Cardiovasc httervent Radiol { 1991 ) 14:106-108
CardioVascular andInterventional
Radiology
9 Springer-Verlag New York Inc. 1991
Percutaneous Drainage of Postappendectomy Abscesses Complicated by Enteric Communication Amir Peer and Simon Strauss Department of Diagnostic Radiology, A,,,saf Harofeh Medical Center, Zeriiin and the Sacktt:r School of Medicine, f e l Aviv University, Tel Aviv. Israel
Abstract. Four patients with postappendectomy ab-
scesses complicated by enteric fistulae were treated by percutaneous drainage. Sinograms. obtained at the time of the initial drainage, demonstrated communication to the cecum in 3 patients and to the small bowel in I patient. Complete cure was attained in 3 patients by percutaneous drainage. In the fourth patient, surgery was performed after 7 days of catheter drainage. Percutaneous drainage of abscesses with enteric communication requries a modified technique, which includes longer-term drainage than for simple noncommunicating abscesses. Key words: Appendiceal a b s c e s s - - P e r c u t a n e o u s drainage--Surgery complication--Enteric fistula-Interventional radiology
One major complication following appendectomy for acute appendicitis is the development of a pelvic abscess. Uncommonly. the abscess cavity communicates with the gastrointestinal tract. Several recent reports have discussed the feasibility of percutaneous treatment of abscesses that have enteric communication [I-4], but none have dealt specifically with postappendectomy cases. We report our experience in the percutaneous drainage of four postappendectomy abscesses with documented enteric communication. Materials and Methods Three female patients and I male. aged 9. 39. 59. and 33 years respectively, developed postappendectomy abscesses. The operAddress reprint request,~" to: Dr. A. Peer. Department of Diagnos-
tic Radiology, Assaf Harofeh Medical Center. Zerifin 70300, Israel
ative lindings ~ele gangrenous appendicitis in 2 patients, and perforated appendix with free pus in the abdomen in the other 2 patients. The clinical tliagno~is of postoperative abscess formation was suspected in 2 cases 5 days after surgery, in I case 2 weeks after, and in a fourlh patient nearly 2 month:, after surgery. All patients pre,,ented with fever m d abdominal tenderness in the appendectomy site. None of the patient,,, had clinical evidence of underlying bowel d i s e a s e The presumptive diagnosis of abscess '.',.as established by computed lomography {CT) (3 cases) and sonographv (all cases). Fluid collections were demonstrated in the right Iov, er quadrant in all eases. Perculaneous abe,tess drainage (PAD) >,'as pel-t'ormed u',ing catheters ranging from 8.3 F pigtail to 16-F sump dram. Access route and site nfentry were determined by both sonography and CT in 2 patients. Contrast injection through the catheter, used to define the extent or'the cavily, established the presence ol"enteric communication in the 4 patients. The patients were given nothing by mouth, nutrition was provided parenteraIly, and antibiotics were given intravenously.
Results
Escherichia coil was cultured in all 4 cases from the purulent material aspirated. Communication with the gastrointestinal tract was demonstrated by catheter sinography in 4 patients: three of the communications were to the cecum (Fig. IA and B) and one to the small intestine (Fig. 2). In 3 patients, complete cure was achieved by percutaneous drainage. The catheters were withdrawn in 3 patients after 12, 14, and 18 days, respectively, following a repeat sinogram. ~vhich showed that the communication had closed, and when no discharge from the catheter was observed for 2 consecutive days. Duration of follow-up in these patients has been 18-24 months, with no evidence of abscess recurrence. In I patient, surgery was performed after 7 days of PAD, and the postsurgical period was complicated by repeated episodes of ileus and wound infection.
A. Peer arid S. Strau:,.s; Pm,tappendeciomy Abscess. Drainage
s
107
i 84
C}
,!~{7:7
Fig. 1. Sinogram with cntheler in abscess (AI. sho,.ving iJ:-,Itila (alrOW) to coiorl 4(7). :'k Single ;d)xces~, cavity, B muhiloCLlluted abscess cavity. Fig. 2. Pigtailcatheter in abscess (Ai ,,vilh fistula (alTO'W)It) -,mall bowel {S).
Discussion
Postoperative complications occur in only 5!;,r of patients if an unpeil'orated appendix is removed intact, but in over 30% with gangrenous or perforated appendicitis. The more frequent complications of a p p e n d e c t o m y inchlde wound infection, abscess lormarion, fecal fistula, pylephlebitis, and intestinal obstruction. Peh'ic. subphrcnic, or intraabdominal abscesses occur in" up to 20~Z9 of patients with gangrenous or perforated appendicitis [5]. Despite earlier reports suggestmg that percutaneous drainage of abscesses associated with enteric fistulae would most likely lail [6-8], recent progress in the drainage techniques and overall patient care has restltted in several reports of successful treatmerit [1-4, 9, 10]. These abscesses, however, take longer to resolve than abscesses without enteric fistulae and the indwelling catheter may have to be left in place for several weeks I10]. In 1 of our patients, surgical drainage was peii'ormed {bllowing only 7 days of percutaneous catheter drainage due to persistent lever and pain. In retrospect, it is possible that PAD was interrupted prematurely and. if continued for longer, could have provided a complete cure. It has been suggested that two drainage catheters be used, one in the abscess cavity itself', the other
at the site of entry of the communicating tract into the cavity [21. However, Papanicolaou et al. [101 found that one catheter was sufficient in most cases, especially when the catheter side holes could be positioned to drain both the abscess and the area of the enteric communication. Fistulae that conlmunicate with the alimentary canal t\)llowing a p p e n d c c t o m ) are usually of the low-output type, producing less than 200 el/day'. They are generally identified by sinography, although sinograms obtained on the day of a drainage proccdLlre may fail to disclose the communication. The fistula may only be demonstrated on a sinogram perfornled ,,several days after the initial drainage, when proteinaceous debris in the cavity of the abscess has been cleared ill. In a study of the ti,~e of PAl) in 21 patients with periappendiceal abscesses, van Sonnenberg el al. 141 mentioned 4 patients \~ith p o s t a p p c n d e c t o m y absces~,es and 4 with communication to the gastrointestinal tract. Catheters were left in place 4-15 days. although the report does not state duration of catheter drainage specifically for the p o s t a p p e n d e c t o m y cases or those with enteric communication. In conclusion, PAl) m;ty be successfully used in patients with p o s t a p p e n d e c t o m y abscesses complicated by enteric fistula. The procedure can obviate a surgical operation for the abscess, and reduce hospital stay and cost. In high-risk patients, PAD may be used as a temporizing procedure, and definitive surgery can be performed at a later date. /-Iowever, it is important to realize that abscesses with enteric communication require longer-term drainage than simple abscesses.
108
A. Peer and S. Ntrau',s: Postappendectomy Abscess Drainage
References 6. I. Kerlan RK. Jeffrey RB Jr. Pogany AC, Ring E.I /1985) Abdominal abscess with Iov,-output fistutv: Successful percutaneous drainage. Radiolog) 155:73-75 2. Lambiase RE, Cronan JJ. Dorfman GS, Paolella LP. Haas R,.k (1989) Postoperative abscesses with enteric communication: Percutaneous treatment. Radiology 171:497-50(I 3. Nunez D. Huber JS. Yrizarry JM. Mendez G, Russell E (1986) Nonsurgical drainage of appendicc'd absce~,ses. A JR 146:597-589 4. van Sonnenberg E. Wittich GR, Casota G. Neff CC, Hoyt DI4. t'olansky AD. Keightley A (19871 Periappendiceal abscesse~: Percutaneous drainage. Radiolog} 163: 23-26 5. Condon RE (1981j Appendicitis. In: Sabistc, n DC Jr tedl:
7 8.
9. Ill.
Davi_'~-Christopher Textbook of Surgery. 12th ed. r o l l . WI~ Saunder:,. Philadelphia. pp 1(148-1('~3 Haaga J R. Wcim, tein AJ (I 981)) CT-guided percutaneous a,,piration and drainage of a,ice'-,s. AJP, 135:1187- 1194 Welch CE ( 19811 Catheter drainage of abdominal absce',se~.,. N Engl J Med 305:694-695 van Sonnenberg E. Ferrucci JT Jr. Mueller PR. Wittenberg J. Simetme JF (19821 Percutaneom, catheter drainage of al-> sces-,e,, and l!uid collections: Technique. results al~d applications. RadioR)gy 142:1-10 Gerzof SG. John,,,on WC (l~.;'Sa) Radiologic aspects of diagnosis and treatment of abdominal absce>ses. Surg Clin N Am 64:53-65 Papanicolaou N. Mueller PF,. Ferrucci JT Jr. Dawson SL,. Johnson RI). Simeone JF. 13arch RJ. Wiltenberg J {1984) ,.~.bscess-fistula a,,,sociation: Radiologic recognition and percutanec)us management. A JR 143:811-815
CardioVascular andInterventional
Radiology
9 Springer-Verlag New York Inc. 1991
Percutaneous Drainage of Postappendectomy Abscesses Complicated by Enteric Communication Amir Peer and Simon Strauss Department of Diagnostic Radiology, A,,,saf Harofeh Medical Center, Zeriiin and the Sacktt:r School of Medicine, f e l Aviv University, Tel Aviv. Israel
Abstract. Four patients with postappendectomy ab-
scesses complicated by enteric fistulae were treated by percutaneous drainage. Sinograms. obtained at the time of the initial drainage, demonstrated communication to the cecum in 3 patients and to the small bowel in I patient. Complete cure was attained in 3 patients by percutaneous drainage. In the fourth patient, surgery was performed after 7 days of catheter drainage. Percutaneous drainage of abscesses with enteric communication requries a modified technique, which includes longer-term drainage than for simple noncommunicating abscesses. Key words: Appendiceal a b s c e s s - - P e r c u t a n e o u s drainage--Surgery complication--Enteric fistula-Interventional radiology
One major complication following appendectomy for acute appendicitis is the development of a pelvic abscess. Uncommonly. the abscess cavity communicates with the gastrointestinal tract. Several recent reports have discussed the feasibility of percutaneous treatment of abscesses that have enteric communication [I-4], but none have dealt specifically with postappendectomy cases. We report our experience in the percutaneous drainage of four postappendectomy abscesses with documented enteric communication. Materials and Methods Three female patients and I male. aged 9. 39. 59. and 33 years respectively, developed postappendectomy abscesses. The operAddress reprint request,~" to: Dr. A. Peer. Department of Diagnos-
tic Radiology, Assaf Harofeh Medical Center. Zerifin 70300, Israel
ative lindings ~ele gangrenous appendicitis in 2 patients, and perforated appendix with free pus in the abdomen in the other 2 patients. The clinical tliagno~is of postoperative abscess formation was suspected in 2 cases 5 days after surgery, in I case 2 weeks after, and in a fourlh patient nearly 2 month:, after surgery. All patients pre,,ented with fever m d abdominal tenderness in the appendectomy site. None of the patient,,, had clinical evidence of underlying bowel d i s e a s e The presumptive diagnosis of abscess '.',.as established by computed lomography {CT) (3 cases) and sonographv (all cases). Fluid collections were demonstrated in the right Iov, er quadrant in all eases. Perculaneous abe,tess drainage (PAD) >,'as pel-t'ormed u',ing catheters ranging from 8.3 F pigtail to 16-F sump dram. Access route and site nfentry were determined by both sonography and CT in 2 patients. Contrast injection through the catheter, used to define the extent or'the cavily, established the presence ol"enteric communication in the 4 patients. The patients were given nothing by mouth, nutrition was provided parenteraIly, and antibiotics were given intravenously.
Results
Escherichia coil was cultured in all 4 cases from the purulent material aspirated. Communication with the gastrointestinal tract was demonstrated by catheter sinography in 4 patients: three of the communications were to the cecum (Fig. IA and B) and one to the small intestine (Fig. 2). In 3 patients, complete cure was achieved by percutaneous drainage. The catheters were withdrawn in 3 patients after 12, 14, and 18 days, respectively, following a repeat sinogram. ~vhich showed that the communication had closed, and when no discharge from the catheter was observed for 2 consecutive days. Duration of follow-up in these patients has been 18-24 months, with no evidence of abscess recurrence. In I patient, surgery was performed after 7 days of PAD, and the postsurgical period was complicated by repeated episodes of ileus and wound infection.
A. Peer arid S. Strau:,.s; Pm,tappendeciomy Abscess. Drainage
s
107
i 84
C}
,!~{7:7
Fig. 1. Sinogram with cntheler in abscess (AI. sho,.ving iJ:-,Itila (alrOW) to coiorl 4(7). :'k Single ;d)xces~, cavity, B muhiloCLlluted abscess cavity. Fig. 2. Pigtailcatheter in abscess (Ai ,,vilh fistula (alTO'W)It) -,mall bowel {S).
Discussion
Postoperative complications occur in only 5!;,r of patients if an unpeil'orated appendix is removed intact, but in over 30% with gangrenous or perforated appendicitis. The more frequent complications of a p p e n d e c t o m y inchlde wound infection, abscess lormarion, fecal fistula, pylephlebitis, and intestinal obstruction. Peh'ic. subphrcnic, or intraabdominal abscesses occur in" up to 20~Z9 of patients with gangrenous or perforated appendicitis [5]. Despite earlier reports suggestmg that percutaneous drainage of abscesses associated with enteric fistulae would most likely lail [6-8], recent progress in the drainage techniques and overall patient care has restltted in several reports of successful treatmerit [1-4, 9, 10]. These abscesses, however, take longer to resolve than abscesses without enteric fistulae and the indwelling catheter may have to be left in place for several weeks I10]. In 1 of our patients, surgical drainage was peii'ormed {bllowing only 7 days of percutaneous catheter drainage due to persistent lever and pain. In retrospect, it is possible that PAD was interrupted prematurely and. if continued for longer, could have provided a complete cure. It has been suggested that two drainage catheters be used, one in the abscess cavity itself', the other
at the site of entry of the communicating tract into the cavity [21. However, Papanicolaou et al. [101 found that one catheter was sufficient in most cases, especially when the catheter side holes could be positioned to drain both the abscess and the area of the enteric communication. Fistulae that conlmunicate with the alimentary canal t\)llowing a p p e n d c c t o m ) are usually of the low-output type, producing less than 200 el/day'. They are generally identified by sinography, although sinograms obtained on the day of a drainage proccdLlre may fail to disclose the communication. The fistula may only be demonstrated on a sinogram perfornled ,,several days after the initial drainage, when proteinaceous debris in the cavity of the abscess has been cleared ill. In a study of the ti,~e of PAl) in 21 patients with periappendiceal abscesses, van Sonnenberg el al. 141 mentioned 4 patients \~ith p o s t a p p c n d e c t o m y absces~,es and 4 with communication to the gastrointestinal tract. Catheters were left in place 4-15 days. although the report does not state duration of catheter drainage specifically for the p o s t a p p e n d e c t o m y cases or those with enteric communication. In conclusion, PAl) m;ty be successfully used in patients with p o s t a p p e n d e c t o m y abscesses complicated by enteric fistula. The procedure can obviate a surgical operation for the abscess, and reduce hospital stay and cost. In high-risk patients, PAD may be used as a temporizing procedure, and definitive surgery can be performed at a later date. /-Iowever, it is important to realize that abscesses with enteric communication require longer-term drainage than simple abscesses.
108
A. Peer and S. Ntrau',s: Postappendectomy Abscess Drainage
References 6. I. Kerlan RK. Jeffrey RB Jr. Pogany AC, Ring E.I /1985) Abdominal abscess with Iov,-output fistutv: Successful percutaneous drainage. Radiolog) 155:73-75 2. Lambiase RE, Cronan JJ. Dorfman GS, Paolella LP. Haas R,.k (1989) Postoperative abscesses with enteric communication: Percutaneous treatment. Radiology 171:497-50(I 3. Nunez D. Huber JS. Yrizarry JM. Mendez G, Russell E (1986) Nonsurgical drainage of appendicc'd absce~,ses. A JR 146:597-589 4. van Sonnenberg E. Wittich GR, Casota G. Neff CC, Hoyt DI4. t'olansky AD. Keightley A (19871 Periappendiceal abscesse~: Percutaneous drainage. Radiolog} 163: 23-26 5. Condon RE (1981j Appendicitis. In: Sabistc, n DC Jr tedl:
7 8.
9. Ill.
Davi_'~-Christopher Textbook of Surgery. 12th ed. r o l l . WI~ Saunder:,. Philadelphia. pp 1(148-1('~3 Haaga J R. Wcim, tein AJ (I 981)) CT-guided percutaneous a,,piration and drainage of a,ice'-,s. AJP, 135:1187- 1194 Welch CE ( 19811 Catheter drainage of abdominal absce',se~.,. N Engl J Med 305:694-695 van Sonnenberg E. Ferrucci JT Jr. Mueller PR. Wittenberg J. Simetme JF (19821 Percutaneom, catheter drainage of al-> sces-,e,, and l!uid collections: Technique. results al~d applications. RadioR)gy 142:1-10 Gerzof SG. John,,,on WC (l~.;'Sa) Radiologic aspects of diagnosis and treatment of abdominal absce>ses. Surg Clin N Am 64:53-65 Papanicolaou N. Mueller PF,. Ferrucci JT Jr. Dawson SL,. Johnson RI). Simeone JF. 13arch RJ. Wiltenberg J {1984) ,.~.bscess-fistula a,,,sociation: Radiologic recognition and percutanec)us management. A JR 143:811-815
