Published online before print March 28, 2006, 10.1148/radiol.2392050301
(Radiology 2006;239:591-598.)
© RSNA, 2006
Vascular and Interventional Radiology |
Percutaneous Drainage of Postoperative Abdominal Abscess with Limited Accessibility: Preexisting Surgical Drains as Alternative Access Route1
Young Jun Kim, MD2,
Joon Koo Han, MD,
Jeong Min Lee, MD,
Se Hyung Kim, MD,
Kyoung Ho Lee, MD,
Seong Ho Park, MD,
Su Kyung An, MD,
Jae Young Lee, MD and
Byung Ihn Choi, MD
1 From the Department of Diagnostic Radiology and Institute of Radiation Medicine, Seoul National University Hospital, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea. Received February 22, 2005; revision requested April 20; revision received July 8; final version accepted August 2.
Address correspondence to J.K.H. (e-mail: hanjk{at}radcom.snu.ac.kr).
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ABSTRACT
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Purpose: To retrospectively assess the effectiveness and safety of postoperative percutaneous drainage of abdominal abscesses with limited accessibility by using a preexisting surgical drain as an access route.
Materials and Methods: The study was approved by the institutional review board, and informed consent was not required. The authors reviewed the medical records of 92 patients (62 male, 30 female; median age, 59 years; age range, 3–79 years) with postoperative abdominal abscesses in whom percutaneous drainage was performed by using surgical drains as an access. Factors evaluated included the location and size of the lesion; time between surgery and the drainage procedure; distance between the lesion and surgical drain; presence of fistula; duration of drainage; type of surgical drain; size, type, and length of drainage catheter; and complications. Technical success was defined as adequate placement of a new drainage catheter into the target abscess. Midterm success was defined as avoidance of surgery or additional percutaneous drainage during the 6 months of follow-up. Univariate analysis and multiple logistic regression analysis were performed to determine factors that affected the technical or midterm success of the procedure.
Results: Of 92 postoperative abscesses for which the technique was attempted, 56 (61%) had a subphrenic location and 36 (39%) had a peripancreatic location. Technical success was achieved in 87 of the 92 patients (95%). Technical success was not significantly associated with any of the factors tested. Midterm success was achieved in 75 of the 87 patients (86%) in whom technical success was achieved. Midterm failure showed a statistically significant relationship with the presence of fistula (P = .04). No procedure-related complications were identified.
Conclusion: Percutaneous drainage by using the surgical drain as an access route is an effective and safe alternative for draining postoperative abdominal abscesses that are less accessible with direct puncture.
© RSNA, 2006
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INTRODUCTION
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Poor accessibility is a major concern in the management of many abdominal abscesses, and the absence of a safe percutaneous path often precludes the possibility of percutaneous drainage (1,2). Postoperative abdominal abscesses, in particular, may be challenging given anatomic distortions secondary to surgery (1,3). Percutaneous access to some of these lesions may often necessitate invasive transgressions of surrounding organs (eg, stomach, liver, and pleura) rather than straightforward access. In some cases, even with such second-line access routes, abscesses are inaccessible and eventually necessitate open surgical drainage.
Prophylactic intraoperative placement of surgical drains is a widely adopted practice for decreasing the risk of postoperative complications. Sometimes, the drain may not drain properly despite an abdominal abscess and must be promptly removed because it may be a source of ascending infection (4–6). Before its removal, however, the nonfunctioning surgical drain itself or its tract can serve as an access route to the space in which it was placed, usually the surgical bed or the dependent space (eg, Morrison pouch or subphrenic area), where postoperative abdominal abscesses most commonly develop. The use of a preexisting surgical drain as an access route to postoperative abdominal abscesses was described in 1982 by Sacks et al (7). This concept was also adopted by Zajko et al (8). Despite the obvious potential utility of this approach for postoperative abscesses with problematic locations, to our knowledge only one published study since has documented its use—and that was only as a subgroup in the study without an exclusive analysis (9). For the past 5 years, we have used this alternative access technique to drain postoperative intraabdominal abscesses for which a straightforward percutaneous access appeared to be difficult or impossible. Thus, the purpose of our study was to retrospectively assess the effectiveness and safety of postoperative percutaneous drainage of abdominal abscesses with limited accessibility by using a preexisting surgical drain as an access route.
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MATERIALS AND METHODS
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Medical Record Review
Patients.—By query of the hospital database and the interventional radiology division database, three authors (Y.J.K., J.M.L., S.H.K.) together retrospectively identified all patients at our hospital from January 1998 to February 2003 in whom percutaneous drainage of postoperative abdominal abscesses had been performed by using surgical drains as an access route. A total of 92 procedures were performed in 92 patients (62 male and 30 female patients; median age, 59 years; age range, 3–79 years) with abdominal abscesses after various surgical procedures (Table 1). All postoperative abscesses were diagnosed with computed tomography (CT) before percutaneous drainage. Results from 6-month follow-up were available for all patients. Medical records of all patients were reviewed with the permission and approval of our institutional review board; informed consent was not required.
Record review.—Each patient's medical record was reviewed separately by one of three radiologists (Y.J.K., J.M.L., S.H.K.) to determine the location and size of the target abdominal abscess, time between surgery and the drainage procedure, duration of drainage, procedure-related complications, subsequent catheter manipulation, and documentation of a fistula at imaging. The types of exchanged surgical drain and size, type, and length of the radiologic drainage catheter were also recorded. An interventional radiologist with 15 years of experience (J.K.H.), who was blinded to other data obtained for this study, reviewed the CT scans used for diagnosing the postoperative abdominal abscesses and procedure planning to determine the location of the surgical drain with respect to the target abdominal abscess. If the surgical drain was outside of the abdominal abscess, the shortest distance between the drain and the collection was determined.
Drainage Procedure
Our drainage procedure was indicated when (a) direct percutaneous access of a CT-documented localized abdominal abscess appeared to be difficult or impossible, (b) a surgical drain was located within or close to the target abdominal abscess so that access to the lesion through it seemed possible, (c) the surgical drain ceased to function and thus was subject to removal, and (d) there were no other causes of fever and/or leukocytosis other than the abdominal abscess. The accessibility of the lesions was determined by the attending interventional radiologist. An abscess was deemed less accessible when a direct safe access route was not apparent, necessitating transgression of adjacent organs or structures, including the stomach or liver. A deep-seated lesion with proximity to mesenteric or retroperitoneal vessels was also regarded as less accessible. Thus, our study was composed of subphrenic and peripancreatic lesions. The functionality of the surgical drain was determined by the surgeons on the basis of drainage output, which is dependent on various factors such as type of surgical procedure, location of surgical drain, and the patient's diet. In general, drainage of less than 10 mL/d was invariably considered to be indicative of a nonfunctioning drain. Only surgical drains to be removed were subject to this procedure.
Drainage procedures were performed with fluoroscopic guidance by using surgical drains placed at the time of surgery as an access route. Intravenous analgesia was provided with 25–50 mg of meperidine hydrochloride (Demerol; Sanofi Winthrop, New York, NY). This was administered in keeping with institutional guidelines, with continuous monitoring of heart rate, blood pressure, and oxygen saturation every 5 minutes. All procedures were performed by one of three attending interventional radiologists (J.K.H., J.M.L., and K.H.L., with 15, 8, and 5 years of experience, respectively, with interventional procedures at the time of his or her first procedure included in our study). One of six interventional radiology fellows was also involved in each procedure.
Gentle injection of 10–20 mL of ioxitalamate meglumine (Telebrix 30 Meglumine; Guerbet, Aulnay-sous-Bois, France) through the surgical drain was performed to outline the tract to guide subsequent steps in the procedure (Fig 1). A 0.035-inch J-shaped stiff hydrophilic guidewire (Terumo, Tokyo, Japan) was inserted into the surgical drain with fluoroscopic guidance and was advanced until the distal part of the guidewire passed through a distal side hole or an end hole of the drain. Once the guidewire tip was advanced out of the surgical drain, negotiation of a potential communicating tract into the target lesion and looping of the guidewire within the cavity were performed. The surgical drain was removed over the guidewire, and a 5-F curved radiologic catheter (Kumpe; Cook, Bloomington, Ind) was manipulated into the optimal position for abscess drainage. For cases in which the surgical drain hindered negotiation of the potential tract, we removed the drain over the guide before negotiation of the potential tract with the 5-F curved radiologic catheter and the guidewire.
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Figure 1a: Images in a 54-year-old man who underwent right trisegmentectomy (segments VI, VII, and VIII) for hepatocellular carcinoma. (a) Transverse CT scan shows large abdominal abscess (arrows) at resection bed in the right subphrenic space. Note the radiopaque Jackson-Pratt drain (arrowhead) just outside the lesion. (b) Coronal sinogram after contrast material injection through surgical drain (arrowheads). Most contrast material has leaked out the proximal side holes of the drain; thus, only the immature tract and subhepatic peritoneal cavity (arrows) are opacified, which is indicative of occlusion of the distal part of the drain. (c) Coronal fluoroscopic image obtained to help negotiation of a communicating tract into the cavity after insertion of a 0.035-inch guidewire (arrowheads) through the surgical drain. (d) Coronal fluoroscopic image shows guidewire being looped into the cavity. (e) Coronal fluoroscopic image after injection of small amount of contrast material into the abscess cavity after aspiration of fluid and placement of a curved 5-F radiologic catheter into the cavity. A small amount of injected contrast material is seen (arrowheads). The catheter was then replaced with a drainage catheter over the guidewire (not shown).
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Figure 1b: Images in a 54-year-old man who underwent right trisegmentectomy (segments VI, VII, and VIII) for hepatocellular carcinoma. (a) Transverse CT scan shows large abdominal abscess (arrows) at resection bed in the right subphrenic space. Note the radiopaque Jackson-Pratt drain (arrowhead) just outside the lesion. (b) Coronal sinogram after contrast material injection through surgical drain (arrowheads). Most contrast material has leaked out the proximal side holes of the drain; thus, only the immature tract and subhepatic peritoneal cavity (arrows) are opacified, which is indicative of occlusion of the distal part of the drain. (c) Coronal fluoroscopic image obtained to help negotiation of a communicating tract into the cavity after insertion of a 0.035-inch guidewire (arrowheads) through the surgical drain. (d) Coronal fluoroscopic image shows guidewire being looped into the cavity. (e) Coronal fluoroscopic image after injection of small amount of contrast material into the abscess cavity after aspiration of fluid and placement of a curved 5-F radiologic catheter into the cavity. A small amount of injected contrast material is seen (arrowheads). The catheter was then replaced with a drainage catheter over the guidewire (not shown).
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Figure 1c: Images in a 54-year-old man who underwent right trisegmentectomy (segments VI, VII, and VIII) for hepatocellular carcinoma. (a) Transverse CT scan shows large abdominal abscess (arrows) at resection bed in the right subphrenic space. Note the radiopaque Jackson-Pratt drain (arrowhead) just outside the lesion. (b) Coronal sinogram after contrast material injection through surgical drain (arrowheads). Most contrast material has leaked out the proximal side holes of the drain; thus, only the immature tract and subhepatic peritoneal cavity (arrows) are opacified, which is indicative of occlusion of the distal part of the drain. (c) Coronal fluoroscopic image obtained to help negotiation of a communicating tract into the cavity after insertion of a 0.035-inch guidewire (arrowheads) through the surgical drain. (d) Coronal fluoroscopic image shows guidewire being looped into the cavity. (e) Coronal fluoroscopic image after injection of small amount of contrast material into the abscess cavity after aspiration of fluid and placement of a curved 5-F radiologic catheter into the cavity. A small amount of injected contrast material is seen (arrowheads). The catheter was then replaced with a drainage catheter over the guidewire (not shown).
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Figure 1d: Images in a 54-year-old man who underwent right trisegmentectomy (segments VI, VII, and VIII) for hepatocellular carcinoma. (a) Transverse CT scan shows large abdominal abscess (arrows) at resection bed in the right subphrenic space. Note the radiopaque Jackson-Pratt drain (arrowhead) just outside the lesion. (b) Coronal sinogram after contrast material injection through surgical drain (arrowheads). Most contrast material has leaked out the proximal side holes of the drain; thus, only the immature tract and subhepatic peritoneal cavity (arrows) are opacified, which is indicative of occlusion of the distal part of the drain. (c) Coronal fluoroscopic image obtained to help negotiation of a communicating tract into the cavity after insertion of a 0.035-inch guidewire (arrowheads) through the surgical drain. (d) Coronal fluoroscopic image shows guidewire being looped into the cavity. (e) Coronal fluoroscopic image after injection of small amount of contrast material into the abscess cavity after aspiration of fluid and placement of a curved 5-F radiologic catheter into the cavity. A small amount of injected contrast material is seen (arrowheads). The catheter was then replaced with a drainage catheter over the guidewire (not shown).
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Figure 1e: Images in a 54-year-old man who underwent right trisegmentectomy (segments VI, VII, and VIII) for hepatocellular carcinoma. (a) Transverse CT scan shows large abdominal abscess (arrows) at resection bed in the right subphrenic space. Note the radiopaque Jackson-Pratt drain (arrowhead) just outside the lesion. (b) Coronal sinogram after contrast material injection through surgical drain (arrowheads). Most contrast material has leaked out the proximal side holes of the drain; thus, only the immature tract and subhepatic peritoneal cavity (arrows) are opacified, which is indicative of occlusion of the distal part of the drain. (c) Coronal fluoroscopic image obtained to help negotiation of a communicating tract into the cavity after insertion of a 0.035-inch guidewire (arrowheads) through the surgical drain. (d) Coronal fluoroscopic image shows guidewire being looped into the cavity. (e) Coronal fluoroscopic image after injection of small amount of contrast material into the abscess cavity after aspiration of fluid and placement of a curved 5-F radiologic catheter into the cavity. A small amount of injected contrast material is seen (arrowheads). The catheter was then replaced with a drainage catheter over the guidewire (not shown).
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Aspiration of cavity fluid and injection of 5–10 mL of ioxitalamate meglumine into the cavity was performed through the radiologic catheter to help confirm proper placement into the index cavity. The radiologic catheter was then replaced by a drainage catheter over the guidewire. The preexisting surgical drain tracts were large enough that tract dilation was required only for the placement of 18-F or larger drainage catheters.
The choice of catheter size and type was made by the attending radiologist who performed the drainage procedure on the basis of the nature of the aspirated fluid as well as the distance between the target abdominal abscess and the skin exit site of the surgical drain. If the procedure was technically unsuccessful, a percutaneous drainage procedure was immediately performed with a new puncture and either combined ultrasonographic (US) and fluoroscopic guidance or CT guidance.
Catheter Management
Immediately after catheter placement, fluid was aspirated until the flow ceased; after aspiration, the catheter was left in place to enable gravity drainage. Postdrainage imaging with fluoroscopy and/or US was performed to verify satisfactory placement. To maintain patency, the catheters were flushed with 10–30 mL of 0.9% sterile saline solution every 8–12 hours. Catheter manipulation, when necessary, was considered to be part of routine management and not a complication or failure (10). Catheters were removed when (a) drainage stopped or was less than 10 mL/d, (b) substantial clinical improvement was observed, and (c) follow-up CT and/or US, if performed, documented complete or near-complete resolution of the abdominal abscess. If there was continuing substantial drainage output of more than 50 mL/d or persistent drainage of bilious or enteric material, an abscessogram (a radiograph of the abscess after injection of contrast material through a catheter) was obtained to search for a fistula.
Outcome Assessment
Technical success was defined as adequate placement of a new drainage catheter into the target abdominal abscess by exchanging the preexisting surgical drain, with confirmation by means of subsequent aspiration of cavity fluid. Thus, technical success was determined by using both fluoroscopy and adequacy of drainage obtained during the procedure. Midterm success of this procedure was ascribed to patients who did not require postoperative complication–related surgery or additional percutaneous drainage with imaging-guided puncture of the target lesion during 6-month follow-up after initial technical success. Mortality related to postoperative complications was regarded as midterm failure. A recurrent abdominal abscess, which developed in the same location as that of a previously drained lesion, was considered a midterm failure. A new abdominal abscess, which occurred in a different location from that of the previously drained lesion, was not deemed a midterm failure but was evaluated separately. The overall success of percutaneous drainage, to be distinguished from midterm success, was merely defined as the nonnecessity of postoperative complication–related surgery within 6 months of follow-up. Therefore, a patient in whom a recurrent or new abdominal abscess was successfully treated with percutaneous drainage was included in this overall success group.
Statistical Analysis
Univariate analysis was performed with the Mann-Whitney U test for continuous variables, and the Fisher exact test was used for categorical variables. Variables with P values not greater than .25 at univariate analysis were chosen for multiple logistic regression analysis. Odds ratios and 95% confidence intervals were calculated along with P values in multivariate analysis. In both univariate and multiple logistic regression analysis, a P value of .05 was considered to be indicative of a statistically significant difference. Statistical analysis was performed with commercially available software (SPSS 10.0 for Windows; SPSS, Chicago, Ill). All reported P values are two tailed.
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RESULTS
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Technical Success and Complications
Abdominal abscesses ranged from 2.5 to 13.5 cm in maximal transverse diameter, and the initial volume of the aspirate ranged from 5 to 1000 mL. Technical success was achieved in 87 (95%) of the 92 procedures in the 92 patients (Fig 2). Pigtail drainage catheters (Cook, Bloomington, Ind) ranging from 10 to 14 F in size and from 25 to 40 cm in length or straight drainage catheters (Cook; Kumitomo Bakelite, Tokyo, Japan) ranging from 12 to 20 F in size and from 33 to 50 cm in length were used for the procedures. Sixty-four (74%) of the 87 catheters were 14–20 F. Seventy catheters (80%) were straight catheters and 17 (20%) were pigtail catheters. In addition to these procedures involving surgical drains, 11 percutaneous drainages with direct puncture of other separate abdominal abscesses were performed simultaneously in 10 patients; these abscesses were easily accessible.
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Figure 2a: Images in a 61-year-old woman who underwent distal pancreatectomy for pancreatic cancer. (a) Transverse CT scan shows abscess (arrow) at site of distal pancreatectomy. Note the tip of the surgical drain (arrowhead) is located within the target abscess. (b) Coronal fluoroscopic image obtained during exchange of surgical drain shows distal end of the 5-F catheter successfully placed into the target abscess cavity (arrow).
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Figure 2b: Images in a 61-year-old woman who underwent distal pancreatectomy for pancreatic cancer. (a) Transverse CT scan shows abscess (arrow) at site of distal pancreatectomy. Note the tip of the surgical drain (arrowhead) is located within the target abscess. (b) Coronal fluoroscopic image obtained during exchange of surgical drain shows distal end of the 5-F catheter successfully placed into the target abscess cavity (arrow).
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Catheter manipulation (repositioning, up- or downsizing, or replacement with a same-sized catheter) was necessary in 20 abdominal abscesses. Six catheters were considered to be in a suboptimal location. Two catheters had retracted out of the abdominal abscess. Two catheters were changed to larger-caliber catheters. Ten catheters were changed to smaller ones in preparation for gradual withdrawal of the drainage catheter in the setting of fistulas per the surgeons' request after achieving near-complete resolution of the cavity; these were not related to malposition or malfunction of the drainage catheters.
The technical success rate was not significantly associated with any of the following variables: patient age (P = .88), patient sex (P > .99), size of the abdominal abscess (P = .81), time between surgery and drainage procedure (P = .40), location of the postoperative abscess (P > .99), position of the surgical drain with respect to the abdominal abscess (P = .63), and type of surgical drain (P > .99) (Table 2).
The surgical drains were outside of the abscesses in 27 patients. The abscess was still accessible through the drains in 25 (93%) of these patients, whereas an actual communication between the abscess and the drain location could not be established in two (7%). In the 25 patients in whom drainage was considered to be technically successful, the shortest distances between the surgical drain and the target cavity were as follows: less than 5 mm (n = 12), 5–10 mm (n = 4), 10–15 mm (n = 4), 15–20 mm (n = 3), and 20–25 mm (n = 2). In the two patients in whom drainage was considered to be a technical failure, the distance between the surgical drain and target cavity was 5–10 mm.
Five procedures in five patients were considered to be technical failures. In two patients, there was no actual communication between the surgical drain tract and the target abdominal abscess found during the procedure, as described earlier. In the other three patients, surgical drain tracts were lost during the procedure. Immediately after confirmation of technical failure, percutaneous drainage with a direct puncture was successfully performed in all five patients. Transgression of adjacent organs was required in all five patients by means of transpleural (n = 3), transhepatic (n = 1), and transgastric (n = 1) routes.
No procedure-related complications (eg, anastomosis site injury, hemorrhage, or organ injury) were identified during the procedure or the 6-month follow-up period.
Midterm Results
Of the 87 patients in whom technical success was achieved, midterm success was achieved in 75 (86%). Of the 12 patients in whom there was midterm failure, five underwent subsequent percutaneous drainage with imaging-guided direct puncture for the target abdominal abscess because of recurrence (n = 2) or incomplete drainage (n = 3). These patients were successfully treated with percutaneous drainage alone. The time to recurrence in the two patients with recurrence was 12 and 20 days. Two patients underwent surgery for colorectal fistulas. Five patients eventually died of postoperative sepsis during the 6-month follow-up.
At univariate analysis, the midterm success rate was significantly lower in patients with fistula than in those without fistula (22 [73%] of 30 patients with fistula vs 53 [93%] of 57 patients without fistula; P = .02, Fisher exact test), whereas the midterm success rate was not significantly associated with patient age (P = .25); sex (P = .74); lesion size (P = .10); time between surgery and the drainage procedure (P = .91); location of the abscess (P = .53); or size (P = .08), type (P = .70), and length (P = .77) of radiologic drainage catheter (Table 3). At multivariate analysis including variables of patient age, lesion size, drainage catheter size, and presence or absence of fistula, only the presence or absence of fistula showed a statistically significant relationship with midterm success. When fistula was present, the odds of midterm failure was 4.3 times higher than that when fistula was absent (P = .04). Patients with fistula needed longer drainage periods (median, 30 days; range, 10–93 days) than did patients without fistula (median, 9 days; range, 3–34 days) (P < .01).
During 6 months of follow-up, two new abscesses developed in two patients. One was a liver abscess in a patient whose index abdominal abscess in a subhepatic location had undergone successful percutaneous drainage, and the other was a subhepatic abdominal abscess in a patient whose index lesion in a left subphrenic location had undergone successful percutaneous drainage. Both new lesions underwent successful percutaneous drainage.
Of the five patients with technical failure, four patients were successfully treated with percutaneous drainage without subsequent surgery and one patient underwent surgery for a small bowel fistula. Therefore, 84 (91%) of our 92 patients were treated successfully with percutaneous drainage accessed by means of a surgical drain and/or a new puncture (Fig 3).
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Figure 3: Chart shows overall distribution of results in 92 patients with postoperative abdominal abscesses. * = abscess successfully treated with additional percutaneous drainage by using direct puncture during 6-month follow-up period.
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DISCUSSION
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The use of a preexisting surgical drain as an access route to postoperative abdominal abscesses was reported by Sacks et al (7), who performed postoperative abscess drainage through a sinus track or an indwelling surgical drain in 16 patients and reported that 14 of those patients could avoid subsequent surgery. Zajko et al (8) also described exchanging and repositioning surgical drains with a coaxial approach in four patients. In a study by Aassar et al (9), 15 of 19 patients underwent percutaneous treatment by means of the preexisting surgical drain alone (seven patients) or in combination with a new puncture (eight patients) for postoperative abscesses following pancreaticoduodenectomy. They reported an overall success rate of 89% but did not provide separate results exclusively regarding the exchange of surgical drains. To our knowledge, our study of 92 patients is the most substantial with regard to sample size and diversity of surgical procedures.
The technical success rate of 95% in our study was acceptable, although it is not possible to compare our results with those from the studies mentioned earlier in which precise data indicating technical results were not provided. In our study, five technical failures were attributed to two causes—loss of tract during the procedure and no actual communication between the surgical drain and the abscess. In our drainage procedure, we typically used a stiff guidewire because the surgical drain tract, which is shrouded by the surrounding omentum, is usually long and tortuous and sometimes not fully matured, which makes it difficult to secure such a tract otherwise. Nonetheless, we lost the tract in three (3%) of the 92 patients, and these patients account for more than half of the five technical failures. However, because the procedure was applied only to nonfunctioning surgical drains that were intended to be removed, with agreement of the referring surgeons, such tract loss did not impose any change in the postoperative treatment of the patients.
When the surgical drain is outside of the abscess, an effort to opacify the entire tract and the possible communication between the tract and cavity may be useful before attempting the procedure. In real practice, however, this is often not possible. As with radiologic catheters, the most common cause of surgical drain malfunction is luminal occlusion (4,5). One cannot easily demonstrate the communication between the tract and the target cavity by injecting contrast material through a Jackson-Pratt drain (which was the drain used most often in our study) occluded distally with numerous proximal side holes. In patients with a Penrose drain (which lacks side holes and is larger in caliber than the Jackson-Pratt drain and, thus, is less likely to be occluded), the tract was often so large that it was not easy to achieve satisfactory opacification, a precondition for the successful demonstration of a fistulous communication between the tract and the target cavity unless such communication opens extremely wide.
Although the forceful injection of a large amount of contrast material into the surgical drains may have demonstrated the communications in more cases, it also may promote potential ascending infections as with other interventional drainage procedures. In addition, the surgical drains themselves would barricade the fistulous communication. During our initial experience, we inserted a 5-F catheter into the surgical drain and attempted to demonstrate a communication by injecting contrast material through the inserted catheter. In many cases, however, such effort could not easily overcome the limitations mentioned previously. Therefore, our purpose of injecting contrast material through the surgical drain was simply to outline the tract for guidance of subsequent steps in the procedure rather than to delineate a communication between the tract and the target cavity for the purpose of predicting technical feasibility.
In our study, the distance between the drain and the abscess was up to 2.5 cm. Although we could not accurately predict accessibility before exploration with a guidewire when the surgical drain was out of the abscess cavity, we successfully negotiated the communication between the surgical drain tract and the target abscess in 25 (93%) of 27 such cases. This technical success rate was not significantly different from that obtained when the surgical drain was located within the lesion (95%, 62 of 65 cases). Therefore, we believe that it is feasible to attempt this procedure if the surgical drain is positioned less than about 2.5 cm outside of the target abdominal abscess.
The stab incision for surgical drain exit is almost always at the side of the lower subcostal abdomen or lower flank (6). If the target abscess is located far from the exit site, a longer drainage catheter is required. Therefore, the selection of a drainage catheter was based on not only the nature of the aspirated fluid but the distance between the target abscess and the skin exit site of the surgical drain. The latter peculiar consideration, which does not apply to percutaneous drainage with a new puncture, led us to prefer straight catheters, which are typically longer than pigtail catheters, unless the target lesion was close to the stab incision. Of the 87 drainage catheters used, 70 (80%) were straight. The catheter type or length was not significantly predictive of midterm outcome. Likewise, abscesses in subphrenic locations, which were farthest away from skin exit site of the surgical drain, were not associated with lower technical or midterm success rates than those in peripancreatic locations.
The midterm success rate of 86% achieved in our study seems lower than those for percutaneous abscess drainage reported by many investigators (11–14). When postoperative abscesses are specially considered, however, our success rate compares quite favorably with those reported by others, ranging from 40% to 81% (3,15–17). This comparison is especially notable because our study included only postoperative patients with indwelling surgical drains, which would tend to be selected for more complicated cases. Furthermore, we used a more stringent definition of midterm success to include only patients who did not require either surgery or additional percutaneous drainage. Therefore, our 91% success rate of percutaneous drainage, accessed by surgical drain and/or new puncture, is more relevant for fair comparison with those of other reports.
The documentation of fistula involving the abdominal abscess was a significant predictor of midterm failure consistent with other previous reports on percutaneous abscess (16,18–21). In our study, one-third of the patients with midterm failure did not have a fistula. However, small undetectable fistulas might have contributed to failure in such patients because only fistulas that are persistent or large enough would have been documented with imaging (21). No major complications were encountered in our series, which validates this procedure as safe. However, we were unable to determine the exact procedure times from this retrospective study.
In conclusion, a preexisting surgical drain may provide an effective and safe alternative access route for percutaneous drainage of less-accessible postoperative abdominal abscesses.
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ADVANCE IN KNOWLEDGE
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- A preexisting surgical drain tract is effective and safe as an access route for postoperative abdominal abscesses.
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ACKNOWLEDGMENTS
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We thank Nam C. Yu, MD, Department of Radiology, University of California, Los Angeles, for the linguistic revision and helpful discussions.
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FOOTNOTES
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2 Current address: Department of Radiology, Konkuk University Hospital, Seoul, Korea. 
Author contributions: Guarantors of integrity of entire study, Y.J.K., J.K.H.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, Y.J.K.; clinical studies, Y.J.K., J.K.H., J.M.L., S.H.K., S.K.A.; statistical analysis, S.H.P.; and manuscript editing, Y.J.K., J.K.H., J.M.L., B.I.C.
Authors stated no financial relationship to disclose.
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ABSTRACT
INTRODUCTION
