainage, or open thoracotomy with decortication. Seventy-nine of 87 patients (91%) were cured without conversion to open thoracostomy. Four patients required conversion to open thoracostomy, and there were three deaths. Even though a majority of our patients required decortication, successful management of posttraumatic empyema thoracis also was achieved with closed-tube thoracostomy or image-guided catheter drainage based on clinical and radiographic findings with appropriate patient selection. When thoracic empyema did occur in our group, Staphylococcus aureus was the most common microbe isolated, followed by anaerobic bacteria. In correlating microbiologic data with outcomes, S. aureus, especially methicillin-resistant S. aureus, was the most frequent cause of antibiotic failure. Because of the low incidence of posttraumatic empyema thoracis, we do not recommend routine antibiotic prophylaxis for all trauma patients who undergo closed-tube thoracostomy. A review of the role of tube thoracostomy, intrapleural fibrinolytic therapy, image-guided catheter drainage, video-assisted thoracoscopy, and open thoracotomy for the management of thoracic empyema is provided.

The evaluation of image-guided catheter drainage in pleural effusion and empyema

연구배경 : 흉수질환은 특히 복잡흉수나 농흉의 경우 치료상의 난제로 등장한다. 이들 경우의 치료의 근간은 빠른 완전한 배액과 무기폐의 재확장에 있다. 과거에는 통상 상기질환에서 흉수천자와 외과적 흉강삽관을 통해 진단 및 치료에 임하였으나 맹검적 흉강삽관시 때로는 잘못된 부위에 위치하거나 기술적으로 삽입하기 어려운 조건등으로 실패하는 경우를 경험하였다. 최근에는 영하에 도관을 정확히 삽관하고 배액하여 높은 치료성적을 보고하고 있다. 방법 : 1994년 1월부터 1996년 2월까지 흉수질환으로 관삽입을 요했던 환자 28명을 대상으로 후향적인 조사를 하였다. 맹검적 흉강삽관을 요했던 환자와 영상유도하 도관삽관을 시행받았던 환자로 구분하여 배액성공율을 비교하였다. 결과 : 전통적 방법의 흉강삽관 환자는 14명으로 원인별로 농흉 6명, 결핵성흉막염 6명, 부폐렴흉막염 2명인데 반해, 영상유도하도관삽입 역시 14명이었으나 원인별로는 농흉 2명, 결핵성흉막염 6명, 부폐렴흉막염 5명, 원인미상이 1명 있었다. 인상적 및 방사선학적으로 성공적인 배액을 보인 경우가 전자의 방법에서는 79%인데 반해 후자는 93%로서 영상유도하 도관배액에서 높은 치료성적을 보여주었으며 합병증은 한예에서 미미하게 발생하였다. 결론 : 영상유도하의 도관배액술은 복잡흉수나 국소화된 농흉환자에서 안전하며 성공율을 가진 치료법으로 적용할 수 있을 판단되니 향후 좀 더 많은 환자를 대상으로 한 비교연구가 뒷따라야 하겠다. 【Background : Pleural fluid collections may pose a difficult therapeutic problem. Complete drainage of complicated effusions or empyemas and reexpansion of atelectatic lung are important in obtaining a satisfactory clinical outcome. The usual approach to the diagnosis and treatment of patients with pleural effusion and empyema has been with needle thoracentesis and chest tube drainage. With chest tube drainage, technical difficulties and failures may occur as a result of improper tube drainage, particularly when there is a loculation or multiple and inaccesible collections. Fluoroscopic or sonographic guidance facilitates the proper tube insertion and drainage. Method : Twenty eight patients were required for tube drainage due to pleural fluid collections between January 1994 to February 1996. The author compared the results of drainage under applying each different method between blind chest tube insertion and image guided catheter insertion. Results : The conventional blind chest tube group comprised 14 patients; 6 empyema, 6 tuberculous effusion, and 2 parapneumonic effusion. The image guided catheter group of smaller french were composed of 14 patients; 2 empyema, 6 tuberculous effusion, 5 parapneumonic effusion, and 1 effusion of undetermined origin. Radiologic improvement with successful drainage was noticed in 79% with the blind chest tube group, whereas in 93% with the image guided catheter group. The complication with the latter method was unremarkable. Conclusion : Image guided catheter drainage was safe and highly successful in treating patients, not only with complicated effusion also with loculated empyema. Image guided catheter drainage offers an alternative in patients in whom closed drainage is required as the initial treatment.】