Management Of Intra-abdominal Abscesses Research Articles

Curative resection after percutaneous drainage followed by preoperative panitumumab monotherapy for locally advanced sigmoid colon cancer with intra-abdominal abscess: a case report

BackgroundThe gold standard treatment for locally advanced colon cancer is curative surgery followed by adjuvant chemotherapy, although this approach is associated with serious concerns, such as high recurrence rates and occasionally unnecessary oversurgery. Neoadjuvant chemotherapy may be a promising strategy for overcoming these issues. This study reports a case of a recurrence-free patient who underwent curative resection without significant organ dysfunction after preoperative chemotherapy for locally advanced sigmoid colon cancer. The tumor coexisted with a large intra-abdominal abscess, and the patient was quite frail at the first visit. We performed percutaneous drainage followed by preoperative panitumumab monotherapy, which yielded favorable outcomes.Case presentationA 78-year-old frail woman was emergently transferred to our hospital with fever and abdominal pain. The diagnosis was locally advanced sigmoid colon cancer stage IIIC (T4bN2aM0) with a large intra-abdominal abscess. Immediate curative surgery was inappropriate, considering both tumor progression and the patient’s frailty. We performed percutaneous drainage and colostomy construction, which was followed by seven cycles of preoperative panitumumab monotherapy without significant adverse events. After these treatments, inflammation was well controlled, and the tumor shrank remarkably. Furthermore, the patient recovered well from frailty; therefore, curative sigmoidectomy combined with resection of the left ovary and stoma closure was possible without any postoperative complications. The final pathological finding was T3N0M0, stage IIA disease. The patient was recurrence-free and had no significant organ dysfunction 21 months after the curative surgery.ConclusionsThe management of intra-abdominal abscesses and tailor-made preoperative chemotherapy based on the patient’s frailty may have been the key factors responsible for the favorable course of this patient. Although further research is needed on the appropriateness of percutaneous drainage for malignancies related to intra-abdominal abscesses and preoperative panitumumab use for locally advanced colon cancer, the study findings can serve as reference for managing similar cases in an aging society.

Oral vs Intravenous Discharge Antibiotic Regimens in the Management of Intra-abdominal Abscesses in Penetrating Crohn's Disease.

Antibiotics are a cornerstone in management of intra-abdominal abscesses in Crohn's disease (CD). Yet, the optimal route of antibiotic administration is poorly studied. We aimed to compare surgical and nonsurgical readmission outcomes for patients hospitalized for intra-abdominal abscesses from CD discharged on oral (PO) or intravenous (IV) antibiotics. Data for patients with CD hospitalized for an intra-abdominal abscess were obtained from 3 institutions from January 2010 to December 2020. Baseline patient characteristics were obtained. Primary outcomes of interest included need for surgery and hospital readmission within 1 year from hospital discharge. We used multivariable logistic regression models and Cox regression analysis to adjust for abscess size, history of prior surgery, history of penetrating disease, and age. We identified 99 patients discharged on antibiotics (PO = 74, IV = 25). Readmissions related to CD at 12 months were less likely in the IV group (40% vs 77% PO, P = .01), with the IV group demonstrating a decreased risk for nonsurgical readmissions over time (hazard ratio, 0.376; 95% confidence interval, 0.176-0.802). Requirement for surgery was similar between the groups. There were no differences in time to surgery between groups. In this retrospective, multicenter cohort of CD patients with intra-abdominal abscess, surgical outcomes were similar between patients receiving PO vs IV antibiotics at discharge. Patients treated with IV antibiotics demonstrated a decreased risk for nonsurgical readmission. Further prospective trials are needed to better delineate optimal route of antibiotic administration in patients with penetrating CD.

Usefulness of intraoperative culture swabs in laparoscopic appendectomy for complicated appendicitis.

Intraabdominal abscess (IAA) is a feared complication after laparoscopic appendectomy (LA) for complicated appendicitis. Benefits of obtaining intraoperative culture swabs (ICS) still remain controversial. We aimed to determine whether ICS modify the rate and management of IAA after LA for complicated appendicitis. A consecutive series of patients who underwent LA for complicated appendicitis from 2008 to 2018 were included. The cohort was divided into two groups: group 1 (G1), with ICS, and group 2 (G2), without ICS. Demographics, operative variables, pathogen isolation, antibiotic sensitivity, and postoperative outcomes were analyzed. A total of 1639 LA were performed in the study period. Of these, 270 (16.5%) were complicated appendicitis; 90 (33%) belonged to G1 and 180 (67%) to G2. In G1, a higher proportion of patients had generalized peritonitis (G1, 63.3%; G2, 35%; p < 0.01). Seventy-two (80%) patients had positive cultures in G1. The most frequently isolated bacteria were E. coli (66.7%), Bacteroides spp. (34.7%), and Streptococcus spp. (19.4%). In 26 (36%) patients, the initial empiric antibiotic course was modified due to bacterial resistance. The rate of IAA was higher in patients with ICS (G1, 21.1%; G2, 9.4%; p = 0.01). IAA was treated similarly in both groups. A different type of bacteria was isolated in 7 (53.8%) patients with new culture swabs. Obtaining ICS in LA for complicated appendicitis with further antibiotic adjustment to the initial pathogen did not lower the incidence of postoperative IAA and did not modify the treatment needed for this complication.

Drainage of Intra-abdominal Abscesses

This review focuses on the current management of intra-abdominal abscesses that arise from various etiologies. Advances in imaging and percutaneous techniques now lead to image-guided percutaneous drainage as a major factor for the management of intra-abdominal abscesses. In many cases, drainage combined with systemic antibiotic therapy is often all that is necessary for abscess resolution. Emerging surgical techniques now incorporate percutaneous drainage procedures in a stepwise, methodical approach to managing pancreatic necrosis. Image-guided intra-abdominal abscess are a frequent clinical problem encountered in the trauma setting. In most cases, image-guided percutaneous drainage plays a vital role in managing.

A Randomized Prospective Assessment of Safety and Effectiveness of Instillation of Tissue Plasminogen Activator in the Management of Intra-Abdominal Abscesses

Purpose: Catheter drainage of intra-abdominal abscesses has shown to be effective in reducing sepsis and mortality. We sought to determine whether or not tissue plasminogen activator (tPA), a fibrinolytic, is safe and facilitates resolution when used as an adjunct during drainage of intra-abdo-minal abscesses. Methods: A single-blinded, prospective, multi-center, randomized control trial was performed on patients presenting with image confirmed abscesses; the first group (n = 24) received catheter-directed tPA of their abscess and the second group (n = 23) had their abscess drained without tPA instillation. Variables examined included patient age, gender, location of the abscess, pre-drainage volumes and size of catheters inserted. Baseline variables were compared between tPA and non-tPA groups using a chi-square test for discrete variables and a Wilcoxon rank sum test for continuous variables and for the outcome of drainage volume. Results: Technical success of the drainage procedures was 100% for both groups. The tPA group had higher volume of drainage over the first three days (median for total after 3 days: without tPA: 300 mL vs. with tPA: 322 mL, p = 0.42). At days 4 to 7 the tPA group had significant greater drainage volume than did the non-tPA patient group, 150 mL vs. 110 mL (p = 0.046). The number of days to resume diet was also assessed in the 20 patients where this datum was available, 11 tPA and 9 non-tPA with no difference between groups. No adverse events, such as localized or systemic bleeding were encountered. Conclusion: Instillation of tPA into catheter directed intra-abdominal abscesses was safe, easy to perform and was associated with significantly improved drainage of abscesses from days 4 -7.

Risk and Management of Intra-Abdominal Abscess in Crohn's Disease Treated with Infliximab

Background and Aims: Infliximab (IFX) is a monoclonal antibody used to treat patients with Crohn's disease (CD). Intra-abdominal abscess formation is a major complication of CD with negative effects on patient prognosis. We have analyzed risk factors for abscess formation in CD patients treated with IFX. Methods: CD patients who received IFX between January 2000 and April 2011 at Keio University Hospital were analyzed retrospectively. Risk factors for abscess formation were assessed by univariate and multivariate logistic regression analyses. Results: Intra-abdominal abscess was seen in 15 of 258 patients. Univariate analyses showed serum C-reactive protein (CRP) concentration at 14 weeks after initiation of IFX (p = 0.021), serum albumin concentration at week 0 (p = 0.022) and week 14 (p = 0.004), the presence of anal lesions (p = 0.036), progression of intestine deformation (p = 0.015) and early loss of response to IFX (p < 0.0001) to be risk factors. Multivariate analysis showed that CRP concentration at 14 weeks [odds ratio (OR) 1.361] and loss of IFX response within 6 months (OR 5.361) were independent risk factors. Conclusions: Abscess formation should be suspected in patients with symptoms of CD recurrence during IFX therapy. Uncontrolled CRP concentration and early loss of response to IFX are risk factors.

Comparative Outcomes of Trocar Puncture With Sump Drain, Percutaneous Drainage, and Surgical Drainage in the Management of Intra-abdominal Abscesses in Crohn’s Disease

Intra-abdominal abscess is a common complication in Crohn's disease (CD). Traditional percutaneous catheter drainage (PCD) and surgical intervention could not obtain satisfactory results in some cases. We herein demonstrate a novel management option and compare it with traditional strategies. A total of 77 patients were retrospectively collected into 3 groups. Postoperative complication, postoperative recurrence of abscess, subsequent surgery, ultimate stoma creation rate, and survival rate were analyzed. Patients were divided into the trocar group (n = 21), PCD group (n = 25), and surgery group (n = 31). The incidences of postoperative complication as well as the incidence of recurrent abscess were lowest in trocar group, and ultimate stoma creation rate was highest in the surgery group. Subsequent surgery after initial intervention and survival rate during the follow-up period were similar among the 3 groups. Trocar puncture with sump drain had lower incidence of postoperative complication, postoperative recurrence of abscess, and ultimate stoma creation compared with conventional PCD and surgical interventions. This novel technique might be an optimal option in the management of intra-abdominal abscesses in CD.

Variation in Management of Intra-Abdominal Abscesses in Children with Crohnʼs Disease

Complications of Crohn's disease may include intra-abdominal abscesses, which often result in hospitalization, surgery, and increased cost. There is a paucity of primary research and practice guidelines regarding optimal management in children. The study objective was to assess the current standard of care in an effort to define best practices and identify priority areas for additional research. The web-based survey was approved by the Institutional Review Board and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. We examined preferences in imaging, drainage, anti-tumor necrosis factor-α therapy, and antibiotic use. We assessed for associations between provider level of experience and management strategies. A total of 248 of 1608 North American Society for Pediatric Gastroenterology, Hepatology and Nutrition members responded. Of them, 64% were male, 87% practiced in the United States, and 74% practiced in an academic setting. Approximately 26% cared for >50 patients with Crohn's disease and 25% were in practice for >20 years. For initial imaging, computed tomography was chosen by 52%, followed by magnetic resonance imaging (26%) and ultrasound (21%), and upon reassessment computed tomography was chosen by 13%, magnetic resonance imaging by 33%, and ultrasound by 47%. About 77% recommended percutaneous drainage, whereas 21% would only do so if antibiotics were unsuccessful, and 2% proceed to immediate surgery. If a fistula was demonstrated, 70% planned medical therapy followed by surgical resection; only 30% planned surgical resection if no fistula was present. Approximately 55% would consider infliximab before surgery. There were no clinically significant associations between treatment strategies and practitioner experience. There is considerable variation in diagnostic and therapeutic interventions in the management of intra-abdominal abscesses, which was not explained by practitioner experience.

Sa1973 Variation in Management of Intra-Abdominal Abscesses in Children With Crohn's Disease

Sa1973 Variation in Management of Intra-Abdominal Abscesses in Children With Crohn's Disease

Current Strategies in the Management of Intra-abdominal Abscesses in Crohn's Disease

Crohn's disease is characterized by inflammation that involves the full thickness of the bowel wall, which can lead to serious complications including intra-abdominal and pelvic abscesses. The combination of an intra-abdominal abscess with active Crohn's disease poses a particular dilemma for the treating physician, who must weigh the benefits of using immunosuppressive therapies for the inflammatory bowel disease against the risks of immunosuppression in the presence of serious abdominal infection. Traditionally, Crohn's-related abscesses were managed with early surgery, which often involved external drainage procedures, bowel resection, and the creation of diverting ostomies in acutely ill patients. Today such abscesses often can be managed initially with antibiotics and percutaneous drainage, with evaluation for the need for delayed surgery in selected patients. With delayed surgery performed electively, the surgeon frequently can resect the diseased bowel and create a primary anastomosis, thus avoiding emergency operations and multistage procedures. In highly selected cases, surgery might be avoided entirely. This report reviews the literature on the pathophysiology and management of intra-abdominal abscesses in Crohn's disease (including the roles of percutaneous drainage, immunosuppressive therapy, and surgery), and provides a suggested approach to the management of patients with this difficult problem.

Intra-abdominal, retroperitoneal, and visceral abscesses in children.

This review describes the microbiology, diagnosis, and management of intra-abdominal abscesses (including subphrenic, hepatic, splenic, and retroperitoneal abscesses) in children. They often occur as a complication of local or generalized peritonitis, commonly secondary to appendicitis, necrotizing enterocolitis, pelvic inflammatory disease, and tubo-ovarian infection, surgery or trauma. The original infection generally occurs because of the entry of enteric microorganisms into the peritoneal cavity through a defect in the wall of the intestine or other viscus as a result of obstruction, infarction, or direct trauma. Mixed aerobic and anaerobic flora can be recovered from most abscesses. The predominant aerobic isolates are Escherichia coli, Staphylococcus aureus, and Enterococcus spp. and the main anaerobic bacteria are Bacteroides fragilis group Peptostreptococcus spp., Fusobacterium spp., and Clostridium spp. The treatment of intraabdominal abscesses includes drainage, surgical correction of pathology, and administration of antimicrobials effective against both aerobic and anaerobic microorganisms.

A Modern Analysis of Morbidity after Pancreatic Resection

Complications after pancreatic resection remain prevalent. Procedure-related morbidity has previously focused on prevention of pancreatic and biliary fistulas (PFs and BFs) with other complications receiving less attention. We examined morbidity and its impact on reoperation, length of stay (LOS), and mortality following pancreatic resection. We retrospectively reviewed patients having elective pancreatectomy at the University of Tennessee affiliated hospitals during a recent 5-year time period. Factors examined included morbidity, mortality, and the need for reoperation. Patient deaths were analyzed with a focus on antecedent complications. Comparisons were made using Student's t test and chi2 analysis where appropriated. From 1997 to 2003, 125 patients had pancreatic resections: 93 Whipple procedures, 27 distal, and 5 total pancreatectomies. Twenty-nine patients (23%) did not have intraperitoneal drainage (IPD). Resections were performed for cancer in 75 per cent. Seventy complications occurred in 55 patients (44%). Morbidity related to an intra-abdominal process resulted in 16 reoperations and 4/6 deaths in this series (overall mortality, 4.8%). There were no BFs. Of 10 patients with PFs (8%), none required reoperation, and there was no PF-related mortality. No patient without IPD developed a PF. The presence of a PF significantly increased LOS when compared to those without (30.9 +/- 13.1 vs 17.4 +/- 12.2 days, P < 0.01). Forty-four per cent of all complications were related to either intra-abdominal abscess (IAA), hemorrhage, or feeding tube placement (18, 8, and 5, respectively). Management of IAA included percutaneous drainage in 16 and reoperation in 2 with 1 associated death. Hemorrhage necessitated reoperation in 6, resulted in 1 patient death, and was followed by IAA in 2. Of 5 jejunostomy tube complications, 4 required reoperation and 2 patients died. LOS was significantly greater in these 28 patients when compared to all others (28.1 +/- 16.9 vs 15.8 +/- 9.9 days, P < 0.001). Following pancreatectomy, 1) BFs should be a rare event; 2) PFs remain important but are most often managed nonoperatively with few sequelae; 3) in this series, IAA and hemorrhage were more common than PF, frequently mandated reoperation, prolonged hospitalization, and were associated with procedure related mortality; 4) feeding tube complications, though rare, are often catastrophic; 5) future efforts should focus on factors that could reduce abscess formation and a reduction in overall complications--many of which are potentially preventable.

Management of Intraabdominal Abscesses in Crohn's Disease

Management of Intraabdominal Abscesses in Crohn's Disease

Diagnosis and treatment of intra-abdominal abscesses.

Despite recent advances in the diagnosis and management of intra-abdominal abscesses, these infections still cause substantial morbidity and mortality. Low pH, large bacterial inocula, poor perfusion, the presence of hemoglobin, and large amounts of fibrin (which impedes antibiotic penetration) make the abscess a cloistered environment that is penetrated poorly by many antimicrobial therapies. Therefore, management of these infections requires prompt recognition, early localization, and effective drainage, as well as appropriate antimicrobial use. Although various imaging techniques, such as ultrasonography, gallium scans, and indium-labeled white-blood-cell scans, can be used for the diagnosis and localization of intra-abdominal abscesses, computer-assisted tomography is the most useful study. Once the diagnosis is made and the abscess is localized, treatment should begin promptly. Percutaneous or open surgical drainage should be used. Broad-spectrum antibiotics should be given until culture and sensitivity data are obtained. Once these data are obtained, a therapy with appropriate coverage that is likely to work in the abscess environment should be chosen. Percutaneous drainage is inappropriate for abscesses in the posterior subphrenic space or in the porta hepatis, for those among loops of small bowel, for suspected echinococcal cysts, and for abscesses containing necrotic or neoplastic tissues. Finally, surgeons need to be cognizant of risk factors, such as advanced age, obesity, complex abscesses, and high Acute Physiology and Chronic Health Evaluation (APACHE) II or APACHE III scores, which correlate with poor outcomes for these patients.

Imaging intraabdominal abscesses and nonoperative drainage procedures

With state-of-the-art imaging and interventional techniques, the diagnosis and management of intraabdominal abscesses have improved. Radionuclide scanning, ultrasound, and computed tomography are very accurate for the diagnosis and staging of intraabdominal abscesses, permitting the use of percutaneous drainage methods. Percutaneous abscess drainage (PAD) has gained wide acceptance and applications now include not only curative drainages but also certain palliative ones. Although some controversy exists relative to results and palliative procedures, PAD is now accepted as an effective alternative to operative drainage.

NEW INTERVENTIONAL TECHNIQUES IN THE DIAGNOSIS AND MANAGEMENT OF INFLAMMATORY DISEASE WITHIN THE ARDOMEN

The detection of intra-abdominal abscesses remains a stimulating challenge. Although most patients with abscesses present with a typical febrile septic course, there are a selected number who have an insidious onset and manifest only subtle signs of infections. In these patients, accurate and expeditious diagnosis of abscesses is essential. If abscesses are correctly diagnosed without delay, percutaneous or surgical drainage procedures and antibiotic therapy can effect a complete cure in a high percentage of cases. In recent years, three technically sophisticated imaging modalities have been introduced and investigated for the diagnosis and management of intra-abdominal abscesses. Our purpose in this paper is to describe the characteristics of intra-abdominal abscesses, discuss the diagnostic and interventional attributes of these modalities, and discuss our views concerning the role of gray scale ultrasound, computerized tomography, and gallium 67 scintigraphy.