Percutaneous Drainage Procedures Research Articles

Pyomyositis and Infectious Myositis: A Comprehensive, Single-Center Retrospective Study.

BackgroundPyomyositis is a bacterial infection of skeletal muscle that classically leads to abscess formation. A related, but distinct, entity is infectious myositis. The epidemiology of these infections has changed in recent years.MethodsTo better characterize both pyomyositis and infectious myositis, we conducted a retrospective study at our tertiary care institution. We identified 43 cases of pyomyositis and 18 cases of infectious myositis treated between January 2012 and May 2020.ResultsThe mean age of patients was 48 years, and 66% were male. Diabetes mellitus affected one third of patients, and 16% had other immunocompromising comorbidities. Staphylococcal species accounted for 46% of all infections, and common symptoms included muscle pain (95%) and subjective fever (49%). Altered mental status was a presenting symptom in 16% of cases. Approximately half of all patients received >1 class of antibiotic, and the median length of antimicrobial therapy was 18 days. Open and percutaneous drainage procedures figured prominently in the management of these infections, with 28% of patients requiring multiple procedures. Pathology specimens were available for 12 of 61 cases. Overall, the treatment success rate was 84%.ConclusionsGram-positive bacteria accounted for most infections at our institution, and management commonly involved open or percutaneous drainage procedures. Future studies that prospectively evaluate treatment strategies for pyomyositis and infectious myositis are warranted.

Utility of Abdominal Drain in Gastrectomy (ADiGe) Trial: study protocol for a multicenter non-inferiority randomized trial

BackgroundProphylactic use of abdominal drain in gastrectomy has been questioned in the last 15 years, and a 2015 Cochrane meta-analysis on four RCTs concluded that there was no convincing evidence to the routine drain placement in gastrectomy. Nevertheless, the authors evidenced the moderate/low quality of the included studies and highlighted how 3 out of 4 came from Eastern countries. After 2015, only retrospective studies have been published, all with inconsistent results.MethodsADiGe (Abdominal Drain in Gastrectomy) Trial is a multicenter prospective randomized non-inferiority trial with a parallel design. It aimed to verify whether avoiding routine use of abdominal drain is burdened with complications, particularly an increase in postoperative invasive procedures. Patients with gastric cancer, scheduled for subtotal or total gastrectomy with curative intent, are eligible for inclusion, irrespective of previous oncological treatment.The primary composite endpoint is reoperation or percutaneous drainage procedures within 30 postoperative days. The primary analysis will verify whether the incidence of the primary composite endpoint is higher in the experimental arm, avoiding routine drain placement, than control arm, undergoing prophylactic drain placement, in order to falsify or support the null hypothesis of inferiority. Secondary endpoints assessed for superiority are overall morbidity and mortality, Comprehensive Complications Index, incidence and time for diagnosis of anastomotic and duodenal leaks, length of hospital stay, and readmission rate.Assuming one-sided alpha of 5%, and cumulative incidence of the primary composite endpoint of 6.4% in the control arm and 4.2% in the experimental one, 364 patients allow to achieve 80% power to detect a non-inferiority margin difference between the arm proportions of 3.6%. Considering a 10% drop-out rate, 404 patients are needed. In order to have a balanced percentage between total and subtotal gastrectomy, recruitment will end at 202 patients for each type of gastrectomy. The surgeon and the patient are blinded until the end of the operation, while postoperative course is not blinded to the patient and caregivers.DiscussionADiGe Trial could contribute to critically re-evaluate the role of prophylactic drain in gastrectomy, a still widely used procedure.Trial registrationProspectively registered (last updated on 29 October 2020) at ClinicalTrials.gov with the identifier NCT04227951.

Scrubbing needles: a simple and costless technique to improve needle tip visibility during US-guided liver interventions.

To evaluate the echogenicity of a commercially available needle, modified on the tip, by comparing two groups of patients undergoing to percutaneous biliary drainage. In this retrospective analysis 16 percutaneous transhepatic biliary drainage (PTBD) procedures performed on 16 oncologic patients were evaluated. Patients were randomly divided into two groups of eight subjects each; in the first group, a standard needle was adopted (group A); in the second group, the needle was manually modified to create a rough surface (group B), by scrubbing the tip with an 11 scalpel blade for 150s all around its surface. To objectively quantify US needle tip visibility, the contrast-to-noise ratio (CNR) was calculated analyzing B-mode images by positioning region of interests in correspondence of needle tip and liver parenchyma. Needle tip echogenicity was significantly higher in group B where the needle tip was modified compared to control group A (p value = 0.014). CNR, considered to objectively evaluate differences among needle tip echogenicity, was significantly higher in group B with respect to control group A (p value = 0.018). The proposed method, scrubbing a 22 gauge commercially available needle tip with a scalpel blade, represents an effective technique to improve needle visibility during US-guided punctures of the liver.

Minimally invasive approaches for pancreatic pseudocysts: robotic cystgastrostomy

Presenter: Ola Ahmed MD | Washington University, St. Louis Background: The majority of pancreatic pseudocysts resolve without the need for operative intervention. In a select few, surgery may be warranted for large cysts causing symptoms and unamenable to endoscopic or percutaneous drainage procedures Methods: We present the case of 2 patients: a 35 year old lady with a background of EtOH-related pancreatitis and a 43 year old gentleman with a history of gallstone pancreatitis. Both patients developed large symptomatic pancreatic pseudocysts that were unsuited to drain insertion because of the size of the cavity and the presence of a large amount of necrotic debris. Their symptoms of abdominal pain, fullness and early satiety persisted over an 8 – 10 week period and the patients underwent a robotic cystgastrostomy with pancreatic debridement. Results: The post-operative course for both was uneventful and one patient was discharged post-op day 1 while the second patient required a longer stay for social issues and was discharged on day 6. Conclusion: Pancreatic pseudocysts seldom require operative intervention. In a select number of patients, robotic cystgastrostomy is safe and feasible and the robotic approach can be advantageous with enhanced angulation and offering 3 dimensional views for complex retroperitoneal structures

Medical Error, Adverse Events, and Complications in Interventional Radiology: Liability or Opportunity?

This review suggests that there is a critical need to renew understanding of adverse events and complications within interventional radiology and to redefine a robust commitment to patient safety a...

Cancer prevalence, inpatient mortality and its predictors after pericardiocentesis

Objective: Pericardiocentesis is a percutaneous drainage procedure performed in cardiac tamponade or a moderate-large pericardial effusion that does not respond to medical treatment. The prognosis varies according to the etiology of pericardial effusion, and the parameters that can determine the prognosis are unknown. In this study, we aimed to find predictors that can determine inpatient mortality in patients who underwent pericardiocentesis and to determine cancer etiology. Method: Ninety-one patients who underwent pericardiocentesis due to moderate-large pericardial effusion or pericardial tamponade were evaluated retrospectively. Baseline characteristics of the patients, their cancer diagnosis before and after pericardiocentesis, pericardial effusion cytology, echocardiographic parameters and laboratory parameters in the baseline evaluation were evaluated. The group with inpatient death (n = 14) and the surviving group (n = 77) were compared with each other. Results: There was no significant difference between baseline demographic characteristics and echocardiographic parameters when the patients with inpatient mortality and survivors were compared; only patients diagnosed with cancer (p <0.001) and patients with malignant cytology (p = 0.041) were statistically significantly higher in the group with inpatient mortality. When patients with inpatient mortality and survivors were compared in terms of laboratory parameters, aspartate aminotransferase (AST) [55 (27-455), 26 (19-45); p = 0.007, respectively], lactate dehydrogenase (LDH) [527 (438-944), 282 (225-381); p <0.001, respectively], C-reactive protein (CRP) [120.5 (19.8-140.7), 36.5 (8.26-86.15); p = 0.016, respectively], NTproBNP [8964 (7780-9432), 1310 (351-4556); p = 0.049] values were significantly higher in the inpatient mortality group than in the surviving group. The presence of cancer (p = 0.001), AST (p = 0.008), alanine aminotransferase (ALT) (p = 0.013), LDH (p = 0.015), CRP (p = 0.046) parameters were detected to be predictors that can be used to predict inpatient mortality in the univariate logistic regression analysis conducted to determine the predictors that could indicate inpatient mortality. Conclusions: Inpatient mortality is high in patients that were detected to have underlying malignancy and pericardial involvement after pericardiocentesis. In the initial evaluation of these patients, simple laboratory tests such as AST, ALT, NTproBNP, LDH, CRP can give an idea about the short-term prognosis of the disease.

Rogue cell-like chromosomal aberrations in peripheral blood lymphocytes of interventional radiologists: A case study

We report two cases of interventional radiologists who had been exposed to radiation while performing fluoroscopically-guided interventional procedures (FGIPs), mainly transcatheter arterial chemoembolization, percutaneous catheter drainage, and percutaneous transhepatic biliary drainage procedures, for over 10 years. They had a unique multi-aberrant cell type with not only high numbers of dicentrics and/or centric rings but also excess acentric double minutes, similar to a rogue cell. As revealed in a self-administered questionnaire, they wore personal dosimeters and protective equipment at all times and used shielding devices during interventional fluoroscopy procedures. However, the exposed dose levels derived from cytogenetic dosimetry were much higher than the doses recorded on their personal dosimeters. A large number of unstable and stable chromosomal aberrations that were found in the peripheral blood lymphocytes of these interventional radiologists might be due to repeated and long-term exposure to ionizing radiation while performing FGIPs. Further investigations of chromosomal aberrations in interventional radiologists may improve the understanding of the long-term effects of radiation exposure on medical personnel.

Computed Tomography-Guided Virtual Stereotactic Puncture and Catheter Drainage for a Brainstem Pontine Hemorrhage: A Case Report

Background: Patients with severe hypertensive brainstem hemorrhages have poor prognoses if they only receive conservative medical management. In contrast, aggressive operative interventions may decrease the morbidity and mortality in such patients. These operative treatments include craniotomy for evacuation of the hematoma, stereotactic positioning, and neuronavigational-guided hemorrhage puncture and drainage. Here, we report a novel and relatively simple procedure to achieve satisfactory outcomes in a patient with a brainstem pontine hemorrhage. Case Presentation: A 53-year-old man who was diagnosed with brainstem pontine hemorrhage. On hospital day 6, he underwent CT-guided, virtual stereotactic puncture and catheter drainage of this brainstem pontine hemorrhage. Medical treatments were continued after this procedure. On postoperative day 16 (hospital day 22), the patient was discharged from the hospital, awake and able to answer questions appropriately. Muscle strengths were grades V and IV for the left and right extremities, respectively. The patient was continued with active rehabilitation and achieved a Barthel index of 85 points at one month after the percutaneous drainage procedure. Conclusion: CT-guided, virtual stereotactic percutaneous transcranial puncture and catheter drainage for brainstem pontine hemorrhages has obvious potential advantages and offers a possible alternative to achieve the best outcomes with minimal operative trauma compared to open microcraniotomy.

2127 Splenic Abscess Management With a Lumen Apposing Metal Stent: Case Report

INTRODUCTION: Splenic abscess is an uncommon infection (incidence 0.5%) that if left untreated, could be fatal. The most common source of splenic abscesses is usually hematogenous spread from an infected source from another part of the body. The patient typically presents with fever, left upper quadrant pain, and/or splenomegaly. CT scan is the imaging modality of choice for diagnosing splenic abscess. Management of splenic abscess consists of antibiotic treatment and splenectomy. The use of percutaneous CT-guided drainage is a safer spleen-conserving alternative to surgery. In this case report , we describe novel approach, to treat splenic abscess via endoscopic ultrasound-guided (EUS) placement of a lumen apposing metal stent (AXIOS). CASE DESCRIPTION/METHODS: This is a 44 year old male with a past medical history significant for necrotizing pancreatitis and gastric varicies who presented to our center with fever and weakness. He was previously admitted 3 months prior with post ERCP necrotizing pancreatitis which was managed successfully with endoscopic therapy. The patient reported that on the day of admission, he developed a low-grade fever and lethargy. The abdomen was soft, mildly distended, with tenderness to palpation in the left and right lower quadrants. CT of the abdomen revealed a formation of a splenic abscess measuring 5 cm × 6.5 cm. Blood cultures were positive for ESBL and the patient was started on antibiotics. An EUS was performed that showed a splenic abscess and an abscessgastrostomy was successfully performed using a 10 × 10 mm lumen-apposing metal stent (LAMS). One week later a repeat EGD with debrivement and lavage of the abscess cavity was performed and a 10 F × 5 cm double pigtail stent was exchanged for the LAMS. On month later, a CT scan showed complete splenic abscess resolution and the double pigtail was removed. Six month CT scan showed no abscess recurrence. DISCUSSION: EUS has been described in the drainage of pelvic, mediastinal and intrabdominal abcess. In this report we describe the first use of lumen apposing metal stent for endoscopic management of a splenic abscesses. Lee et al first reported the use of EUS guided splenic abscess drainage with the use of a double pigtail stent. This approach showed to be safe and less invasive alternative to the standard of care. In cases of worsening clinical status and reported morbidities as high as 79% with surgical and percutaneous drainage procedures, endoscopic therapies should be considered in the management of splenic abscess.

Endoscopic Ultrasonography-Guided Versus Percutaneous Drainage for the Recurrent Pancreatic Fluid Collections.

BackgroundUltrasonography-guided percutaneous drainage for pancreatic fluid collections is associated with a high recurrence rate and endoscopic ultrasonography (EUS)-guided drainage is a valuable approach. Our aim was to compare the efficacy and safety of percutaneous and EUS-guided drainage for the recurrent pancreatic fluid collections.Material/MethodsA retrospective analysis of percutaneous-guided and EUS-guided procedures for pancreatic fluid collections drainages at a single tertiary care center between February 2017 and May 2018 was performed. Treatment success, adverse events, recurrence, need for surgery, length of hospital stays, and number of follow-up computed tomography (CT) scan were assessed.ResultsA total of 119 pancreatic fluid collections treated with initial percutaneous drainage were included in this study and 35 patients had recurrent pancreatic fluid collections. Recurrent patients were classified based on drainage method: EUS-guided drainage (18 patients) and the second percutaneous drainage (17 patients). EUS-guided drainage revealed a shorter length of hospital stays (P<0.001), less re-intervention (P=0.047), fewer number of follow-up CT scans (P=0.006) compared with the initial percutaneous drainage. Furthermore, we also compared the clinical outcomes between the EUS-guided drainage and the second percutaneous drainage for the recurrent PFC after initially failed percutaneous drainage. EUS-guided drainage showed higher clinical success (P=0.027), shorter length of hospital stays (P<0.001), less re-intervention (P=0.012), fewer number of follow-up CT scan (P<0.001) and less recurrence P=0.027) compared to the second percutaneous drainage procedure.ConclusionsEUS-guided drainage is an effective and appropriate method to treat the recurrent pancreatic fluid collections after initially failed percutaneous drainage procedure, with the advantage of higher clinical success, shorter length of hospital stays, less re-intervention, fewer number of follow-up CT scan and less recurrence compared to the percutaneous drainage.

Effect of continuous renal replacement therapy during percutaneous drainage in severe acute pancreatitis patients: a retrospective cohort study

To evaluate the clinical efficacy and safety of continuous renal replacement therapy (CRRT) in patients with severe acute pancreatitis (SAP) receiving percutaneous drainage (PCD). Clinical data of SAP patients receiving PCD admitted to department of hepatobiliary surgery of the First Affiliated Hospital of Xi'an Jiaotong University from November 11th 2015 to May 13th 2018 were retrospectively analyzed. The patients were divided into CRRT group and control group according to whether or not receiving CRRT. Demographic data, relevant variables before and after PCD, complication and outcome were all compared. A total of 75 patients were included in the study, 30 were treated with application of CRRT and 45 without CRRT. (1) There was no significant difference in gender, age, body mass index (BMI), medical history (smoking, drinking), complications (cardiovascular disease, chronic lung disease, diabetes, chronic renal insufficiency), etiology (gallstone, alcohol abuse, hyperlipidemia and others), or white blood cell count (WBC), C-reactive protein (CRP), serum procalcitonin (PCT), fluid resuscitation, mechanical ventilation, vasoactive agent or intra-abdominal pressure within 48 hours after admission between the two groups. However, acute physiology and chronic health evaluation II (APACHE II) score within 48 hours after admission of CRRT group was significantly higher than that of control group (18.3±4.5 vs. 12.8±6.2, P < 0.05). (2) There was no significant difference in WBC, PCT, APACHE II score or computed tomography severity index (CTSI) before PCD between the two groups. There was no significant difference in the position or times of PCD procedure between the two groups, but the time interval of PCD in the CRRT group was significantly longer than that in the control group (days: 19.4±5.4 vs. 12.8±2.2, P < 0.05). Meanwhile, there was no significant difference in drainage of fluid properties, incidence of abdominal bleeding, infection, gastrointestinal fistula, endoscopic removal of necrotic tissue, laparotomy for removal of necrotic tissue or the time from PCD to endoscopy or laparotomy between two groups. However, the length of intensive care unit (ICU) stay and the length of hospital stay in the CRRT group were significantly longer than those in the control group (days: 23.2±8.5 vs. 15.3±12.1, 51.2±21.2 vs. 31.2±14.0, both P < 0.01). (3) Kaplan-Meier survival analysis showed that there was no significant differences in 1-year or 3-year cumulative survival rates between the two groups (χ21 = 0.097, P1 = 0.755; χ22 = 0.013, P2 = 0.908). CRRT is safe and feasible in the treatment of SAP patients receiving PCD procedure. It does not increase the risk of bleeding and may delay the time interval of PCD intervention. However, it may prolong the length of ICU stay and the length of hospital stay. It should be worthy of much attention for clinicians.

Catalase-Containing Silica Particles as Ultrasound-Based Hydrogen Peroxide Sensors to Determine Infected From Noninfected Fluid Collections in Humans.

OBJECTIVE. Hydrogen peroxide (H2O2) plays a key role in neutrophil oxidative defense against infection. Catalase-containing silica nanoshells are nanoparticles that generate O2 microbubbles imaged with ultrasound in the presence of elevated H2O2. We aimed to determine whether ultrasound-detectable O2 microbubbles produced by catalase-containing silica nanoshells can determine whether fluid collections drained from patients are infected. SUBJECTS AND METHODS. During this HIPAA-compliant, institutional review board-approved study, 52 human fluid samples were collected from clinically required image-guided percutaneous drainage procedures. Catalase-containing silica nanoshells were added to the fluid samples during imaging in real time using a Sequoia-512 15L8-S linear transducer (Siemens Healthcare). Production of detectable microbubbles was graded subjectively as negative (noninfected) or positive (infected) with low, moderate, or high confidence by a single observer blinded to all clinical data. The truth standard was microbiology laboratory culture results. Performance characteristics including ROC curves were calculated. RESULTS. Microbubble detection to distinguish infected from noninfected fluids was 84% sensitive and 72% specific and offered negative and positive predictive values of 89% and 64%, respectively. The AUC was 0.79. Six of nine false-positive samples were peritoneal fluid collections that were all collected from patients with decompensated cirrhosis. CONCLUSION. The presence of elevated H2O2 indicated by microbubble formation in the presence of catalase-containing silica nanoshells is sensitive in distinguishing infected from noninfected fluids and offers a relatively high negative predictive value. False-positive cases may result from noninfectious oxidative stress. Catalase-containing silica nanoshells may constitute a novel point-of-care test performed at time of percutaneous drainage, potentially obviating placement of drains into otherwise sterile collections and minimizing risk of secondary infection or other complication.

Dislocation of intra-abdominal drains after pancreatic surgery: results of a prospective observational study.

The use of intra-abdominal drains after major surgical procedures represents a well-established but controversial practice. No data are available regarding both the occurrence and the potential impact of their postoperative accidental dislocation. The aim of this study is to assess the actual rate of dislocation of intra-abdominal drains postoperatively and to evaluate its clinical impact. This is a prospective observational study using major pancreatic surgery as a model. Ninety-one consecutive patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) underwent low-dose, non-enhanced computed tomography (LDCT) on postoperative days (POD) 1 and 3 in a blinded fashion to assess the position of drains. We compared the outcomes of patients with dislocated and correctly placed drains. Overall, drains were dislocated in 30 patients (33%), without differences between PD and DP. Most of dislocations were already present on POD 1 (77%). Postoperative complications occurred in 57% of patients, and the rate of postoperative pancreatic fistula (POPF) was 27%. The dislocated cohort had lesser morbidity (40% vs. 66%; relative risk (RR), 0.35; 95% CI, 0.14-0.86; P = 0.020), and the rate of POPF (3% vs. 39%, respectively; RR, 0.05; 95% CI, 0.01-0.42; P < 0.001). After PD, patients with dislocated drains had a shorter hospital stay (12 vs. 20days; P = 0.015). No significant differences in terms of need for percutaneous drainage procedures, abdominal collections, or grade C POPFs were found between the groups. Dislocation of intra-abdominal drains is an early and frequent event after major pancreatic resection. Its occurrence might protect against the negative effects of maintaining drainage, eventually leading to better postoperative outcomes. This data reinforces the knowledge that surgical drains might be detrimental in selected cases.

Causes and Rates of 30-day Readmissions after Percutaneous Transhepatic Biliary Drainage Procedure.

Purpose To investigate rates and causes of 30-day readmission for patients who undergo percutaneous transhepatic biliary drainage (PTBD) procedures. Materials and Methods In this retrospective study, PTBD procedures performed at a tertiary care institution (June 2008 to May 2013) were reviewed. For each patient, the first 30-day readmission was used to determine cause of readmission. Two interventional radiologists independently categorized causes for readmission as planned or unplanned, and unplanned causes as related to or unrelated to interventional radiology. Interventional radiology-related readmissions were categorized as potentially preventable or unpreventable. Factors associated with higher odds for 30-day readmission were identified with univariable and multivariable analysis. Results There were 266 procedures in 266 patients (mean age, 67 years; interquartile range, 57-76 years; 53.4% men). The cause of obstruction was malignant in 50.0% of patients (133 of 266). There were 122 of 266 patients (45.9%) readmitted within 30 days. Of these readmissions, 44 of 122 (36.1%) were planned and 78 of 122 (63.9%) were unplanned. A majority of unplanned readmissions (57 of 78; 73%) were related to interventional radiology. Of unplanned interventional radiology-related readmissions, 16% (nine of 57) were related to periprocedural complications and 51% (29 of 57) were considered preventable. At multivariable analysis, Medicaid insurance (odds ratio, 3.68; 95% confidence interval: 1.52, 9.99; P = .009) and bilateral PTBDs (odds ratio, 5.81; 95% confidence interval: 1.79, 18.90; P = .003) were associated with 30-day readmission. Conclusion Thirty-day readmissions after primary biliary drainage are common and a majority of unplanned readmissions are drain-related. Nearly half of unplanned interventional radiology-related readmissions are potentially preventable. © RSNA, 2018 See also the editorial by Nikolic in this issue.

Dislocation of intra-abdominal drains after pancreatic surgery: results of a prospective observational study

The use of intra-abdominal drains after major surgical procedures represents a well-established but controversial practice. No data are available regarding both the occurrence and the potential impact of their postoperative accidental dislocation. The aim of this study is to assess the actual rate of dislocation of intra-abdominal drains postoperatively and to evaluate its clinical impact. This is a prospective observational study using major pancreatic surgery as a model. Ninety-one consecutive patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) underwent low-dose, non-enhanced computed tomography (LDCT) on postoperative days (POD) 1 and 3 in a blinded fashion to assess the position of drains. We compared the outcomes of patients with dislocated and correctly placed drains. Overall, drains were dislocated in 30 patients (33%), without differences between PD and DP. Most of dislocations were already present on POD 1 (77%). Postoperative complications occurred in 57% of patients, and the rate of postoperative pancreatic fistula (POPF) was 27%. The dislocated cohort had lesser morbidity (40% vs. 66%; relative risk (RR), 0.35; 95% CI, 0.14–0.86; P = 0.020), and the rate of POPF (3% vs. 39%, respectively; RR, 0.05; 95% CI, 0.01–0.42; P < 0.001). After PD, patients with dislocated drains had a shorter hospital stay (12 vs. 20 days; P = 0.015). No significant differences in terms of need for percutaneous drainage procedures, abdominal collections, or grade C POPFs were found between the groups. Dislocation of intra-abdominal drains is an early and frequent event after major pancreatic resection. Its occurrence might protect against the negative effects of maintaining drainage, eventually leading to better postoperative outcomes. This data reinforces the knowledge that surgical drains might be detrimental in selected cases.

Minimally invasive treatment of complex collections: safety and efficacy of recombinant tissue plasminogen activator as an adjuvant to percutaneous drainage.

ObjectiveTo analyze the efficacy of recombinant tissue plasminogen activator (r-TPA) injection in the evolution of percutaneous drainage of thick collections.Materials and MethodsThis was a single-center study involving the retrospective analysis of hospitalized patients undergoing percutaneous drainage of thick (superficial or intracavitary) fluid collections, followed by injection of a fibrinolytic agent (r-TPA) into the affected space.ResultsA total of 53 percutaneous drainage procedures, with r-TPA injection, were performed in 51 patients. Abdominal and pelvic collections were the most common, being seen in 38 (73%) of the procedures; in 35 (66%), the etiology of the collection was attributed to postoperative complications. A total of 61 catheters were used in order to drain the 53 collections. Of those 61 catheters, 52 (85%) were large (12-16 Fr) and 9 (15%) were small (4-10 Fr). The mean r-TPA dose was 5.7 mg/collection per day, and the mean time from r-TPA injection to drain removal was 7.7 days. Percutaneous drainage in combination with r-TPA injection was successful in 96% of the cases. None of the patients showed coagulation changes during the study period.ConclusionThe use of once-daily, low-dose r-TPA for up to three consecutive days, as an adjunct to percutaneous drainage of thick collections, with or without loculation, appears to be an effective technique.

Use of Ultrasound Contrast Agents in Relation to Percutaneous Interventional Procedures: A Systematic Review and Pictorial Essay

The aim of this article is to provide an inventory of the use of contrast-enhanced ultrasound (CEUS) in relation to percutaneous interventional procedures. The article is structured into a systematic literature review followed by a clinical part relating to percutaneous CEUS-guided procedures. A literature search identified 3109 records. After abstract screening, 55 articles were analyzed and supplemented with pictorial material to explain the techniques. In conclusion, the best-evidenced indications for CEUS-guided interventions are biopsy and ablation of inconspicuous or B-mode-invisible tumors, intraprocedural ablation control and follow-up, as well as percutaneous transhepatic cholangiography and drainage procedures.

Rates and trends for inpatient surgeries in pediatric Crohn's disease in the United States from 2003 to 2012

BackgroundPediatric Crohn's disease (CD) is increasing in incidence globally. Trends in specific types of inpatient pediatric CD-related surgical procedures have not been widely reported. MethodsPatients ≤20 years of age with CD were identified in the Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Bowel resection, stoma creation, and perianal or percutaneous drainage procedures were identified using ICD-9 procedure codes, and trends were identified. Logistic regression was used to identify factors associated with surgical intervention and trends. ResultsRates of overall bowel resection (including ileocolic resection, other small bowel resection, or other colon resection) did not change significantly over time. However, the odds of having a laparoscopic colon resection increased by 41% annually (p<0.001). Rates of subsequent ileostomy formation increased (odds ratio 1.09, p<0.001). Older age, male sex, fewer comorbidities, and treatment in large urban teaching hospitals were also associated with higher odds of undergoing bowel resection. ConclusionsThis study noted a stable rate of all types of bowel resections and increase in post resection ileostomy formation in US pediatric inpatients with CD from 2003–2012. Other rates of many CD-related procedures have remained stable. Further studies correlating the effects of biologic agents on surgical rates are warranted. Type of studyTreatment Study Level of evidenceLevel III.

An Update on the Current Management of Perforated Diverticulitis

The management of perforated diverticulitis is a challenging aspect of general surgery. The prevalence of colonic diverticular disease has increased over the last decade and will continue to increase as the baby boomers add to the elderly population. Improvements in diagnostic imaging modalities, efforts to maintain intestinal continuity, and percutaneous drainage procedures now result in several alternatives when selecting a management strategy for complicated presentations. Specifically, laparoscopic lavage and resection with primary anastomosis have emerged as options for treatment of Hinchey III and IV diverticulitis in place of diversion in the appropriately selected patient. Percutaneous drainage of Hinchey II diverticulitis in centers equipped with interventional radiology provides another minimally invasive adjunct. The objective of this paper is to provide an update on the current management of perforated diverticulitis, with a focus on the advantages and disadvantages of the surgical options for the treatment of Hinchey III and IV diverticulitis.

Management of Pediatric Perforated Appendicitis: Comparing Outcomes Using Early Appendectomy Versus Solely Medical Management.

There is controversy regarding whether children with perforated appendicitis should receive early appendectomy (EA) versus medical management (MM) with antibiotics and delayed interval appendectomy. The objective of this study was to compare outcomes of children with perforated appendicitis who receive EA versus MM. Case review of consecutive children <18 years of age with perforated appendicitis who received either EA or MM during an 8-year period. Criteria for hospital discharge included patient being afebrile for at least 24 hours, pain-free and able to tolerate oral intake. Of 203 patients diagnosed with perforated appendicitis, 122 received EA and 81 received MM. All received parenteral antibiotic therapy initiated in the emergency department and continued during hospitalization. There were no significant differences between groups in mean patient age, mean complete blood count total white blood cells count, gender distribution, rates of emergency department fever or rates of intra-abdominal infection (abscess or phlegmon) identified on admission. Compared with patients receiving MM, those receiving EA experienced significantly fewer (1) days of hospitalization, parenteral antibiotic therapy and in-hospital fever; (2) radiographic studies, percutaneous drainage procedures and placement of central venous catheters performed; (3) post admission intra-abdominal complications and (4) unscheduled repeat hospitalizations after hospital discharge. Only 1 EA-managed patient developed a postoperative wound infection. Children with perforated appendicitis who receive EA experience significantly less morbidity and complications versus those receiving MM. The theoretical concern for enhanced morbidity associated with EA management of perforated appendicitis is not supported by our analysis.