What is the role of percutaneous abscess drainage in the treatment of abdominal abscess?

Updated: Mar 27, 2020
  • Author: Alan A Saber, MD, MS, FACS, FASMBS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Drainage of pus is mandatory and is the first line of defense against progressive sepsis. Percutaneous computed tomography (CT)-guided catheter drainage has become the standard treatment of most intra-abdominal abscesses (see the image below). It avoids anesthesia and possibly difficult laparotomy, prevents the possibility of wound complications from open surgery, and may reduce the length of hospitalization. It also obviates the possibility of contaminating other areas within the peritoneal cavity. Percutaneous drainage, when feasible, is typically preferred to open drainage. [10]

Percutaneous computed tomography (CT) scan–guided Percutaneous computed tomography (CT) scan–guided drainage of postoperative subhepatic collection.

CT-guided drainage delineates the abscess cavity and may provide safe access for percutaneous drainage. When performed by experienced physicians, it also prevents the possibility of injury to adjacent viscera or blood vessels. [12, 13]

A diagnostic needle aspiration initially is performed to confirm the presence of pus, which makes Gram staining and culture possible. A large-bore drainage catheter is then placed in the most dependent position.

In patients who are critically ill, initial percutaneous drainage can control sepsis and improve hemodynamics before definitive surgical treatment (if this becomes necessary). Initial catheter drainage also may drain a peridiverticular abscess enough to make a single-stage resection and bowel anastomosis possible, thus avoiding multiple-stage procedures. A visualized collection may be sterile (eg, bile, hematoma) or infected, and CT-guided aspiration is most helpful in distinguishing between these states. [14]

After drainage, clinical improvement should occur within 48-72 hours. Lack of improvement within this time frame mandates repeat CT to check for additional abscesses. Surgical drainage becomes mandatory if residual fluid cannot be evacuated with catheter irrigation, manipulation, or additional drain placement.

Criteria for removal of percutaneous catheters include resolution of sepsis signs, minimal drainage from the catheter, and resolution of the abscess cavity as demonstrated by ultrasonography or CT. Persistent drainage usually reflects the presence of an enteric fistula, and CT with contrast should be performed. Frequently, this fistula can be documented by sinography.

Complications of percutaneous drainage include bleeding or inadvertent puncture of the gastrointestinal (GI) tract.

Percutaneous drainage is effective in 90% of patients who have a single unilocular abscess with no enteral communication. Complex abscesses that include multiple loculations or interloop abscesses or those associated with an enteric fistula may necessitate surgery. Surgical intervention also may be indicated for abscesses with tenacious contents, such as infected hematoma, infected pancreatic necrosis, or fungal abscesses.


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