Percutaneous Image-guided Drainage Research Articles

Percutaneous Image-Guided Drainage of Abdominal Fluid Collections in Children: Technical Considerations and Clinical Scenarios

AbstractWhile initially conceived and designed for adults, percutaneous image-guided drainage of abdominal pelvic and fluid collections has revolutionized the management of several pediatric pathologies. Interventional radiology procedures markedly reduce morbidity and mortality by offering a definitive minimally invasive approach or allowing a cleaner and less challenging subsequent open approach. These procedures are associated with improved patient comfort and rapid recovery. While similar techniques apply to children and adults, successful adaptation of image-guided interventional techniques in children requires consideration of several critical differences. This review aims to discuss the indications, contraindications, and technical aspects of percutaneous image-guided drainage of abdominal and pelvic fluid collections in children.

Transthoracic drainage of liver abscess

Liver abscess is a commonly encountered condition. Most abscesses are amenable to transabdominal drainage. However, abscesses located in the superior and posterior parts of the liver are difficult to drain through the abdomen. Percutaneous image-guided drainage helps in resolving some of these abscesses, but when these abscesses are chronic with thickened walls and thick pus, a small bore per cutaneous catheter is not adequate. We describe three cases in which a transthoracic transdiaphragmatic approach was used by which the contents of the abscess were evacuated and the cavity drained with large bore chest tubes. At the same time, the intrathoracic complications were managed.

Laparoscopy-guided liver abscess drainage: An additional use of veress needle

Percutaneous image-guided drainage is the standard of care in the treatment of liver abscess. However this may not suffice in multi-loculated abscesses and those associated with concomitant biliary pathology. We report the case of a 34 year old male who presented to our hospital with a huge hepatic abscess that could not be aspirated percutaneously. Subsequently he had a laparoscopic guided aspiration of the abscess, with the aid of veress needle. Three weeks post operatively, no residual abscess cavity was noticeable. We believe that minimal access surgery techniques should always be considered in the management of liver abscess, and that the veress needle can be an additional aspiration device, in our environment.

Factors Affecting the Successful Management of Intra-Abdominal Abscesses With Antibiotics and the Need for Percutaneous Drainage

There is no definite consensus on the management of intra-abdominal abscesses in adults. This retrospective study evaluated the use of antibiotic therapy and percutaneous image-guided drainage in adult patients with intra-abdominal abscesses. A retrospective chart review of 114 patients with intra-abdominal abscesses was conducted. Data collected included patient demographics, presenting symptoms, radiographic interpretation, vital signs, antibiotic coverage, laboratory values, and details of the hospital course. Bivariate statistical tests were performed using the Wilcoxon rank-sum test, chi-squared test, or Fisher's exact test, where appropriate. Sixty-seven of 114 patients (59 percent) had intra-abdominal abscesses resulting from appendicitis, diverticulitis in 30 patients (26 percent), postoperative in 13 patients (11 percent), and undetermined in 4 patients (4 percent). Three patients (3 percent; 95 percent confidence interval, 1-8 percent) failed conservative management and underwent urgent operation. Sixty-one (54 percent; 95 percent confidence interval, 44-63 percent) patients improved with intravenous antibiotic therapy alone. Fifty patients (44 percent; 95 percent confidence interval, 35-54 percent) underwent image-guided percutaneous drainage after 48 to 72 hours of antibiotic therapy. Patients who improved on antibiotics alone had average abscess diameter of 4 cm, whereas patients who underwent percutaneous drainage had average diameter of 6.5 cm (P<0.0001). Maximal temperature at time of admission was 100.8 degrees F for antibiotic group and 101.2 degrees F for percutaneous drainage group (P=0.0067). The majority of the patients with intra-abdominal abscesses improved with antibiotic therapy alone. Those patients with an abscess diameter>6.5 cm and temperature at admission>101.2 degrees F have higher likelihood of failing conservative therapy with antibiotics alone and requiring percutaneous drainage.

Gas Distribution in Intraabdominal and Pelvic Abscesses on CT Is Associated with Drainability

Intraabdominal and pelvic abscesses are treated by percutaneous image-guided drainage, under sedation or general anesthesia. This study attempts to determine if the CT features of gas distribution are associated with "drainability." Our premise was that gas may be trapped deep in a collection as bubbles, if the material is thick. Gas may rise to the surface if the material is thin, forming either an air-fluid level or superficial bubbles. Patients with intraabdominal and pelvic abscesses were identified by the interventional radiology database, after research ethics board approval. Patients without prior CT were excluded. The imaging and clinical records were analyzed retrospectively. Intracollection gas distribution was recorded as superficial bubbles, deep bubbles, or air-fluid levels. Collections were classified accordingly: type 1, air-fluid levels; type 2, superficial or deep bubbles and air-fluid levels; type 3, superficial bubbles; type 4, deep bubbles; and type 5, no gas. One hundred five abscesses were examined in 61 patients, ranging in age from 2-17 years. Eight of 8 of type 1, 16 of 16 of type 2, 19 of 21 of type 3, 8 of 13 of type 4, and 43 of 47 of type 5 were drainable. The abscesses of all patients with an air-fluid level were drainable. Of abscesses with deep bubbles, 61.5% were drainable, versus 90.5% of those with superficial bubbles. Of those with superficial gas (superficial bubbles or air-fluid levels), 95.6% were drainable. In comparison with superficial gas, abscesses with deep trapped gas were associated with a longer duration of drainage, longer hospital stay, lower percentage of successful drainage, and higher percentage of residual collections. The difference is significant for drainability (p = 0.0048; p = 0.0331 after statistical adjustment for multiple testing). Distribution of gas in an intraabdominal or pelvic abscess is associated with drainability. Abscesses with superficial gas (superficial bubbles or air-fluid levels) have a greater chance of being drained successfully than do abscesses with deep trapped gas.

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

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

Determinants for Successful Percutaneous Image-Guided Drainage of Intra-abdominal Abscess

Characteristics of intra-abdominal abscess can be used to predict successful outcome for percutaneous catheter drainage (PCD). We performed a multicenter prospective study of patients who had intra-abdominal infections treated with PCD and intravenous antibiotics. Multivariate regression analysis determined predictors of successful outcome. The study included 96 patients (59% men; mean +/- SD age, 48 +/- 17 years; mean +/- SD Acute Physiology and Chronic Health Evaluation II score, 7.4 +/- 4.9). Postoperative abscess was present in 53% of patients. Isolated microorganisms included Bacteroides species (17%), Escherichia coli (17%), Streptococcus species (14%), Enterococcus species (10%), and fungi (11%). Single abscesses were present in 83% of patients. Computed tomographic guidance was used for drainage in 80% of patients, and ultrasound was used in 20%. The duration of abscess drainage was less than 14 days in 64%. Complete resolution of the infection with a single treatment of PCD was achieved in 67 patients (70%), and with a second attempt in 12 (12%). Thirty-three patients (34%) had PCD for the resolution of intra-abdominal sepsis prior to an elective, definitive procedure. Open drainage as a result of PCD failure was required in 15 (16%) and was more likely in patients with yeast (P<.001) or a pancreatic process (P =.02). Postoperative abscess (P =.04) was an independent predictor of successful outcome. Percutaneous catheter drainage of intra-abdominal infections was effective with a single treatment in 70% of patients and increased to 82% with a second attempt. A successful outcome is most likely with abscesses that are postoperative, not pancreatic, and not infected with yeast. Percutaneous catheter drainage is now a commonly used staging method for the resolution of intra-abdominal sepsis prior to corrective operation.