Percutaneous Catheter Drainage of Infected Pancreatic and Peripancreatic Fluid Collections David B.
Adams, MD; Tracy S. Harvey, MD; Marion C. Anderson, MD
Operative drainage is the cornerstone of therapy for pancreRecently it has been suggested that successful percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections may serve as definitive therapy. We undertook therapeutic, computed tomography\p=n-\directedpercutaneous drainage in a selected group of 29 patients with infected pancreatic and peripancreatic fluid collections. Twenty-three patients (79%) were successfully treated with percutaneous drainage. Of six patients (21%) representing failures of percutaneous drainage, four died and two recovered after operative drainage. The four patients who died had a mean APACHE (acute physiology and chronic health evaluation) II score of 23 and five of Ranson's prognostic signs. Ranson's signs and APACHE II scores were predictive of success and mortality. We conclude that in selected patients, infected pancreatic and peripancreatic fluid collections can be treated definitively with therapeutic percutaneous catheter drainage. Based on this experience, recommendations regarding patient selection are included. (Arch Surg. 1990;125:1554-1557) \s=b\
atic abscess.
past decade, percutaneous Over drainage (PCD) pancreatic peripancreatic reported,1"5 recently the
successful catheter of infected and fluid collections has been and it has been suggested that PCD of pancreatic abscess may serve as defin¬ itive therapy when walled-off, liquefied collections of pus are present.6 Infected pseudocysts and selected pancreatic ab¬ scesses have been identified as infectious complications of pancreatic inflammatory disease that are suitable for radiologic drainage. Infected pancreatic necrosis is cited as an absolute indication for open operative drainage. A selected group of patients with infected pancreatic and peripancreatic fluid collections treated with PCD form the basis of this Accepted for publication August 24,1990. From the Department of Surgery, Veterans Administration Medical Center
and the Medical University of South Carolina, Charleston. Read before the 14th Annual Surgical Symposium of the Association of Veterans Affairs Surgeons, Charleston, SC, May 7,1990. Reprint requests to Department of Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425 (Dr Adams).
report, which includes guidelines for patient selection. Our
findings indicate that many patients with infected pancreatic and peripancreatic fluid collections can be successfully treated with PCD. Conversely, patients with infected pan¬ creatic necrosis, including multisystem organ failure (MSOF), did not benefit from this technique. PATIENTS AND METHODS
Twenty-nine patients with infected pancreatic and peripancreatic fluid collections were treated with PCD over a 6-year period (1982 to 1988). This group represented 1.8% of patients with a discharge diagnosis of pancreatitis at the three Medical University Hospitals (Medical University of South Carolina Hospital, Charleston; Veter¬ ans Administration Medical Center, Charleston; and Charleston Me¬ morial Hospital). Pancreatic and peripancreatic fluid collections iden¬ tified on computed tomographic (CT) scan measured at least 4 cm in diameter. Dynamic pancreatography was employed during the last 2 years of the study period. Percutaneous catheter drainage was performed in the radiology department under local anesthesia with CT, ultrasound, or fluoroscopic guidance. Needle and guidewire localization preceded placement of a 7-12F pigtail drainage catheter in the collection (Figure). All patients had a history of pancreatitis, elevated amylase levels, and bacterial or fungal organisms identified by Gram's stain and culture in the drainage fluid. Catheter drainage fluid was collected in a closed drainage system. Collections were observed weekly by CT scan or fluoroscopy. Persistent or new collec¬ tions were treated with repeated PCD when needed. Causes of pancreatitis, organisms yielded by cultures, days of catheter drain¬ age, morbidity, mortality, number of Ranson's prognostic signs, and APACHE (acute physiology and chronic health evaluation) II sever¬ ity of disease score at the time of PCD were reviewed and analyzed retrospectively. All patients received parenteral antimicrobials. Suc¬ cess was defined as "complete resolution of the infected collection without operative intervention." Morbidity and mortality were eval¬ uated during the 30-day postdrainage period until eradication of the infected collection or during the period of hospitalization, whichever was longer. Ranson's prognostic signs and APACHE II score indexes were compared with success and mortality variables by means of the Kruskal-Wallis test for nonparametric data. P
Adams, MD; Tracy S. Harvey, MD; Marion C. Anderson, MD
Operative drainage is the cornerstone of therapy for pancreRecently it has been suggested that successful percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections may serve as definitive therapy. We undertook therapeutic, computed tomography\p=n-\directedpercutaneous drainage in a selected group of 29 patients with infected pancreatic and peripancreatic fluid collections. Twenty-three patients (79%) were successfully treated with percutaneous drainage. Of six patients (21%) representing failures of percutaneous drainage, four died and two recovered after operative drainage. The four patients who died had a mean APACHE (acute physiology and chronic health evaluation) II score of 23 and five of Ranson's prognostic signs. Ranson's signs and APACHE II scores were predictive of success and mortality. We conclude that in selected patients, infected pancreatic and peripancreatic fluid collections can be treated definitively with therapeutic percutaneous catheter drainage. Based on this experience, recommendations regarding patient selection are included. (Arch Surg. 1990;125:1554-1557) \s=b\
atic abscess.
past decade, percutaneous Over drainage (PCD) pancreatic peripancreatic reported,1"5 recently the
successful catheter of infected and fluid collections has been and it has been suggested that PCD of pancreatic abscess may serve as defin¬ itive therapy when walled-off, liquefied collections of pus are present.6 Infected pseudocysts and selected pancreatic ab¬ scesses have been identified as infectious complications of pancreatic inflammatory disease that are suitable for radiologic drainage. Infected pancreatic necrosis is cited as an absolute indication for open operative drainage. A selected group of patients with infected pancreatic and peripancreatic fluid collections treated with PCD form the basis of this Accepted for publication August 24,1990. From the Department of Surgery, Veterans Administration Medical Center
and the Medical University of South Carolina, Charleston. Read before the 14th Annual Surgical Symposium of the Association of Veterans Affairs Surgeons, Charleston, SC, May 7,1990. Reprint requests to Department of Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425 (Dr Adams).
report, which includes guidelines for patient selection. Our
findings indicate that many patients with infected pancreatic and peripancreatic fluid collections can be successfully treated with PCD. Conversely, patients with infected pan¬ creatic necrosis, including multisystem organ failure (MSOF), did not benefit from this technique. PATIENTS AND METHODS
Twenty-nine patients with infected pancreatic and peripancreatic fluid collections were treated with PCD over a 6-year period (1982 to 1988). This group represented 1.8% of patients with a discharge diagnosis of pancreatitis at the three Medical University Hospitals (Medical University of South Carolina Hospital, Charleston; Veter¬ ans Administration Medical Center, Charleston; and Charleston Me¬ morial Hospital). Pancreatic and peripancreatic fluid collections iden¬ tified on computed tomographic (CT) scan measured at least 4 cm in diameter. Dynamic pancreatography was employed during the last 2 years of the study period. Percutaneous catheter drainage was performed in the radiology department under local anesthesia with CT, ultrasound, or fluoroscopic guidance. Needle and guidewire localization preceded placement of a 7-12F pigtail drainage catheter in the collection (Figure). All patients had a history of pancreatitis, elevated amylase levels, and bacterial or fungal organisms identified by Gram's stain and culture in the drainage fluid. Catheter drainage fluid was collected in a closed drainage system. Collections were observed weekly by CT scan or fluoroscopy. Persistent or new collec¬ tions were treated with repeated PCD when needed. Causes of pancreatitis, organisms yielded by cultures, days of catheter drain¬ age, morbidity, mortality, number of Ranson's prognostic signs, and APACHE (acute physiology and chronic health evaluation) II sever¬ ity of disease score at the time of PCD were reviewed and analyzed retrospectively. All patients received parenteral antimicrobials. Suc¬ cess was defined as "complete resolution of the infected collection without operative intervention." Morbidity and mortality were eval¬ uated during the 30-day postdrainage period until eradication of the infected collection or during the period of hospitalization, whichever was longer. Ranson's prognostic signs and APACHE II score indexes were compared with success and mortality variables by means of the Kruskal-Wallis test for nonparametric data. P
