Percutaneous Drainage Of Fluid Collections Research Articles

Intra-abdominal hypertension and abdominal compartment syndrome in acute pancreatitis.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are underrecognized entities in patients of acute pancreatitis (AP). IAH develops in 30% to60% and ACS in 15% to30% of all AP patients and they are markers of severe disease with high morbidity and mortality. The detrimental effect of increased IAP has been recognized in several organ systems, including the central nervous system, cardiovascular, respiratory, renal and gastrointestinal systems. The pathophysiologyof IAH/ACS developmentin patients with AP is multifactorial. Pathogenetic mechanisms include over-zealous fluid management, visceral edema, ileus, peripancreatic fluid collections, ascites and retroperitoneal edema. Laboratory and imaging markers are neither sensitive nor specific enough to detect IAH/ACS and intra-abdominal pressure (IAP) monitoring is vital for early diagnosis and themanagement of patients of AP with IAH/ACS. The treatment of IAH/ACS requires a multi-modality approach with both medical and surgical attention. Medical management consists of nasogastric/rectal decompression, prokinetics, fluid management and diuretics or hemodialysis. If conservative management is not effective, percutaneous drainage of fluid collection or ascites is necessary. Despite medical management, if IAP worsens, surgical decompression is warranted. The review discusses the relevance of IAH/ACS in patients of AP and its management.

Perfusion CT in predicting deep pancreatic necrosis and planning early interventions for severe acute pancreatitis

Aim. To explore the potential of perfusion CT for predicting deep pancreatic necrosis and duct injury as well as for determining treatment strategy. Materials and methods. The prospective study included 74 patients hospitalized within 1–2 days of acute pancreatitis. They were exposed to perfusion CT and examination of their arterial blood flow velocity. In 37 observations, a standard CT was also performed on day 3–9 to study the depth and configuration of the necrosis. The severity of acute pancreatitis was assessed according to standard integral scoring systems, organ failure and severity of peripancreatitis. The alfa-amylase activity in fluid collections was examined. Results. Necrosis was detected in 20 patients: deep necrosis – in 11 cases, shallow – in 9. 17 patients did not reveal necrosis. Necrosis configuration of type 1 was detected in 16 patients, type 2 – in 4. Deep necrosis was preceded by a significant decrease in the arterial blood flow velocity: 39–52 ml/min/100 ml. This rate was greater in patients with shallow necrosis and without necrosis: 72–100 and 95–117 ml/min/100 ml (p < 0.001). In cases of deep necrosis, advanced peripancreatitis was formed, organ failure was noted in 9 patients, 3 patients died. Internal pancreatic fistula was detected in 7 out of 9 patients with deep necrosis and in 1 out of 6 patients with shallow necrosis and type 1 configuration. In cases of necrosis type 2 configuration the pancreatic fistula was not noted. Minimally invasive interventions and transformation of the internal fistula into the external one were performed in 12 out of 20 patients: percutaneous drainage of fluid collections – in 9 observations, stenting of the pancreatic duct – in 3. Conclusion. Perfusion CT can be used to predict pancreatic necrosis on day 1–2 of the disease. A decrease in the arterial blood flow velocity in the range of 39–52 ml/min/100 ml is associated with the risk of parenchyma deep necrosis and duct injury. This parameter can be taken into account when determining indications for early minimally invasive interventions.

Interventional Radiological Management and Prevention of Complications after Pancreatic Surgery: Drainage, Embolization and Islet Auto-Transplantation.

Pancreatic surgery still remains burdened by high levels of morbidity and mortality with a relevant incidence of complications, even in high volume centers. This review highlights the interventional radiological management of complications after pancreatic surgery. The current literature regarding the percutaneous drainage of fluid collections due to pancreatic fistulas, percutaneous transhepatic biliary drainage due to biliary leaks and transcatheter embolization (or stent–graft) due to arterial bleeding is analyzed. Moreover, also, percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also examined. Moreover, a topic not usually treated in other similar reviewsas percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also one of our areas of focus. In islet auto-transplantation, the patient is simultaneously donor and recipient. Differently from islet allo-transplantation, it does not require immunosuppression, has no risk of rejection and is usually efficient with a small number of transplanted islets.

Use of a self-expanding metal stent to treat acute esophageal perforation in a 4-year-old child

Esophageal perforations are associated with a high morbidity and mortality in the pediatric population. Most cases are managed conservatively with antibiotics, nutritional supplementation, and percutaneous drainage of fluid collections. Direct surgical repair is reserved for patients with hemodynamic instability or evidence of clinical worsening due to the high risk of postoperative complications. Utilization of stents in the treatment of acute esophageal perforation has become well-established in adults, but evidence remains lacking in the pediatric population. We present the case of a 4-year old male with an acute esophageal perforation who was successfully treated with an esophageal self-expanding metal stent (SEMS) in lieu of direct surgical repair. He failed extubation on postoperative day (POD) 6 due to tracheal compression by the oversized stent but exhibited good healing with successful extubation on POD 13. This case report demonstrates that esophageal stents may be a promising alternative to surgical repair in the pediatric population. Further studies and trials should be performed to compare the effectiveness of esophageal stenting to direct surgical repair. Modification and downsizing of the adult SEMS design for pediatric anatomy is recommended to prevent complications such as tracheal compression and prolonged intubation.

Interventional management after complicated pancreatic surgery

Despite technical advances in surgical resection and postoperative management of the pancreas, surgical procedures of the pancreas are associated with a high rate of complications, resulting in a relevant morbidity and mortality. Early diagnosis and management of complications associated with pancreas surgery is mandatory, favoring a multidisciplinary approach. Interventional radiology offers minimal invasive techniques to manage post-surgical complications. These procedures are highlighted in this review, including percutaneous drainage of fluid collections, percutaneous transhepatic biliary interventions, arterial embolisation and fistula embolisation. Post-surgical complications of pancreatic surgery are effectively managed by radiological procedures, offering a feasible and safe treatment with low morbidity rates. Accurate patient selection is key to an effective management of clinical situations where these interventions represent the first line approach. Radiologic procedures allow for minimal invasive treatment of postoperative complications after pancreatic surgery, reducing the time of hospitalization and the time of recovery.

Retrospective Study in 40 Patients of Utility of C-arm FDCT as an Adjunctive Modality in Technically Challenging Image-Guided Percutaneous Drainage Procedures.

To explore the utility of C-arm flat detector computed tomography (FDCT) as an adjunctive modality in technically challenging image-guided percutaneous drainage procedures. Clinical and image data were reviewed on 40 consecutive patients who underwent percutaneous drainage of fluid collections in technically challenging anatomic locations that required the use of C-arm FDCT between 2009 and 2013. Percutaneous drainage was performed under ultrasound and fluoroscopic guidance with the use of C-arm FDCT as a problem-solving tool to identify appropriate needle/wire placement prior to drainage catheter placement (n = 33) or to confirm catheter positioning within the fluid collection (n = 8). Technical success and procedural complications were recorded and retrospectively analyzed. Forty one fluid collections were identified in 40 patients. Mean number of C-arm FDCT rotational acquisitions per patient was 1.25. Mean procedure time per patient was 59.3 min. Mean fluoroscopy time was 5.5 min, and mean air kerma was 394.3 mGy. Percutaneous drainage with the use of C-arm FDCT was successful in 35 of 40 patients (87.5%). Technical failure was encountered in 5 of 40 patients due to too narrow window (n = 1), too small or no fluid collection noted on C-arm FDCT images (n = 2), and poor image quality requiring the use of a conventional CT scan (n = 2). Three procedure-related complications occurred (7.5%), which included traversed rectum, traversed spleen, and sepsis. C-arm FDCT is useful as an adjunctive modality in the interventional suite for technically challenging percutaneous drainage procedures by providing sufficient anatomic detail. Complications of catheter misplacement can be avoided if C-arm FDCT is used prior to tract dilatation. If C-arm FDCT image quality of needle and/or wire placement is poor, conventional CT guidance is recommended.

Endoscopic retrograde cholangiopancreatography-related perforations: Diagnosis and management.

Endoscopic retrograde cholangiopancreatography (ERCP) has become an important therapeutic modality for biliary and pancreatic disorders. Perforation is one of the most feared complications of ERCP and endoscopic sphincterotomy. A MEDLINE search was performed from 2000-2014 using the keywords "perforation", "ERCP" and "endoscopic sphincterotomy". All articles including more than nine cases were reviewed. The incidence of ERCP-related perforations was low (0.39%, 95%CI: 0.34-0.69) with an associated mortality of 7.8% (95%CI: 3.80-13.07). Endoscopic sphincterotomy was responsible for 41% of perforations, insertion and manipulations of the endoscope for 26%, guidewires for 15%, dilation of strictures for 3%, other instruments for 4%, stent insertion or migration for 2% and in 7% of cases the etiology was unknown. The diagnosis was made during ERCP in 73% of cases. The mechanism, site and extent of injury, suggested by clinical and radiographic findings, should guide towards operative or non-operative management. In type I perforations early surgical repair is indicated, unless endoscopic closure can be achieved. Patients with type II perforations should be treated initially non-operatively. Non-operative treatment includes biliary stenting, fasting, intravenous fluid resuscitation, nasogastric drainage, broad spectrum antibiotics, percutaneous drainage of fluid collections. Non-operative treatment was successful in 79% of patients with type II injuries, with an overall mortality of 9.4%. Non-operative treatment was sufficient in all patients with type III injuries. Surgical technique depends on timing, site and size of defect and clinical condition of the patient. In conclusion, diagnosis is based on clinical suspicion and clinical and radiographic findings. Whilst surgery is usually indicated in patients with type I injuries, patients with type II or III injuries should be treated initially non-operatively. A minority of them will finally require surgical intervention.

Role of interventional radiology in the management of complications after pancreatic surgery: a pictorial review.

Pancreatic resections are surgical procedures associated with high incidence of complications, with relevant morbidity and mortality even at high volume centres. A multidisciplinary approach is essential in the management of these events and interventional radiology plays a crucial role in the treatment of patients developing post-surgical complications. This paper offers an overview on the interventional radiological procedures that can be performed to treat different type of complications after pancreatic resection. Procedures such as percutaneous drainage of fluid collections, percutaneous transhepatic biliary procedures, arterial embolisation, venous interventions and fistula embolisation are viable treatment options, with fewer complications compared with re-look surgery, shorter hospital stay and faster recovery. A selection of cases of complications following pancreatic surgery managed with interventional radiological procedure are presented and discussed. Teaching Points • Interventional radiology is crucial to treat complications after pancreatic surgery • Percutaneous drainage of collections can be performed under ultrasound or computed tomography guidance • Percutaneous biliary procedures can be used to treat biliary complications • Venous procedures can be performed effectively through transhepatic or transjugular access • Fistulas can be treated effectively by percutaneous embolisation

921 Successful Closure of a Billroth II Duodenal Stump Leak With Fistulization to the Colon Using Stacked Over-the-Scope Clips

Duodenal stump leak after Billroth II gastrectomy is a serious complication and a challenge to close endoscopically. We present the case of a 77 y.o. woman status post Billroth II gastrectomy for GIST referred for a duodenal stump leak and diarrhea. CT scan showed a peri-duodenal stump fluid collection. The patient was not a good candidate for surgical repair. Conservative management was recommended, including percutaneous drainage of fluid collection and direct PEJ placement in the efferent limb for nutritional support.

Clinical Outcomes of Percutaneous Drainage of Breast Fluid Collections after Mastectomy with Expander-based Breast Reconstruction

PurposeTo determine clinical outcomes of patients who underwent imaging-guided percutaneous drainage of breast fluid collections after mastectomy and breast reconstruction. Materials And MethodsA retrospective review was performed including all consecutive patients who underwent percutaneous drainage of fluid collections after mastectomy with tissue expander–based reconstruction between January 2007 and September 2012. During this period, 879 mastectomies (563 patients) with expander-based breast reconstruction were performed. Fluid collections developed in 28 patients (5%), which led to 30 imaging-guided percutaneous drainage procedures. The median follow-up time was 533 days. Patient characteristics, surgical technique, microbiology analysis, and clinical outcomes were reviewed. ResultsThe mean age of patients was 51.5 years (range, 30.9–69.4 y), and the median time between breast reconstruction and drainage was 35 days (range, 4–235 d). Erythema and swelling were the most common presenting symptoms. The median volume of fluid evacuated at the time of drain placement was 70 mL. Drains were left in place for a median 14 days (range, 6–34 d). Microorganisms were detected in the fluid in 12 of 30 drainage procedures, with Staphylococcus aureus being the most common microorganism. No further intervention was needed in 21 of 30 drainage procedures (70%). However, surgical intervention (removal of expanders) was needed after 6 (20%) drainage procedures, and additional percutaneous drainage procedures were performed after 3 (10%) drainage procedures. ConclusionsPercutaneous drainage is an effective means of treating postoperative fluid collections after expander-based breast reconstruction and can obviate the need for repeat surgery in most cases.

Sa1510 Guide Wire Assisted and Balloon-Anchored Direct PerOral Cholangioscopy With Ultra Slim Gastroscope in Humans: Proof of Principal

(24, 41.4%) and others (7, 12.0%). Locations of perforation were duodenal lateral side (7, 12.1%), medial side (30, 51.7%), common bile duct (13, 22.4%), gall bladder (3, 5.2%) and others (5, 8.6%). In contrast to 8 cases (13.8%) of emergent operation, 50 patients (86.2%) were conservatively treated and 11 received elective surgery after recovery. As a conservative treatment, a percutaneous drainage of fluid collection was performed in 10 (17.2%) patients and a percutaneous or an endoscopic biliary drainage was used in 26 (44.8%) patients. With 35 patients, a perforation was detected immediately after procedure, but delayed detections which meant permitted oral intake before detection or detection after 24 hours were 18 cases. Although the majority of patients fully recovered, there were 9 (15.5%) patients who experienced a poor prognosis which consisted of a mortality (4, 6.9%), a loss of cure chance with malignancy (1, 1.7%), and a prolonged hospital stay more than 1 month due to two stage operation (1, 1.7%) or an uncontrolled infection without surgery (3, 5.2%). By multiple logistic regression analysis, a perforation at duodenal lateral wall and a rebound tenderness was statistically associated with poor prognosis (p0.025 and 0.002, respectively). Conclusion: Although most patients fully recovered from a perforation after ERCP, there were 4 mortality cases with this complication. A location of perforation and an existence of rebound tenderness showed association with poor prognosis.

Single-port transumbilical laparoscopic appendectomy: 43 consecutive cases

In this modern era of minimally invasive surgery, cosmesis and early recovery are strongly emphasized. To reduce abdominal trauma and improve cosmesis, surgeons have adopted a single-port laparoscopic appendectomy for patients with acute appendicitis. From August to December 2008, 43 cases of appendectomy were managed using the single-port transumbilical laparoscopic technique. A multichannel single port was created using a surgical glove (no. 6), three trocars, one-three-way catheter, and a wound retractor (Alexis). An umbilical incision (1.5-2.0 cm) was made transumbilically or infraumbilically. The intraabdominal procedures were almost identical to those for conventional laparoscopic appendectomy. The methods for mesenteric dissection and appendiceal stump ligation were identical. Despite slight discomforts with retraction and visualization, the procedure was nevertheless possible. A resected appendix was put into a finger of the single-port glove. The 43 study cases included 23 men and 20 women with a mean age of 31 years (range, 9-65 years) and a mean body mass index (BMI) of 22.3 kg/m(2) (range 15-29.7 kg/m(2)). The mean operative time was 61.3 min (range 24-120 min). Drainage was used in two cases with perforated appendicitis. Bowel movement returned at a mean of 1.2 days, and oral feeding was resumed on postoperative day 1.2. The pathology showed negative inflammation in 4 cases (9.3%), suppurative appendicitis in 29 cases (67.4%), gangrenous appendicitis in 8 cases (18.6%), and perforated appendicitis in 2 cases. Only one patient required readmission due to pericecal inflammation and pain, and another patient needed a percutaneous drainage of fluid collection. Three minor umbilical wound complications were controlled conservatively. Single-port appendectomy may require a longer operative time than laparoscopic appendectomy, but it is a feasible technique with good cosmetic results. It could be one of the alternative methods for treating acute appendicitis.

Treatment of Gallstone Pancreatitis: Six‐year Experience in a Single Center

Acute pancreatitis (AP) is a complicated disease in 20% to 25% of cases and carries a mortality of 8% to 15%. Etiologically, the most frequent form is acute biliary pancreatitis. Treatment of such an entity is still controversial, but minimally invasive techniques undoubtedly play an important role. We retrospectively analyze our cases of AP observed from January 1992 to May 1998. Etiology was biliary in 95/125 (76%) cases. In 90 cases we evaluated the patient within a few hours of the onset of symptoms. According to the Ranson criteria, we observed a mild form in 74/90 (82.2%) cases and a severe form in 16/90 (17.8%) cases. Our standard policy was to perform urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy followed by elective laparoscopic cholecystectomy. In particular clinical settings, other modalities of treatment were employed, such as percutaneous cholecystostomy and percutaneous drainage of fluid collections. Successful ERCP was performed in 86/90 cases (95.5%). The procedure was performed in an emergency setting (within 48 hours) in 62/90 cases (68.9%). Whenever the patient was a candidate for surgery, cholecystectomy was performed, laparoscopically in 67/90 cases (74.4%) and via laparotomy in 7/90 cases (7.8%). In only two cases was pancreatic necrosectomy necessary. Globally, we observed a low procedure-related morbidity (6.7%) and no mortality. In the setting of acute biliary pancreatitis, regardless of the severity of the attack, an urgent ERCP + endoscopic sphincterotomy followed by laparoscopic cholecystectomy is safe and could enable successful management of the patient. Associated morbidity and mortality were low. In addition, when indicated, it is possible to treat a great number of concomitant complications with percutaneous ultrasound-guided drainage.

Percutaneous management of abscess and fistula following pancreaticoduodenectomy.

To evaluate the efficacy of percutaneous drainage of fluid collections following pancreaticoduodenectomy (Whipple's procedure). We performed a retrospective review of 19 patients referred to our service with fluid collections following pancreaticoduodenectomy. The presence of associated enteric or biliary fistulas, the route(s) of access for image-guided drainage, the incidence of positive bacterial cultures, and the duration and success of percutaneous management were recorded. Fistulous communication to the jejunum in the region of the pancreatico-jejunal anastomosis was demonstrable in all 19 patients by gentle contrast injection into drainage tubes. Three patients had concurrent biliary fistulas. In 18 of 19 patients, fluid samples yielded positive bacterial cultures. Successful percutaneous evacuation of fluid was achieved in 17 of 19 patients (89%). The mean duration of drainage was 31 days. Percutaneous drainage of abscess following pancreaticoduodenectomy is effective in virtually all patients despite the coexistence of enteric and biliary fistulas.

Percutaneous drainage of fluid collections in the extremities.

To analyze the results of percutaneous drainage of fluid collections in the extremities. From 1990-1997, 28 patients aged 14-90 years underwent percutaneous drainage of 33 fluid collections in the extremities; two patients underwent multiple drainages. Fluid collections were in the hip-groin area (n = 16), thighs (n = 6), buttocks (n = 6), knees (n = 3), calf (n = 1), and axilla (n = 1). Three intraarticular collections were included. The patients who had undergone prior procedures were eight who had undergone surgical drainage, 10 who had undergone needle aspiration, and one who had undergone surgical débridement. The two most common guidance methods of catheter placement were ultrasound localization and fluoroscopy. The average drainage duration was 18.2 days (range, 1-93 days). The estimated cavity sizes were 4-733 cm3. Purulent fluid was drained in 13 patients. Staphylococcus aureus was the most commonly identified organism (n = 9). Nine patients had postoperative lymphoceles; five of these patients underwent sclerotherapy. Two (7%) patients had two complications, one of which was major. Failure occurred in four (16%) of 25 patients; two needed repeat drainage for recurrence, and two needed subsequent surgery. Success could not be determined in three patients who were lost to follow-up. Percutaneous drainage of fluid collections in the extremities is an effective alternative to open-incision drainage in inpatients and outpatients.

Guide wire protection for trocar puncture of fluid collections.

Guide wire protection for trocar puncture of fluid collectionsE vanSonnenberg, AD Polansky, GR Wittich and OA CabreraAudio Available | Share