| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Commentary |
1 Department of Radiology, University of California, San Diego, 200 W Arbor Dr., San Diego, CA 92103-8756.
Received February 26, 2008; accepted after revision March 6, 2008.
Address correspondence to G. Rivera-Sanfeliz
(gerantrivera{at}ucsd.edu).
Keywords: drainage procedures • imaging-guided intervention • nonvascular intervention
During the past century, abdominal abscess has evolved from a disease with extreme mortality even with surgical intervention to a medical condition with a rather insidious presentation, thanks in part to the wide spread use of antibiotics, particularly in the postoperative setting. In spite of this, abdominal abscesses can be fatal if left untreated.
Seventy years ago, Ochsner and DeBakey [1] stated the classic criteria for optimal surgical abscess drainage: characterized by directness, simplicity, and, above all, avoidance of unnecessary contamination of uninvolved areas. In the era of imaging-guided percutaneous procedures, we might want to add the following: avoidance of inadvertent injury to adjacent, uninvolved organs.
Three landmark articles in the develop ment of percutaneous abscess drainage techniques from the American Journal of Roentgenology are republished online this month [2–4]. Two of these articles were written by John R. Haaga and colleagues [2, 4] during their years at the Cleveland Clinic and Case Western Reserve School of Medicine. The third article was written by Stephen G. Gerzof and colleagues [3] during their tenure at the Boston Veterans Administration Medical Center.
In 1977, Haaga and colleagues [2] wrote of their early experience in percutaneous abdominal abscess drainage using CT guidance. Their series included 26 patients referred for CT evaluation of possible intra abdominal abscess. Seventeen had a proven abscess, most in the upper abdomen. They used three meth ods to diagnose and treat these abscesses: method 1, aspiration for culture performed using a coaxial 18- and 22-gauge needle system; method 2, aspira tion and limited drainage using a Teflon (poly tetrafluoro ethylene, DuPont)-sheathed 18-gauge needle; and method 3, aspiration and definitive drainage using a 14-French Foley catheter introduced with a trocar technique after a positive preliminary aspiration. Given that this was early in their experience, the results were encouraging. Of nine attempted aspirations using methods 1 and 2, eight were reported successful. Method 3 was attempted twice and was successful in one case. More im portant, there were no complications other than the aspiration failures.
Haaga and colleagues [2] accurately concluded that CT is an excellent diagnostic and guidance tool for the percutaneous treatment of abdominal fluid collections. They recognized that CT, despite its ability to show gas and the extraluminal nature of the collection, is somewhat limited in its ability to fully characterize the fluid. Finally, they suggested that for definitive drainage the abscess must be superficial to avoid undesired peritoneal contamination and injury to adjacent structures. In short, the seed had been planted for percutaneous CT-guided drainage procedures.
Two years later, Gerzof and associates [3] reported their experience with percutaneous drainage procedures using both sonographic and CT guidance. In this study, they reviewed their experience in 23 patients in whom they used one of two drainage techniques: Seldinger (over guidewire)—with delivery of an 8-French angiographic pigtail catheter for drainage and trocar—with placement of 12- or 16-French Argyle-Ingram catheters. They used sonographic guidance in 20 of 24 cases and CT guidance in the remaining four cases. The catheters were kept in place an average of 14 days in 22 patients, and only one patient required an open operation after failure of percutaneous drainage.
Gerzof and associates [3] reported two major complications—one empyema and one hemorrhage—as well as three minor complications—chills, fever, and cutaneous sinus tract. Similar to the Haaga et al. [2] article, they concluded that both CT and sonography are exceptional tools for imaging-guided procedures, although both techniques continued to have diagnostic limitations regarding accurate fluid characterization before drainage. With this series, they attempted to challenge the prevailing surgical opinion that small-bore catheters are ineffective in treating abscesses. However, they also mentioned that percutaneous drainage may have limitations when treating complicated and highly viscous collections such as infected pancreatic phlegmon.
In 1980, Haaga and Weinstein [4] reported on a larger series of CT-guided percutaneous drainage procedures. In this article, they reported on successful diagnostic aspirations and drainage procedures in 103 patients with abdominal collections. Although there was inherent bias in this study in selecting patients for percutaneous drainage on the basis of viscosity of aspirate, complexity, and inaccessibility of the collection, the authors made a considerable effort to establish the effectiveness of percutaneous drainage proc edures in patients who could not undergo surgery. In this nonoperative group, per cutaneous drainage became a new alternative because it was effective in seven of nine patients.
The Haaga and Weinstein [4] article also delineated three principles that we currently follow during abscess drainage procedures: safe use of the transperitoneal approach (the surgical dictum was that this would produce unwarranted contamination), the drainage path way does not traverse organs or structures (except for solid organs in which normal parenchyma is traversed ahead of the abscess—thought to prevent peritoneal contamination), and strict adherence to a postprocedure protocol including follow-up imaging to prove successful drainage of the abscess.
Since these dramatic articles almost 30 years ago, percutaneous abscess drainage has become the standard of care for treatment of abdominal and thoracic collections, replacing more invasive surgical procedures in all but the most difficult cases. Initially expected to be successful in only the simpler collections, percutaneous drainage has evolved from a temporizing measure [5] to a curative intervention [6], even for the most complex, septated, and viscous collections. Currently, abscess drainage procedures are successfully performed using small-bore catheters [7, 8] and facilitated by the adjunctive use of intracavitary lytic agents [9].
References
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
