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Original Research |
1 Department of Medical Imaging, Sainte-Justine Mother-Child University
Hospital, 3175 Cote Sainte-Catherine Rd., Montreal, QC H3T 1C5, Canada.
2 Department of Pediatrics, Division of Gastroenterology, Sainte-Justine
Mother-Child University Hospital, Montreal, QC H3T 1C5, Canada.
3 Department of Surgery, Sainte-Justine Mother-Child University Hospital,
Montreal, QC H3T 1C5, Canada.
Received February 8, 2006;
accepted after revision May 30, 2006.
Address correspondence to F. Rypens
(francoise_rypens{at}ssss.gouv.qc.ca).
Abstract
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MATERIALS AND METHODS. This retrospective study included 14 pediatric patients (age range, 12-17 years; median age, 15 years) with proven Crohn's disease. Percutaneous abscess drainage was performed for 15 abdominal or pelvic abscesses or for both abdominal and pelvic abscesses. The abscess was an initial manifestation of Crohn's disease in four patients and complicated well-known disease in 10 patients. Abscesses occurred spontaneously (n = 11), after surgery (n = 3), or after infliximab treatment (n = 1). Their volume ranged from 8 to 442 mL (mean, 113 mL). Fistulas with the bowel were detected in eight cases.
RESULTS. Sixteen percutaneous abscess drainages were performed under sonographic or CT guidance (or both) using 6- or 8-French catheters. The procedure was performed with the patient under conscious sedation (n = 14) or anesthesia (n = 2). The duration of the drainage was 1-30 days (mean, 11 days). An enterocutaneous fistula, medically treated with success, was the only complication observed. Complete resolution of the collection was observed in eight abscesses and partial resolution in seven. Resection of the diseased bowel segment with primary anastomosis was possible in 12 patients. In two patients, percutaneous abscess drainage was not followed by surgery.
CONCLUSION. Percutaneous abscess drainage is a valuable procedure in pediatric patients with Crohn's disease presenting with pelvic or abdominal abscesses (or both). It improves the general status of the patient and allows a less invasive and easier subsequent surgical procedure. Percutaneous abscess drainage should be performed before definitive treatment.
Keywords: abdominal imaging • abscess drainage • Crohn's disease • pediatric imaging • percutaneous drainage
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The patients were identified from the databases of the hospital and of the departments of interventional radiology and gastroenterology. Only patients with proven Crohn's disease and abscesses were included in the study.
The diagnosis of Crohn's disease was established from findings on barium studies, endoscopy, CT, or sonography and was confirmed in all cases by pathologic examination of specimens obtained during endoscopy or after surgery.
The diagnosis of abscess was suspected when a hypoechoic or heterogeneous well-defined collection, sometimes containing gas bubbles, was detected at sonography or when a well-demarcated hypodense collection surrounded by an enhancing wall, and sometimes containing gas bubbles, was observed on CT (or both). The diagnosis was confirmed by aspiration of purulent fluid and by culture.
We examined the patients' records for the following information: clinical information such as demographic characteristics, Crohn's disease history (primary diagnosis, natural history, previous intervention, medical treatment), abscess history (period, diagnosis, location, number, size, cultures, treatment), and clinical course after percutaneous abscess drainage. We also reviewed imaging records to determine which imaging techniques were used for diagnosis, treatment, and follow-up. Finally, we collected information about the percutaneous abscess drainage procedure: the criteria for intervention, type of sedation, procedure (feasibility, imaging guidance, pathways, punctures, drain size), postprocedure survey (irrigation, duration of drainage), complications (hemorrhage, visceral perforation, drain dysfunction, drain dislodgement, fistula), and success or failure.
The volume of the abscess was calculated by approximation to a revolution
ellipsoid with the average formula of
 |
where d1, d2, and d3 were the length, width, and thickness, respectively.
An abscess occurring less than 1 month after pelvic or abdominal surgery was considered postoperative. The other abscesses were defined as spontaneous in this series. Success of the percutaneous abscess drainage was defined as the disappearance of the drained collection without recurrence after 1 month or absence of residual collection at surgery. Persistence of the collection after withdrawal of the drain, rapid reappearance of the collection less than 1 month after withdrawal of the drain, or persistence of a purulent collection detected at surgery were considered as failure of the percutaneous drainage.
All interventional procedures were performed by a staff attending radiologist. The patients were under sedation or general anesthesia depending on the location of the abscess and the estimated duration of the procedure. Most procedures were performed with the patient under conscious sedation with oxygen saturation monitoring. The conscious sedation regimens included intramuscular injection of the Toronto mixture (i.e., chlorpromazine hydrochloride [6.25 mg/mL], meperidine hydrochloride [25 mg/mL], and promethazine hydrochloride [6.25 mg/mL]) at a dose of 0.1 mL per kilogram of body weight, with a maximum dosage of 1.6 mL and, if necessary, was followed by IV injection of midazolam (0.1 mg/kg; maximum dose, 5 mg). Orally administered ketamine hydrochloride and midazolam hydrochloride, IV-administered midazolam hydrochloride, and topical anesthetic cream (lidocaine 2.5% and prilocaine 2.5%) were alternative regimens used.
All patients were treated concomitantly with IV broad-spectrum antibiotics.
Percutaneous abscess drainage was performed using a classical Seldinger technique. After having precisely located the abscess on CT, the staff attending radiologist determined the safest access pathway and local anesthesia was provided accordingly. The collection was punctured with an 18-gauge sheath needle under sonographic or CT guidance (or both) depending on the location of the abscess. A small quantity of fluid was aspirated and sent for bacteriologic analysis. A 0.032-inch guidewire was inserted under fluoroscopic or CT guidance, and a 6- or 8-French pigtail catheter (Navarre Universal Drainage with Nitinol, Bard) was advanced and sutured to the skin. Maximal aspiration of the pus was initially performed in the intervention suite, and the abscess was then allowed to drain by gravity. Four irrigations per day with 10 mL of saline and monitoring of the drain were prescribed. Follow-up imaging was performed depending on the clinical circumstances. The duration of drainage was clinically determined, and the withdrawal of the drain was decided by consensus among the surgeon, microbiologist, gastroenterologist, and radiologist. Opacification of the drain was not systematically performed.
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The age at diagnosis of Crohn's disease varied from 5.8 to 17 years (median age at diagnosis, 12.9 years). The disease affected the ileum and large bowel in eight patients; the ileum alone in four patients; the duodenum, ileum, colon in one patient; and the antrum, duodenum, and ileum in one patient.
The age of the patient at diagnosis of the first abdominal or pelvic abscess ranged from 12 to 17 years, and the duration of Crohn's disease before abscess formation varied from day 0 to 9 years (median, 21 months). In 10 patients, the diagnosis of Crohn's disease was known at least 2 months before the occurrence of the abscess. Two of these patients had already benefited from various surgical procedures: subtotal colectomy with ileostomy, followed by ileostomy revision, was performed in one case 4 years before the abscess occurrence (patient 7) and the other patient (patient 2) underwent multiple perineal surgical drainages. In four patients, the abdominal or pelvic abscess occurred 1 month or less after the initial diagnosis of Crohn's disease (patients 5, 6, 9, 10). One of these patients had ileocecal resection with primary anastomosis performed 1 month before the abscess was detected (patient 9). Pelvic abscess was the first manifestation of Crohn's disease in one patient (patient 10).
The medical treatment during the period preceding the abscess occurrence consisted of steroids (10 patients), steroids with 6-mercaptopurine (six patients), steroids with antibiotics (two patients), and steroids with 6-mercaptopurine and antibiotics (two patients). Two patients were treated with 6-mercaptopurine alone. Two patients had no treatment.
Abscess Characteristics
The 14 patients in this series presented with 15 abdominal abscesses
(Table 2). The location and
characteristics of the abscesses are described in
Table 2. Abscesses occurred
spontaneously in 11 cases, after surgery in three cases, and 41 days after
infliximab treatment in one case. Abscess volume ranged from 8 to 442 mL
(mean, 113 mL). Fistulas between the abscess and the small intestine or the
colon (or both) were detected in eight cases on barium studies, by drain
opacification, or on CT (cases 2, 6, 7a, 8, 10, 11, 12, 13).
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Abscess Drainage
Twenty-two percutaneous procedures (percutaneous abscess drainage,
n = 16; puncture and aspiration, n = 6) were performed. All
the percutaneous procedures were technically feasible.
The aspiration of 10 mL of purulent material under sonographic guidance led to the collapse of the abscess in two patients (cases 10 and 13). The residual cavity was too small to allow the placement of a drain and the patients were medically treated. A small residual cavity was still present at laparotomy in one of these two patients.
Sixteen percutaneous abscess drainage procedures were performed. CT guidance was used in nine cases and sonographic and fluoroscopic guidance, in seven cases. The selected approach was anterior (n = 14), transgluteal (n = 1), or anterior and posterior translumbar (n = 1) (Fig. 1A, 1B, 1C, 1D). All procedures were performed with the patient under conscious sedation except for patients 8 and 14 who underwent general anesthesia.
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There was no correlation between the bacteria cultured from the abscess, the results of percutaneous abscess drainage, and the evolution of the patient.
Complications and Catheter Manipulations
We observed one complication: An enterocutaneous fistula occurred after
percutaneous abscess drainage of an abdominal wall abscess
(Table 2). This patient
(patient 7) already had an enterostomy due to persistent active Crohn's
disease. She developed an abdominal wall abscess related to a fistula from the
enterostomy. After the fall of the catheter, the enterocutaneous fistula
became more obvious and subsided under medical treatment with infliximab. No
hemorrhage or organ injury was noted after percutaneous abscess drainage.
Dislodgment of the drain was observed in three cases (cases 4b, 7b, 14) (Table 2). Catheter manipulations were performed in three cases: replacement of the drain due to the hub's break (n = 1), drain mobilization for better drainage of a residual superficial collection (n = 1), and substitution of a 6-French catheter for an 8-French catheter for drainage of very thick material (n = 1).
Evolution and Follow-Up
Eight abscesses were successfully drained by percutaneous abscess drainage
(n = 7) or by needle aspiration (n = 1)
(Table 2). In six of these
eight cases, percutaneous abscess drainage was followed by surgical resection
of the stenotic bowel section with primary anastomosis. In the two other
cases, no surgery was performed.
Failure of percutaneous abscess drainage as defined by the persistence of a purulent collection at surgery was observed in seven cases. In two patients, abscesses recurred 1.5 months and 16 days, respectively, after percutaneous abscess drainage (cases 4a and 7a). Resection of the diseased bowel segment with primary anastomosis was possible in six of these seven patients, and one patient still has an ileostomy due to diffuse active colonic disease.
Follow-up ranged from 1 to 53 months. Ten patients are now in remission. Two patients still have persistent ileostomy due to residual active colonic disease. Two patients were lost to follow-up.
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Second, percutaneous abscess drainage in combination with medical treatment can be a definitive therapeutic procedure. Some adult series show a success rate of 80% after percutaneous abscess drainage without surgery [3]. In our pediatric series, percutaneous abscess drainage in combination with medical treatment was effective in only two patients, whereas the remaining patients underwent surgery soon after percutaneous abscess drainage because of intestinal stenosis. In our institution, the management of these patients is highly surgical, which obviously biased our results. In fact, the rate of surgery after percutaneous abscess drainage and the definitive treatment vary according to the series [8, 11-13]. In our institution, intestinal resection remains the preferred treatment in cases of residual stenosis. In the literature, the documentation of a fistula seems to predict the need for short-term surgery [13, 14]. Eight patients in our series had documented fistulas. All but one had intestinal resection after percutaneous abscess drainage. The remaining patient already had an ileostomy but needed further treatment with infliximab after two percutaneous abscess drainage procedures to cure the fistula. The use of new anti-tumor necrosis factor agents such as infliximab will probably modify the trend toward rapid surgery. However, infliximab must be used with caution in children because of the reported increased risk of malignancies and infections.
Percutaneous abscess drainage was technically feasible in all of our cases. In our experience, percutaneous abscess drainage can be performed with the patient under conscious sedation in most pediatric cases. No sedation failure was observed in our series. General anesthesia should be favored when the prospected pathway is difficult to access, when using the pathway would be too painful for the patient (as in the posterior or transgluteal approach), and when the child is in excruciating pain or in a very poor clinical status. Only two of our patients required the support of an anesthesiologist. The choice of the drainage pathway depends on the location of the collection. For deep pelvic abscesses, a posterior or endorectal approach can be chosen.
Contraindications to percutaneous abscess drainage are limited to uncorrectable hemostatic defect and the lack of safe access. The choice of the most secure and efficient access is crucial. CT is particularly useful in complex or multiloculated collections or in collections with a deep location [15]. Sonography and fluoroscopy are used for superficial or obviously accessible collections. In complex cases, more than one drain may be needed for optimal drainage, eventually with different access pathways.
Contrary to the results of other published series [10, 13], we obtained successful drainage with small catheters (6- or 8-French). According to the literature, prolonged drainage (8 days-6 weeks) can be necessary to close the fistula [2]. In our series, surgeons elected to operate as soon as the abscess was drained or when the clinical status of the patient was good. This could explain why small abscesses were still present at laparotomy in six of our patients. The duration of drainage in these six cases varied from 2 to 30 days (mean, 14 days). In all of these patients, clinical status was clearly improved after percutaneous abscess drainage, and the presence of a small residual abscess did not preclude primary anastomosis in most of the patients.
Simple puncture and aspiration are usually not effective because an abscess in a patient with Crohn's disease is secondary to a fistula. In our series, only one patient with a postsurgical pelvic abscess and a proven fistula was cured by puncture and medical treatment, including antibiotherapy and IV hyperalimentation.
Paradoxically, percutaneous abscess drainage can be more delicate in cases of a small abdominal wall abscess when there is not enough tissue to ensure correct fitting of the drain. This was the case for one of our patients who presented with recurrent premature fall of the drain (patient 7).
Percutaneous abscess drainage is not risk-free: Damage to adjacent organs can occur if the access route is not carefully determined, and there is a low risk of iatrogenic fistula. Fistulas in patients with Crohn's disease occur spontaneously and after surgery [16]. The creation or the maintenance of a fistula in patients with Crohn's disease after percutaneous abscess drainage is rare [3, 6, 7, 9]. Enterocutaneous fistula occurred in only one of 16 percutaneous abscess drainage procedures in our series. In that case, the patient had already suffered from enterostomy fistulas in the past and had presented with an abdominal wall abscess related to an enterostomy fistula. Furthermore, the abscess had to be drained twice in less than 1 month because of premature removal of the drain. The enterocutaneous fistula observed after percutaneous abscess drainage was medically treated with success.
In fact, percutaneous abscess drainage is less invasive and is less prone to induce enterocutaneous fistulas than surgical drainage. The rate of post-percutaneous abscess drainage fistulas ranged from 0% to 6% in our series, as in those of Safrit et al. [6] and Gervais et al. [13]. Furthermore, the treatment of an iatrogenic fistula in such patients is probably less problematic than the treatment of a spontaneous fistula. Actually, percutaneous abscess drainage compares favorably with surgical drainage because 12-38% of abscess recurrence, 10-15% of complications, and 21-85% of enterocutaneous fistulas are described after surgery [2, 6]. Neither hemorrhage nor significant complications were observed after percutaneous abscess drainage in our series, and the rate of abscess recurrence (13%) was comparable to those reported in series already published [6, 13].
Without any explanation, our series shows a female predominance that is remarkable and unusual. This observation has not, to our knowledge, been described in the literature [2, 3, 6, 12, 14].
In conclusion, percutaneous abscess drainage is a valuable procedure in pediatric patients with Crohn's disease who present with a pelvic abscess or abdominal abscess (or both). Percutaneous abscess drainage should be the first procedure before definitive surgery. More studies will have to be conducted to determine whether surgery should always be performed after percutaneous abscess drainage.
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