Nonoperative Drainage Research Articles

Pseudoaneurysm of the Mesenteric Artery Status Post Drain Placement for Complicated Diverticulitis

Perforated diverticulitis presents a challenging clinical scenario for the surgeon. Development of an abscess in those without an acute abdomen may be amendable to non-operative drainage. Furthermore, early intervention can dramatically alter the hospital course let alone the overall outcome. While relatively safe as a procedure, image-guided drainage does carry risk that needs to be calculated relative to benefit gained. One rare albeit possibly serious risk is pseudoaneurysm formation.

Acute thoracic empyema: Clinical characteristics and outcome analysis of video-assisted thoracoscopic surgery

Acute thoracic empyema is a common clinical problem worldwide, resulting in substantial morbidity and mortality. The objective of this study was to report its clinical characteristics and to evaluate whether thoracoscopic surgery is associated with a lower rate of in-hospital mortality compared with nonoperative drainage. Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriological studies, and treatment outcomes of 602 patients with acute thoracic empyema. Thoracoscopic surgery was performed in 417 (69.2%) patients, while the remaining patients underwent nonoperative drainage. After treatment, 77 patients (12.8%) died in the hospital. A propensity score-based process, matched on potential risk factors for in-hospital mortality, was performed to select patients with equalized potential prognostic factors in the thoracoscopy and nonoperative groups. The log-rank test was used to compare the survival time with discharge between the two matched groups. Multivariate analysis showed that age, malignancy, chronic lung disease, chronic renal insufficiency, liver cirrhosis, polymicrobial infection, and positive bacterial culture were risk factors for in-hospital mortality. The propensity score-matched analysis showed that the in-hospital mortality difference was significant (p = 0.014) and the Kaplan-Meier survival analysis revealed a higher survival rate to discharge (p < 0.001 by log-rank test), both favoring thoracoscopy over nonoperative drainage. Acute thoracic empyema carries a high mortality rate, especially in elderly patients with coexisting medical conditions and polymicrobial and positive bacterial cultures. Our study results also showed that thoracoscopy is feasible and might provide better chances for survival in borderline operable patients than nonoperative drainage.

Surgical Treatment and Prognostic Analysis of 93 Cases of Hilar Cholangiocarcinoma

ObjectiveTo explore the surgical treatment and prognosis of hilar cholangiocarcinoma. MethodsThis was a retrospective study of 93 cases of hilar cholangiocarcinoma that were treated surgically at our hospital from June 1999 to June 2005. Prognostic factors were also analyzed. ResultsFifty-two cases were treated with curative resection, 21 with palliative resection, and 9 with nonoperative drainage. Eleven cases underwent palliative drainage operations. The median survive time was 31months in the curative resection group, 13.7months in the palliative resection group, and 11months in the nonoperative drainage group. Patient age, serum total bilirubin, clinical type of Bismuth-Corlette, tumor differentiation, and lymph node metastases were important factors for predicting the prognosis of hilar cholangiocarcinoma. ConclusionsResection was the main treatment for hilar cholangiocarcinoma, and curative resection was the best way to obtain better prognosis. Age, preoperative serum total bilirubin, bismuth clinical type, tumor histopathological grading, and lymph node metastases were considered to have a significant effect on prognosis.

Prognostic Factors in the Surgical Management of Pericardial Effusion in the Patient With Concurrent Malignancy

Pericardial effusion in the patient with cancer presents a unique management problem. Although multiple methods of operative and nonoperative drainage of pericardial effusions have been described, surgical pericardial window remains the standard approach to long-term drainage. Selecting the patient who may benefit from an operative approach presents a difficult challenge. In the present study, we retrospectively analyzed the clinical outcome of 63 consecutive patients with malignancy who underwent surgical pericardial window for symptomatic pericardial effusion between January 1, 1990, and July 1, 2001, at City of Hope National Medical Center in order to try to determine whether the type of cancer, the presence of malignant cells in pericardial fluid, or tissue specimens or the method of surgery influenced the incidence of recurrent pericardial effusion or duration of survival. The cohort was comprised of 15 patients with non-small cell lung cancer (NSCLC), 22 patients with breast cancer, 17 patients with hematologic malignancy, and 9 patients with other solid tumors. Pertinent clinical, laboratory, hospital stay, and outcome data including long-term follow-up were recorded. Patients were followed up until the time of last clinical follow-up or death. Univariate survival analyses were performed to determine significant clinical factors contributing to outcome. Median follow-up was 6.6 months for the group and 8.3 months for those alive at last follow-up. Median survival rates for patients with lung, breast, hematologic, and other solid-tumor malignancies were 3.2 months, 8.8 months, 17 months, and 16.4 months, respectively. Preoperative factors that negatively correlated with survival included a diagnosis of NSCLC (p = 0.0014), the presence of a pleural effusion (p = 0.003), or positive pathologic (p = 0.02) or cytologic findings (p = 0.02). A surgical approach to pericardial drainage is effective (< 5% failure rate) and provides an opportunity for continued therapy with the potential for relief of dyspnea and improvement in quality of life and survival in selected patients.

Long term outcome of endoscopic drainage of pancreatic pseudocysts.

Nonoperative drainage either by the percutaneous or endoscopic route has become a viable alternative to surgical drainage of pancreatic pseudocysts. Endoscopic drainage has been reported in a few small series with encouraging short term results. The aim of this study was to determine the indications, suitability, and long term outcome of transmural endoscopic drainage procedures. All patients presenting over a 2-yr period to a tertiary referral hepatobiliary unit with pancreatic pseudocysts were studied. Endoscopic drainage was performed in patients with pseudocysts bulging into the stomach or duodenal lumen. Outcome measures were successful drainage of the pseudocyst, complications, and recurrence rates. Of 66 patients presenting with pseudocysts, 34 were considered suitable for endoscopic drainage. Twenty-four (71%) were successfully drained. Failures were associated with thick walled pseudocysts (> 1 cm), location in the tail of the pancreas, and pseudocysts associated with acute necrotizing pancreatitis. There were three recurrences (7%), two of which were successfully redrained endoscopically. The long term success rate (median follow-up, 46 months) of the initial procedure was 62%. Transmural endoscopic drainage is a safe procedure with minimal complications. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of < 1 cm and a visible bulge into the gastrointestinal lumen. Forty percent of pseudocysts fulfilled these criteria in our study.

Case report - oesophageal anastomotic leak complicated by bilateral empyemas: Non-operative management by an interventional radiology service

SummaryComplicated oesophageal perforation is considered a life-threatening surgical emergency for which open thoracotomy and primary repair are indicated. However, several reports of successful conservative management consisting of non-operative drainage exist in the literature. The various imaging modalities and catheter techniques available through an interventional radiology service make interventional radiologists ideally suited for management of this complex problem. We present a case successfully managed by image-guided catheter placement and manipulations.

Interventional Radiology in the Management of Bile Duct Injuries

The advent of laparoscopic cholecystectomy has brought an increased number of bile duct injuries to the attention of surgeons and interventional radiologists. The spectrum of injury ranges from cystic duct stump leakage to partial obstruction to complete occlusion of the ducts and common hepatic or common bile duct ischemic strictures. The proper therapy for any given patient may be surgical or nonsurgical. Frequently, interventional radiologic techniques permit successful nonoperative drainage of postoperative fluid collections and percutaneous management of bile duct injury and stricture. In some patients in whom radiologic techniques are not successful or in whom the extent of injury requires surgical repair, interventional radiologic techniques can provide preoperative anatomic definition of the extent of injury as well as catheter localization of intrahepatic duct strictures before proximal hepaticojejunostomy.

Choice of palliation for malignant hilar biliary obstruction

Clinical data from 50 consecutive patients with unresectable hilar tumors situated at or proximal to the common hepatic duct were retrospectively analyzed to aid in the selection of appropriate palliative measures. Thirty-four patients had cholangioenteric bypass (CEB) to either left (28 patients), right (3 patients), or both (3 patients) intrahepatic ductal systems. Sixteen patients had nonoperative drainage (NOD) established either endoscopically (4 patients), percutaneously (9 patients), or using a combined endoscopic-percutaneous approach (3 patients). When compared with patients with CEB, patients with NOD had more frequent medical problems (p < 0.03) and lower serum albumin levels on admission (p < 0.03). While comparable postprocedural complications (13 CEB patients versus 4 NOD patients) were observed, patients with NOD had a significantly higher hospital mortality (9 CEB patients versus 9 NOD patients, p < 0.05). Excluding the 12 patients (6 CEB patients versus 6 NOD patients) who died within 30 days after drainage, the quality of survival of the remaining 38 patients was analyzed with reference to 6 objective parameters. Although patients with NOD had significantly more frequent admissions relating to their catheters (p < 0.02), there was no qualitative difference in the survival rate between the two groups of patients. For selected high-risk patients with limited life expectancy, NOD should be offered. However, additional prospective studies are required to decide the best choice of palliation for patients who are not at such high risk.

Clinical regression of infected pancreatic necrosis

Infected pancreatic necrosis was diagnosed clinically and radiologically in a patient admitted for acute pancreatitis. As free gas in the pancreatic area was recognized, antibiotic therapy (ceftriaxone) was empirically introduced, while surgical drainage was being planned. After the second week, the patient rapidly started to improve, to the point that he could be discharged home without operation. Control CT-scans and general laboratory tests, at this phase and later on, confirmed a still enlarged gland but free of infection or ongoing inflammation. Cholelithiasis, which had been identified in an early ultrasound scan, was electively treated by cholecystectomy 2 mo after the onset of pancreatitis, in the absence of sepsis, and with uneventful recovery. This case illustrates the rare possibility of spontaneous regression of infected necrotic pancreatitis, without any type of operation or nonoperative drainage.

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.

Urgent biliary decompression after endoscopic retrograde cholangiopancreatography

Acute cholangitis complicating diagnostic endoscopic retrograde cholangiopancreatography (ERCP) is potentially fatal. Among 323 consecutive patients with proved biliary obstruction, 21 (7 percent) developed acute cholangitis after examination. Four patients underwent emergency surgery for the control of sepsis with two deaths. Of the 21 parameters chosen for evaluation, malignant obstruction, fever (higher than 37.5 °C) within 72 hours before the procedure or when afebrile, and an increased aspartate transaminase level of 70 IU or more were the independent predictive factors identified by multivariate analysis. An increased temperature should be regarded as an absolute contraindication to examination unless followed by immediate ductal drainage. Since the risk of septic complications is minimal when none of the risk factors are present, routine urgent biliary decompression after ERCP is probably unnecessary for these selected patients. For patients with malignant obstruction or other risk factors, early elective surgical drainage is advisable. When surgery is not feasible, nonoperative drainage of the obstructed biliary system as a preventive measure might be considered.

Catheter drainage of symptomatic postoperative mediastinal effusion guided by computed tomography: A nonoperative approach

Postoperative mediastinal effusion after cardiac operations is a common phenomenon and has a potential for serious complications, such as tamponade necessitating urgent drainage. Computed tomography of the chest provides excellent postoperative visualization of the mediastinum. Catheter insertion or paracentesis guided by computed tomography has been used to accomplish nonoperative drainage of symptomatic postoperative mediastinal effusion in six cases. This technique offers simplicity, safety, and cost effectiveness.

Complicated pancreatic inflammatory disease: diagnostic and therapeutic role of interventional radiology.

Diagnostic and therapeutic interventional radiology techniques in 41 patients with complications of pancreatic inflammatory disease (noninfected pseudocyst, infected pseudocyst, phlegmon, abscess, hemorrhagic pancreatitis) are described. Computed tomography or ultrasound-guided aspiration or percutaneous pancreatic ductography enabled specific diagnoses in 43 of 45 patients (96%). In almost half the patients, diagnostic aspiration with 22-gauge needles was unsuccessful due to viscous contents or firm cavity walls. Single-step needle aspiration of noninfected pseudocysts was successful in only three of ten patients (30%). Catheter drainage cured six of seven noninfected pseudocysts (85.7%) and seven of nine infected pseudocysts (77.7%). Pancreatic phlegmons were aspirated in five patients to exclude secondary infection and help determine the need for surgery. Pancreatic abscesses were drained successfully in nine of 13 patients (69.2%); temporizing benefit was achieved in the other four who eventually underwent surgery in improved condition. Early diagnosis of the complications of pancreatitis may be established almost uniformly, and at least 70% of patients with infected or noninfected pseudocysts and pancreatic abscesses may be cured by nonoperative drainage.