Published online before print March 27, 2008, 10.1148/radiol.2472070761
(Radiology 2008;247:567-573.)
© RSNA, 2008
Vascular and Interventional Radiology |
Complex Abdominal and Pelvic Abscesses: Efficacy of Adjunctive Tissue-Type Plasminogen Activator for Drainage1
Michael D. Beland, MD,
Debra A. Gervais, MD,
Diane A. Levis, PA-C,
Peter F. Hahn, MD,
Ronald S. Arellano, MD, and
Peter R. Mueller, MD
1 From the Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA 02114. From the 2006 RSNA Annual Meeting. Received May 1, 2007; revision requested June 28; revision received August 13; final version accepted October 31.
Address correspondence to M.D.B. (e-mail: mdbeland{at}gmail.com).
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ABSTRACT
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Purpose: To retrospectively evaluate the effectiveness and safety of tissue-type plasminogen activator (tPA) for drainage of abdominal and pelvic abscesses refractory to simple catheter drainage.
Materials and Methods: This HIPAA-compliant study was approved by the Institutional Review Board; informed consent was waived. Forty-three patients (17 men, 26 women; mean age, 46 years; age range, 10–89 years) with a total of 46 abscesses underwent percutaneous drainage with 8.5–14-F catheters. Etiology was postoperative in 28 abscesses (60.9%) and varied in 18 (39.1%). Intracavitary tPA was initiated on the basis of viscous contents yielding minimal drainage at initial placement or if follow-up imaging showed a large residual collection despite satisfactory catheter position. A treatment cycle was 4–6 mg of tPA in 0.9% saline administered twice daily for 3 days. Drainage success was defined as evacuation of the abscess without surgery. Safety was evaluated on the basis of complications. Statistical analysis was performed by using the Student t test and Fisher exact test.
Results: Forty-six abscesses were initially drained by 51 catheters. Complete evacuation was achieved in 41 (89.1%) abscesses, whereas five (10.9%) required surgical drainage. Three (60%) of these five had a documented fistula, a higher (P = .02) percentage than in successfully drained abscesses. Three (6.5%) of the 46 abscesses recurred (12–95 days after catheter removal). There were no tPA-linked bleeding complications despite four patients receiving full systemic anticoagulation and 24 receiving prophylactic anticoagulation.
Conclusion: Intracavitary tPA is safe and effective for draining complex fluid collections, with most patients avoiding surgery.
© RSNA, 2008
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INTRODUCTION
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Percutaneous drainage is a well-established treatment option for the management of intraabdominal and pelvic abscesses. The ultimate goal of percutaneous drainage is to offer an effective minimally invasive therapy so that surgical drainage can be avoided. This is frequently obtainable, with initial success rates reported to be 70%–91% for abdominal abscesses (1,2) and up to 96% for pelvic abscesses (3). Multiple factors, including pancreatic origin, infection with yeast, and the presence of an enteric fistula, likely account for unsuccessful drainage (1,4). In 2000, a phase II clinical trial on the use of intracavitary urokinase by Haaga et al (5) demonstrated favorable results for improving percutaneous abscess drainage. However, since this promising study, the Food and Drug Administration has removed urokinase from the market. Because of the continued need for augmenting percutaneous drainage with fibrinolytics, many institutions have been using tissue-type plasminogen activator (tPA). To our knowledge, however, the only literature regarding intracavitary infusion of tPA in the abdomen is a single pediatric case report (6).
Since 1999, we have been using intracavitary tPA instillation in poorly draining abdominal and pelvic abscesses with increasing frequency at our institution. Thus, the purpose of our study was to retrospectively evaluate the effectiveness and safety of tPA for drainage of abdominal and pelvic collections that were refractory to simple catheter drainage.
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MATERIALS AND METHODS
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Patient Cohort and Record Review
Our Health Insurance Portability and Accountability Act–compliant study was approved by the hospital Institutional Review Board, and patient informed consent was waived. The patient cohort was obtained through a search of a departmental interventional procedure database for abscess drainage and intracavitary tPA. Records were then reviewed (M.D.B.) for duration of drainage, presence of concurrent systemic anticoagulation therapy, complications, and outcome.
One thousand seven hundred thirty-seven total percutaneous abdominal and pelvic abscess drainages were performed between October 1999 and February 2006. Intracavitary tPA instillation was employed in a total of 46 (2.6%) abdominal and pelvic abscesses in 43 patients (17 men, 26 women; mean age, 46 years; age range, 10–89 years). Abscess etiology was postoperative in 28 (60.9%) of the 46 abscesses that were treated with tPA (gynecologic surgery [n = 12], bowel surgery [n = 11], cholecystectomy [n = 3], sarcoma resection [n = 1], and pancreatic tumor resection [n = 1]). The etiology of the other 18 (39.1%) abscesses included trauma (n = 7), ruptured appendicitis (n = 3), pancreatitis (n = 3), Crohn disease (n = 1), duodenal perforation from endoscopic retrograde cholangiopancreatography (n = 1), diverticulitis (n = 1), pyelonephritis (n = 1), and a psoas abscess with an unidentified source (n = 1).
Drainage and Catheter Management
A total of 51 catheters were placed in the 43 patients who later received tPA. Residents and fellows placed all drainage catheters while under the supervision of one of 15 staff interventional radiologists (including D.A.G., P.F.H., R.S.A., and P.R.M.). The staff radiologist chose the size of the catheters placed on the basis of the fluid viscosity obtained at initial needle placement and determined the number of catheters needed on the basis of the size and shape of the collections. All abscesses drained by a single catheter were single cavity abscesses (n = 42). Four of the abscesses showed enhancing septations on computed tomographic (CT) images, leading to more than one catheter being placed for initial drainage. Twelve catheters were placed with ultrasonographic (US) guidance, and 39 catheters were placed with CT guidance. The number of catheters placed for initial treatment was one to three catheters. Catheter sizes ranged from 8.5 to 14 F (three 8.5-F, 12 10-F, 26 12-F, and 10 14-F catheters). The most common catheter was a 12-F pigtail catheter (Cook, Bloomington, Ind). Three catheters were placed by using the Seldinger technique over a guidewire, and the remaining 48 were placed by using a trocar technique in tandem with a guiding needle. The mean volume drained at initial catheter placement was 116 mL (range, 2–1200 mL). A fistula communicating to bowel was documented in seven patients by catheter fistulogram performed several days after the initial catheter drainage.
Prior to intracavitary tPA instillation, eight patients underwent subsequent catheter manipulation consisting of either an exchange for a larger catheter or placement of additional catheters into the same abscess cavity. The former was preferred if the catheter was in an ideal central or dependent position for drainage, whereas additional catheters were preferred if the abscess was large and complex in shape to provide multiple sites for drainage. The six following catheter exchanges were made: 8.5 F to 10 F, 8.5 F to 18 F, 10 F to 12 F, 10 F to 14 F, 10 F to 12 F, and 14 F to 18 F. Two patients had additional catheters placed: One patient had an additional 14-F catheter placed, and the other had two additional catheters placed (10 F and 12 F). This created a final distribution as follows: one 8.5-F, 11 10-F, 29 12-F, 11 14-F, and two 18-F catheters.
Catheters were managed by the interventional radiology service in conjunction with the referring service and were flushed with sterile 0.9% saline twice daily to maintain patency. Saline lavage was not routinely performed.
tPA Administration
tPA was instilled on the basis of satisfactory catheter position and either (a) extremely viscous contents yielding little to no drainage on the CT or US images obtained immediately following drainage or (b) a large residual collection at follow-up CT imaging. tPA instillation occurred on the same day as drainage in seven abscesses for reason a; the remaining 39 abscesses had tPA instillation performed subsequently for reason b. Overall, the mean number of days between initial catheter placement and intracavitary infusion of tPA was 6.4 days (range, 0–23 days). The requirement of satisfactory catheter position was to ensure that inadequate drainage was not simply due to a suboptimally positioned catheter. In our experience, a large residual collection usually reflects extremely viscous material, as less viscous material would have drained early after catheter placement. It is in cases where the material is viscous that tPA is most likely to be beneficial.
During our early experience with tPA (1999–2000), six patients were administered a tPA dose ranging from 10 to 50 mg, and the total number of doses given in one tPA cycle ranged from two to six given over 2–3 days. In our early experience, we had empirically chosen higher doses. Based on initial experience and discussions with the pharmacy and other local experts, we chose to standardize the dose to 4 or 6 mg of tPA diluted in 25 mL of 0.9% saline for the remaining 37 patients. For patients with multiple catheters, the tPA solution was divided equally among the catheters. The tPA solution was instilled into the cavity through the catheter, which was then clamped for 30 minutes. The catheter was then returned to gravity drainage without aspiration. Additional intracavitary infusion was considered to be an additional cycle if it occurred within 14 days of completion of the last cycle and was infused into the same abscess cavity as the initial cycle. Repeat cycle duration ranged from 2–3 days.
Effectiveness
Complete drainage success after tPA administration was defined as complete or nearly complete resolution of the abscess at CT follow-up in the presence of clinical improvement, such as reduced fever or leukocytosis, with avoidance of surgery. Drainage failure was defined as persistent clinical signs of infection, with a residual abscess cavity at follow-up CT imaging that necessitated surgical drainage and had a residual drainable collection documented in the surgical report. Partial drainage success was defined as an abscess cavity in which adequate drainage was observed on images but for which surgical intervention was still performed to treat the underlying condition.
Safety
In addition to recording complications, we analyzed risk factors for hemorrhage. We searched for documentation of local or systemic hemorrhage and recorded the presence or absence of concurrent therapeutic anticoagulation (full systemic anticoagulation vs prophylactic anticoagulation). tPA-related bleeding was considered relevant if the fluid draining from the catheter became hemorrhagic after instillation of tPA and the patient concurrently had a hematocrit decrease and/or hypotension.
Statistical Analysis
A Student t test was used to compare differences in the drainage failure group versus the remaining patients to assess differences in initial volume drained, the interval to intracavitary tPA infusion, and duration of drainage. The Fisher exact test was used to compare the presence or absence of fistulas and small (8.5–10-F) versus large (12–18-F) catheter size between the two groups. A P value less than or equal to .05 was considered to indicate a significant difference. Statistical tests were performed by using SAS software (version 9.1; SAS Institute, Cary, NC).
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RESULTS
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Effectiveness
Complete drainage success was achieved in 82.6% (38 of 46) of abscesses, with no need for surgery following intracavitary tPA instillation (Fig 1). Partial drainage success was accomplished in 6.5% (three of 46) of abscesses. These three patients were taken to the operating room for primary reasons other than abscess débridement, and their abscess cavities were found to have been completely drained, with no residual pus. Therefore, 41 (89.1%) of 46 abscess cavities were successfully drained following intracavitary tPA administration.
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Figure 1a: Images in a 66-year-old woman with a right upper quadrant abscess that occurred after cholecystectomy. (a) Transverse contrast-enhanced supine CT image shows abscess (arrow) in the gallbladder fossa. (b) Sagittal US image of the abscess obtained immediately prior to US-guided drainage shows multiple septations (arrow). (c) Transverse contrast-enhanced supine CT image shows residual abscess collection (arrow) identified next to the drainage catheter. (d) Transverse contrast-enhanced supine CT image obtained following intracavitary administration of 4 mg of tPA in 50 mL of 0.9% saline twice daily for 3 days shows no residual collection. The catheter was then removed, and there was no recurrence of the abscess cavity.
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Figure 1b: Images in a 66-year-old woman with a right upper quadrant abscess that occurred after cholecystectomy. (a) Transverse contrast-enhanced supine CT image shows abscess (arrow) in the gallbladder fossa. (b) Sagittal US image of the abscess obtained immediately prior to US-guided drainage shows multiple septations (arrow). (c) Transverse contrast-enhanced supine CT image shows residual abscess collection (arrow) identified next to the drainage catheter. (d) Transverse contrast-enhanced supine CT image obtained following intracavitary administration of 4 mg of tPA in 50 mL of 0.9% saline twice daily for 3 days shows no residual collection. The catheter was then removed, and there was no recurrence of the abscess cavity.
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Figure 1c: Images in a 66-year-old woman with a right upper quadrant abscess that occurred after cholecystectomy. (a) Transverse contrast-enhanced supine CT image shows abscess (arrow) in the gallbladder fossa. (b) Sagittal US image of the abscess obtained immediately prior to US-guided drainage shows multiple septations (arrow). (c) Transverse contrast-enhanced supine CT image shows residual abscess collection (arrow) identified next to the drainage catheter. (d) Transverse contrast-enhanced supine CT image obtained following intracavitary administration of 4 mg of tPA in 50 mL of 0.9% saline twice daily for 3 days shows no residual collection. The catheter was then removed, and there was no recurrence of the abscess cavity.
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Figure 1d: Images in a 66-year-old woman with a right upper quadrant abscess that occurred after cholecystectomy. (a) Transverse contrast-enhanced supine CT image shows abscess (arrow) in the gallbladder fossa. (b) Sagittal US image of the abscess obtained immediately prior to US-guided drainage shows multiple septations (arrow). (c) Transverse contrast-enhanced supine CT image shows residual abscess collection (arrow) identified next to the drainage catheter. (d) Transverse contrast-enhanced supine CT image obtained following intracavitary administration of 4 mg of tPA in 50 mL of 0.9% saline twice daily for 3 days shows no residual collection. The catheter was then removed, and there was no recurrence of the abscess cavity.
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Drainage failure was seen in 10.9% of the abscesses treated with tPA (five of 46). These five patients were taken to the operating room for further treatment, and a pus-containing abscess cavity was identified at surgery (Fig 2). In the five drainage failures, abscess etiology was gastrectomy (n = 2), total abdominal hysterectomy and bilateral salpingo-oophorectomy owing to malignancy (n = 1), infected hematoma following trauma (n = 1), and duodenal perforation after endoscopic retrograde cholangiopancreatography (n = 1). In these patients, the initially placed catheters were 8.5–14 F, and each patient had only a single catheter placed. The mean time from initial drainage to intracavitary tPA infusion was 11.2 days in drainage failures versus 5.8 days in drainage successes (P = .07). There was no significant difference in the mean volume of the initially drained material, which was 115.8 mL for the drainage failures versus 116.6 mL for the drainage successes (P = .94). Three (60%) of the five drainage failure abscesses had a documented fistula. This is significantly different from the drainage successes, where only four (9.8%) of the 41 abscesses had a documented fistula (P = .02).
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Figure 2a: Images in a 59-year-old man who developed left subphrenic abscess after partial gastrectomy. (a) Transverse contrast-enhanced supine CT image shows abscess (arrow) in left subphrenic region and adjacent colon (*). (b) Transverse contrast-enhanced supine CT image obtained 8 days after initial drainage shows residual abscess collection with gas bubbles (arrow) next to the drainage catheter. (c) Coronal reformatted contrast-enhanced CT image obtained after catheter exchange for 18-F multi-sidehole catheter and intracavitary administration of 4 mg of tPA in 50 mL of 0.9% saline twice daily for 3 days. Image shows catheter (arrow) positioned within the cavity and residual collection with gas bubbles (*). Patient continued to demonstrate clinical signs of infection and was taken to the operating room for surgical débridement.
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Figure 2b: Images in a 59-year-old man who developed left subphrenic abscess after partial gastrectomy. (a) Transverse contrast-enhanced supine CT image shows abscess (arrow) in left subphrenic region and adjacent colon (*). (b) Transverse contrast-enhanced supine CT image obtained 8 days after initial drainage shows residual abscess collection with gas bubbles (arrow) next to the drainage catheter. (c) Coronal reformatted contrast-enhanced CT image obtained after catheter exchange for 18-F multi-sidehole catheter and intracavitary administration of 4 mg of tPA in 50 mL of 0.9% saline twice daily for 3 days. Image shows catheter (arrow) positioned within the cavity and residual collection with gas bubbles (*). Patient continued to demonstrate clinical signs of infection and was taken to the operating room for surgical débridement.
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Figure 2c: Images in a 59-year-old man who developed left subphrenic abscess after partial gastrectomy. (a) Transverse contrast-enhanced supine CT image shows abscess (arrow) in left subphrenic region and adjacent colon (*). (b) Transverse contrast-enhanced supine CT image obtained 8 days after initial drainage shows residual abscess collection with gas bubbles (arrow) next to the drainage catheter. (c) Coronal reformatted contrast-enhanced CT image obtained after catheter exchange for 18-F multi-sidehole catheter and intracavitary administration of 4 mg of tPA in 50 mL of 0.9% saline twice daily for 3 days. Image shows catheter (arrow) positioned within the cavity and residual collection with gas bubbles (*). Patient continued to demonstrate clinical signs of infection and was taken to the operating room for surgical débridement.
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To evaluate whether catheter diameter affected drainage success, the distribution of catheter sizes immediately prior to tPA administration was divided into two groups: small catheters (n = 12; one 8.5-F, 11 10-F) and large catheters (n = 42; 29 12-F, 11 14-F, two 18-F). There were 12 successes and zero failures in the small catheter group and 37 successes and five failures in the large catheter group. There was no significant difference (P = .58) between these two groups.
Duration of Catheterization
Overall, the mean number of days between initial catheter placement and catheter removal was 18.1 days (range, 1–61 days). In the drainage failure group, the mean duration of drainage prior to catheter removal was 33.2 days, which was significantly longer than the mean of 16.5 days recorded in the drainage success group (P = .002).
One to three repeat tPA cycles (2–4 total cycles) were performed in seven patients. The mean number of additional cycles was 1.6. After additional cycles, 86% (six of seven) of these abscess cavities were successfully drained. A single patient in the drainage failure group had three additional cycles of intracavitary tPA administered prior to undergoing surgical drainage.
Safety
Twenty-eight (60.9%) of the 46 patients were receiving anticoagulant therapy at the time of tPA instillation. Twenty-four (52.2%) of the 46 were undergoing prophylactic anticoagulation (
5000 U of dalteparin sodium [Fragmin; Eisai, Woodcliff, NJ] subcutaneously twice daily or 5000 U of heparin sodium [Hospira, Lake Forest, Ill] subcutaneously once or twice daily); four (8.7%) of the 46 were undergoing full therapeutic systemic anticoagulation (oral warfarin [Coumadin; Bristol-Meyers Squibb, Princeton, NJ] or intravenous unfractionated heparin [Hospira] per hospital protocol). There were no systemic or intracavitary hemorrhagic complications identified while the catheters remained in place. One patient undergoing prophylactic anticoagulation had arterial bleeding from the catheter site after catheter removal. This patient underwent angiography and embolization of a lacerated left inferior epigastric artery. It was believed to have been the result of injury during catheter insertion, rather than a consequence of thrombolysis that had been completed more than 24 hours earlier.
Abscess Recurrence
Three patients experienced recurrence of their abscess after catheter removal. One patient had a diverticular abscess recurrence 38 days after drain removal that was not redrained. Because of the patient's general debility, comfort measures were administered until the time of death instead of further aggressive therapy. The second patient had a small presacral abscess that was initially redrained 12 days after catheter removal and required two more subsequent drainages prior to eventual resolution but never necessitated surgical intervention. The third patient underwent surgery 95 days after catheter removal to drain a recurrent posttraumatic perihepatic abscess. No attempt at repeat catheter drainage was made.
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DISCUSSION
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Although there is a lack of large-study data, groups (7) have reported improved clinical outcomes in draining thoracic loculated empyemas when intracavitary instillation of a fibrinolytic agent is performed. Prior in vitro analysis has demonstrated that urokinase decreases the viscosity of purulent drainage and increases flow rates for all sizes of catheters (8). There are a few small series in the literature reporting the safety and efficacy of intracavitary urokinase (5,9). However, urokinase has been virtually replaced in the United States with the widely available fibrinolytic tPA. To our knowledge, our series represents the largest reported cohort of percutaneous abdominal and pelvic abscess drainages with tPA to date.
Our results show that 89.1% (41 of 46) of abscess cavities refractory to simple percutaneous drainage were completely drained following the instillation of tPA, thus avoiding surgical abscess drainage in these patients. Sixty percent (three of five) of the patients who underwent surgical drainage had a documented fistula, a number significantly higher (P = .02) than that in the successfully treated group. Interestingly, despite having a significantly longer mean drainage time prior to catheter removal, only one of these drainage-failure patients received additional cycles of tPA. Given our results, these patients may have benefited from additional tPA cycles. Future research in this area may address the potential benefits of additional tPA cycles.
In addition, the successfully drained abscess cavities underwent tPA instillation earlier (5.8 days) than did the drainage failure group (11.2 days). While this trend does not reach statistical significance (P = .07), it raises the possibility that administering intracavitary tPA earlier in the drainage therapy may improve the likelihood of drainage success. Owing to the retrospective nature of our study, we are not able to definitively assess the influence of early versus late initiation of tPA. This provides grounds for further study.
There were no bleeding complications directly attributable to tPA identified in our study. This is despite the fact that 24 (52.2%) of 46 patients were undergoing prophylactic anticoagulation and four (8.7%) of 46 were undergoing full therapeutic systemic anticoagulation. This is consistent with work done by Lahorra et al (9), who monitored the effects of intracavitary urokinase in 31 abscesses and found no associated bleeding complications or changes in systemic coagulation parameters. A single patient in our study did require arterial embolization to treat an arterial injury. The injured vessel was outside of the abscess cavity, was likely transgressed by the catheter during placement, and bled at catheter removal due to loss of a tamponade effect. Proposed theories for why there is no substantial systemic effect include slow release of tPA from the abdominal cavity because of its high molecular weight and its high affinity for fibrin, which keeps it within the abscess cavity. It is also thought that tPA might be inhibited by elevated levels of plasminogen activator inhibitor, which are present in patients with active bacterial infections (6,10).
The major limitation of our study was its retrospective nature. We were unable to control for variables such as catheter diameter or when tPA was administered. The decision to administer intracavitary tPA was based on the experience of the interventional radiologist in conjunction with the patient's clinical status and consultation with the referring service. In the thorax, imaging findings, such as a thick pleural rind, have been suggested as indicators of inadequate simple drainage and as a reason to consider a fibrinolytic (11). However, the same does not appear to be true in the abdomen. Mueller et al (12) described the results of their study of 250 percutaneous abscess drainages and found inconsistent correlation between imaging appearance, aspiration results, and predicting drainability of the abscess contents. The average duration of catheter drainage prior to tPA instillation in our study was 6.4 days. Most would consider this length of time as an acceptable trial of simple percutaneous drainage before changing management. In addition, before tPA instillation, all patients had residual abscess cavities at imaging. tPA was administered as a salvage technique even in cases where the traditional measures of increasing catheter size and/or placing additional catheters had failed. The purpose of this retrospective study was to obtain preliminary evidence of effectiveness in a patient cohort that has failed conventional drainage in which many patients then went on to successful drainage with tPA. An ideal prospective study would limit, eliminate, or otherwise account for the variability described above. Future trials specifically investigating the ideal time to abandon simple catheter drainage and consider intracavitary tPA would be beneficial and may shorten the hospital stay.
The use of intracavitary tPA in abdominal and pelvic abscesses that are refractory to simple catheter drainage is associated with a high effectiveness (89.1% [41 of 46] in our series) and appears safe, with no local bleeding complications encountered. We believe the results suggest that patients who do not respond to a single cycle may benefit from additional cycles and that the presence of a fistula may make successful drainage less likely despite the addition of intracavitary tPA.
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ADVANCES IN KNOWLEDGE
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- Adjunctive intracavitary tissue-type plasminogen activator (tPA) instillation enables complex collections refractory to simple catheter drainage to be evacuated.
- Intracavitary tPA appears safe even when used concurrently with therapeutic or prophylactic doses of systemic anticoagulation.
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IMPLICATION FOR PATIENT CARE
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- Adjunctive intracavitary tPA in percutaneous abscess drainage of refractory collections can be safely utilized to maximize percutaneous efforts and possibly avoid surgical intervention.
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ACKNOWLEDGMENTS
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We acknowledge the help given by Elkan F. Halpern, PhD, in the statistical analyses for this study.
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FOOTNOTES
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Abbreviations: tPA = tissue-type plasminogen activator
Author contributions: Guarantors of integrity of entire study, M.D.B., D.A.G., D.A.L.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, M.D.B., D.A.G., D.A.L.; clinical studies, M.D.B., D.A.G., D.A.L., P.F.H., R.S.A.; statistical analysis, M.D.B., D.A.L.; and manuscript editing, all authors
Authors stated no financial relationship to disclose.
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References
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- Akinci D, Akhan O, Ozmen MN, et al. Percutaneous drainage of 300 intraperitoneal abscesses with long-term follow-up. Cardiovasc Intervent Radiol 2005;28:744–750.[CrossRef][Medline]
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- Haaga JR, Nakamoto D, Stellato T, et al. Intracavitary urokinase for enhancement of percutaneous abscess drainage: phase II trial. AJR Am J Roentgenol 2000;174:1681–1685.[Abstract/Free Full Text]
- Diamond IR, Wales PW, Connolly B, Gerstle T. Tissue plasminogen activator for the treatment of intraabdominal abscesses in a neonate. J Pediatr Surg 2003;38:1234–1236.[CrossRef][Medline]
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- Park JK, Kraus FC, Haaga JR. Fluid flow during percutaneous drainage procedures: an in vitro study of the effects of fluid viscosity, catheter size, and adjunctive urokinase. AJR Am J Roentgenol 1993;160:165–169.[Abstract/Free Full Text]
- Lahorra JM, Haaga JR, Stellato T, Flanigan T, Graham R. Safety of intracavitary urokinase with percutaneous abscess drainage. AJR Am J Roentgenol 1993;160:171–174.[Abstract/Free Full Text]
- van Goor H, de Graaf JS, Kooi K, et al. Effect of recombinant tissue plasminogen activator on intra-abdominal abscess formation in rats with generalized peritonitis. J Am Coll Surg 1994;179:407–411.[Medline]
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ABSTRACT
INTRODUCTION
