Tech Coloproctol (2002) 6:159–164
© Springer-Verlag 2002
O R I G I N A L A RT I C L E
M. Khurrum Baig • R. Hua Zhao • O. Batista • J.P. Uriburu • J.J. Singh • E.G. Weiss • J.J. Nogueras S.D. Wexner
Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery
Received: 20 July 2002 / Accepted: 4 November 2002
Abstract Intra-abdominal abscesses are a frequent source of morbidity and mortality following both elective and emergent surgery of the alimentary tract. CT-guided percutaneous drainage of intra-abdominal abscess is an alternative to immediate surgical intervention. We studied the clinical characteristics and outcomes of patients undergoing percutaneous drainage of intra-abdominal abscesses arising after elective colorectal procedures. We retrospec-
This paper was presented in part as a poster at the annual meeting of the Association of Coloproctology of Great Britain and Ireland, Southport, UK, 9-11 June 1999.
tively identified 40 patients with postoperative intraabdominal abscess following elective colorectal surgery who underwent CT-guided percutaneous drainage with a Von Sonnenberg sump drain between 1990 and 1998. The most common presenting symptoms were pyrexia in 39 (97%), abdominal tenderness in 32 (80%), guarding in 1 (2.5%) and abdominal mass in 3 (7.5%); no patient had generalized peritonitis. The most common index procedure was proctocolectomy with ileoanal anastomosis and ileal Jpouch in 12 (30%) patients. Drainage was performed using an anterior approach in 32 (80%) and a transgluteal window in 8 (20%) patients. Thirty-five (87.5%) patients had a single collection, while 2 (5.0%) patients had 2 collections and 3 (7.5%) patients had 3 collections. Thirteen (32.5%) patients had perioperative steroids, 30 (75%) had preoperative antibiotics, and 40 (100%) had postoperative antibiotics. Follow-up at a mean of 35.8 days revealed complete resolution of abscess in 26 (65%) patients; 14 (35%) patients had residual or recurrent abscess successfully treated by repeat drainage in 8 patients and requiring laparotomy in 6. Percutaneous CT-guided abscess drainage is an effective method for treating intra-abdominal abscess following elective colorectal surgery. The primary success was 65% after the first and 85% after a second drainage. In conclusion, this technique should be considered as the treatment of choice in patients with localized intra-abdominal abscess without signs of generalized peritonitis. Key words Intra-abdominal abscess • Percutaneous drainage • CT-guided drainage
M. Khurrum Baig • R. Hua Zhao • O. Batista • J.P. Uriburu J.J. Singh • E.G. Weiss • J.J. Nogueras • S.D. Wexner () Department of Colorectal Surgery Cleveland Clinic Florida 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA e-mail:
[email protected]
Introduction Abscess formation within the peritoneal cavity is a dynamic process, representing the body’s ability to localize the contamination but its inability to completely abolish the
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bacteria and neutralize their toxic products. In most instances, the source of microbial insult is from bacteria that colonize in the intestinal lumen. Drainage of intraabdominal abscess is a difficult problem and, although laparotomy is effective, it is associated with high morbidity and mortality, especially during the early postoperative period when the healing process is acute. The risk of enterotomy, myotomy, and postoperative enterocutaneous fistulas is daunting in this setting. Therefore, computed tomography (CT)-guided percutaneous drainage of intraabdominal abscess provides an alternative to immediate surgical intervention. Numerous reports [1–14] have proven the benefits of percutaneous drainage, as compared to laparotomy and drainage, in the treatment of abscess of heterogeneous etiologies. Accordingly, the aim of this study was to assess the results of percutaneous intraabdominal drainage of abscesses that developed after elective colorectal surgery.
bleeding time and prothrombin time were measured [15]. Patients with previous non-life-threatening allergic reactions to intravenously administered contrast medium were premedicated with steroids. Although a number of premedication regimens exist, we followed the American College of Radiology’s regimen of 32 mg methylprednisolone administered orally 12 and 2 hours before the anticipated contrast medium administration [16]. An initial limited tomogram was taken to localize the abscess and plan the drainage route (Fig. 1). Percutaneous drainage was performed using a Von Sonnenberg 10–12 French sump drain with multiple side holes (Fig. 2), although smaller catheters such as 8–10 French may be adequate for drainage of serous collections [17]. The pigtail configuration has the advantage of a greater length of catheter with side holes inside a relatively small cavity; however, kinking may occur as well as obstruction without frequent lavage. The overlying site was prepared and draped in the sterile fashion and lidocaine was administered locally. After introduc-
Patients and methods All patients with postoperative intra-abdominal abscess following elective colorectal surgery who underwent CT-guided percutaneous drainage between 1990 and 1998 were identified from a computerized database. Patients with superficial abscess confined to the abdominal wall and those who had abscesses prior to their elective colorectal procedure were excluded from analysis. Percutaneous intra-abdominal abscess drainage was considered successful if the abscess resolved within 7 days with no recurrence. Retrospective chart review was performed and data were collected regarding the clinical symptoms, method of drainage, and outcome.
CT-guided percutaneous drainage Specific inquiry was made regarding the history of any bleeding, diatheses, allergies, and relevant underlying medical problems. If the history suggested the possibility of a coagulation defect,
Fig. 1 Computed tomogram showing an intra-abdominal abscess (arrow)
Fig. 2 Von Sonnenberg drainage catheter
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Results
Fig. 3 Route of catheter placement (arrow)
tion of the needle into the abscess (Fig. 3), an aspirate was obtained for culture and gram stain. To avoid intraperitoneal spillage of the abscess contents, we ensured that all side holes were within the abscess cavity. The drainage catheter was then fixed to the skin and left to gravity drainage. A limited postdrainage CT scan was obtained to provide baseline images of residual cavity and to verify optimal catheter position. Irrigation was not routinely performed as it may increase the incidence of bacteremia [18]. Post-drainage monitoring included clinical surveillance and sequential CT scans. The catheter remained in situ for varying lengths of time, depending upon the individual patient’s underlying disease processes, the size and contents of the abscess, and the healing time [19, 20].
A total of 40 patients underwent percutaneous drainage of intra-abdominal abscess following elective colorectal surgery, including 23 men and 17 women with a mean age of 52.5 years (range, 19–74 years). A wide variety of surgical procedures had been used (Table 1). Common presenting symptoms included pyrexia in 39 (97%) patients, abdominal tenderness in 32 (80%), guarding in 1 (2.5%), and abdominal mass in 3 (7.5%). Thirty-six patients (90%) had leukocytosis at the time of diagnosis; none had diffuse peritonitis. CT revealed unilocular abscess in 35 (88.5%) and multilocular abscess in 5 (12.5%) patients. The wall of the abscess cavity was well defined in 4 (10%) patients but poorly defined in 36 (90%) patients. The size of the abscess cavity was on average 4x6x5 cm3, and ranged from 3x2x4 cm3 to 14x7x10 cm3. Thirty-five (87.5%) patients had one collection and 5 (12.5%) had 2 or 3 collections (2 and 3 patients, respectively). Thirteen (32.5%) patients had perioperative steroids, 30 (75%) had preoperative antibiotics, and 40 (100%) had postoperative antibiotics. The route of catheter placement was anterior in 32 (80%) and transgluteal in 8 (20%) patients. The drain was left in situ for a range of 3–20 days. At a mean follow-up of 35.8 days (range, 6–8 days), complete resolution of abscess with no recurrence was noted in 26 (65%) patients (Fig. 4). Fourteen (35%) patients had residual abscess or re-accumulation, of whom 8 were successfully treated by repeat drainage, whereas 6 required laparotomy and drainage (Table 2, Fig. 4). Overall, 34 (85%) patients were treated successfully (after one or two attempts) with CT-guided percutaneous intra-abdominal drainage.
Table 1 Surgical procedure and indications for surgery in 40 patients who developed intra-abdominal abscess Surgery
Diagnosis
Proctocolectomy and J pouch
Ulcerative colitis
12 (30.0)
Total colectomy and ileostomy
Ulcerative colitis
6 (15.0)
Anterior resection
Patients, n (%)
Diverticular disease
1
(2.5)
Adenocarcinoma
3
(7.5)
Ileocolic resection
Crohn’s disease
4 (10.0)
Sigmoid colectomy
Diverticular disease
3
Small bowel resection
Small bowel obstruction
3
(7.5)
Abdominoperineal resection
Adenocarcinoma
2
(5.0)
Appendectomy
Appendicitis
2
(5.0)
Right hemicolectomy
Adenocarcinoma
2
(5.0)
(7.5)
Perineal rectosigmoidectomy
Rectal prolapse
1
(2.5)
Transverse colectomy
Adenocarcinoma
1
(2.5)
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Table 2 Characteristics of the 14 of 40 patients in whom percutaneous intra-abdominal drainage was insufficient to cure an abscess developed after elective colorectal surgery, by type of secondary treatment Patient Age, years
Indication Gender
Repeat percutaneous drainage 19 M
Drain attempts, n
1
NA
J-pouch
Anterior
7x10
Sigmoid colectomy J-pouch Appendectomy Small bowel resection J-pouch Small bowel resection Repeat J-pouch
Anterior Transgluteal Anterior Transgluteal
6x4 4x5 5x5 5x5
Streptococcus (group B) E. coli E. coli E. coli E. coli
Anterior Anterior
7x10 4x6
Streptococcus E. coli
1 1
Transgluteal
4x7
E. coli
1
Transgluteal Anterior Anterior Anterior
5x4 4x6 7x6 5x4
Bacteroides sp. E. coli E. coli E. coli
2 2 2 2
Anterior Anterior
4x5 7x5
E. coli Streptococcus (group B)
2 2
NA NA NA NA
61 87
M F
NA NA
F F
Culture result
Approach
M F M F
76 38
Abscess size, cm
Type
74 55 37 72
29 F Laparotomy and drainage 43 F 30 M 51 F 36 F
Primary surgery
NA Cancer Crohn’s disease Crohn’s disease Rectal prolapse
Sigmoid colectomy Ileocolic resection Ileocolic resection Perineal rectosigmoidectomy Diverticular disease Anterior resection Crohn’s disease Ileocolic resection
1 1 1 1
NA, not applicable
Discussion
Fig. 4 Treatment protocol and outcome in 40 patients who developed intra-abdominal abscess after elective colorectal surgery, by type of abscess as revealed by computed tomography
In 1922, Rogers [21] first reported the utility of percutaneous aspiration in the treatment of amebic abscesses. However, it was not until two decades ago that percutaneous drainage emerged as a routine procedure in the management of abdominal abscess, particularly those collections of enteric origin [1, 11, 18, 22, 23]. Initially, it was used for simple superficial fluid collections, however, as radiologists gained experience with this technique, its role expanded. Currently, percutaneous drainage is applied in the management of complex multiseptate abscesses associated with enteric communications and fistulas in severely ill patients [8, 9, 11, 14, 22, 24–29]. The continued improvement in the quality of imaging (ultrasound and computed tomography) and advances in drainage techniques and catheter technology have led to the refinement of this procedure and have contributed to its widespread acceptance [23]. Contraindications to the technique include some coagulopathies and abscesses that cannot be safely transgressed. It is difficult to predict the response of percutaneous drainage simply based on radiological evaluation. Therefore, a prospective trial to gauge the results of percutaneous drainage is the ideal method for determining its therapeutic value. Hyde and Gerzof [18] summarized their approach to percutaneous drainage by stating “the shortest distance between two points is a straight needle” and “nothing ventured, nothing drained”.
M. Khurrum Baig et al.: Percutaneous intra-abdominal abscess drainage
Intra-abdominal abscess can be diagnosed and drained utilizing either ultrasound (US) or CT guidance. Each technique has its advantages and disadvantages and may be used in complement. However, the crucial role of CT for accurate diagnosis of intra-abdominal abscesses, as well as planning for a safe puncture route, has been well established [30, 31]. It has been suggested that US alone is not a reliable guiding method due to its limitations in delineating the intricate loops of bowel. Furthermore, CT is particularly helpful if the abscess lies deep within the peritoneal cavity, or lays adjacent to or initiates from the bowel [8, 15, 24, 27, 32–34]. Sonographic guidance is reserved for abscesses that lay in relatively superficial locations or that occur in critically ill patients when the abscess must be drained at the bedside [32]. Thus, CT is the superior guidance technique. The exact percentage of collections that can be treated by this method is unclear, however, Voros et al. [35] indicated 70%–80%. The tubes used initially for percutaneous drainage were atraumatic and relatively small in diameter. Although these tubes were “comfortable” for the patient due to their narrow caliber, they often became blocked by thick pus or necrotic material, rendering drainage of large abscesses difficult [12, 15, 16]. Although large Argyle tube drains have been described for the use of percutaneous abscess drainage [14], the Von Sonnenberg tubes are also an option. The preferred mode of catheter placement is directly from the skin, through the abdominal wall, and into the abscess cavity without traversing bowel, blood vessels or other vital structures [18]. Furthermore, the ideal position for the catheter is within the abscess to facilitate gravitational drainage. Although this route is often possible and certainly preferred, approaches such as transgluteal, transrectal, or transvaginal must occasionally be used for collections located deep in the abdomen and pelvis [20, 36–40]. A transgluteal approach is especially suited to drain abscesses in the presacral space. This approach requires the catheter to be introduced into the presacral space and kept as close as possible to the lateral margin of the sacrum, thereby avoiding the sciatic nerve. A major disadvantage to this approach is the pain associated with transgressing large muscle bundles and with irritation of the sciatic nerve. Accordingly, the paracoccygeal approach has been proposed for presacral abscesses as this method does not traverse large muscle bundles and avoids the sciatic nerve [41]. The site of entry does not necessarily have to be at the level of the greatest diameter of the abscess or at its most inferior point. The abscess should, however, have sufficient depth at the level of entry to avoid inadvertent passage of the needle or trocar through to the distal wall or cause damage to adjacent organs. Furthermore, if loops of bowel are adjacent to the tube, this may cause an enteric fistula [1, 10, 13, 14, 25]. Percutaneous drainage is not associated with a 100% success rate. The 65% success rate in this series is lower than that noted in other series [2, 42]. This could be related to the fact that patients in this series may have had compromised
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immune function due to their recent bowel surgery. Patients with well-defined postoperative abscess without diffuse peritonitis are the ideal candidates for percutaneous drainage. However, patients who present with a more fulminant course including septicemia and diffuse peritonitis may benefit from immediate surgical exploration [25]. In a study by Schechter et al. [33], 82% of the abscesses occurring after colorectal surgery were treated successfully with percutaneous drainage, a rate strikingly similar to that noted after repeat drainage in our series (85%). Various factors have been implicated as a cause of failure of percutaneous drainage of postoperative intra-abdominal abscess. However, none of them have been definitively proven. Recently, Benoist et al. [43], in a series of 73 patients treated with CT-guided percutaneous drainage, demonstrated successful drainage in 81% of patients. Multivariate analyses showed that only an abscess with a diameter of
