Paired Drainage Catheter Insertion: Feasibility of Placing Two Catheters within the Same Complex Abscess Cavity as a Primary and Salvage Percutaneous Drainage Technique.

RATIONALE AND OBJECTIVES: To assess the feasibility of paired catheter drainage for management of complex abdominal abscesses. MATERIALS AND METHODS: This was a single-center retrospective study of 54 patients (35 males; mean age 48.9 years) that underwent paired catheter insertion for complex abdominal fluid collections in an 18-month period. Complex collections were defined as abscesses ≥6 cm in diameter with septations, high viscosity fluid or necrotic debris, or abscesses with an associated fistula. Abscess etiologies included postoperative (n = 28), pancreatitis (n = 12), perforated bowel (n = 7), liver abscess (n = 4), and perihepatic from gallbladder perforation (n = 3). Paired catheter insertion was defined two catheters co-located within one collection through the same skin incision or two closely spaced insertion sites. Paired catheter insertion was used primarily as initial drainage for complex intraabdominal abscesses and for salvage drainage in collections that could not be evacuated by a single catheter. Primary paired catheter insertion was used in 45 patients and as salvage in nine patients. RESULTS: Abscess resolution occurred in 51 (94.4%) patients. Patients had a median of three drainage procedures. Median duration of paired catheterization was 22 days. Seven abscesses recurred and all resolved with repeated drainage. Complications included one hemorrhage that was taken for surgical exploration. Overall, 48 patients had good clinical outcome, 3 patients died (multiorgan failure, n = 2; sepsis, n = 1), and 3 patients were lost to follow-up. CONCLUSION: Percutaneous paired catheter drainage is a feasible technique for the treatment of both complex intraabdominal abscesses and abscesses unresponsive to single catheter drainage.

Parasitic leiomyoma presenting as an inguinal hernia in a postmenopausal woman.

Uterine leiomyomas are one of the most common tumors affecting reproductive-age women. Leiomyomas can present as an intrauterine mass or rarely as an extrauterine tumor. Depending on its location, the diagnosis of extrauterine leiomyoma can be challenging, and multiple imaging modalities may be needed for correct identification and differentiation from malignant entities. We report the case of a 48-year-old-postmenopausal female who presented with a painful left inguinal mass, which was clinically diagnosed as inguinal hernia. Ultrasound, computed tomography, magnetic resonance imaging, and percutaneous biopsy were used to characterize the mass. Surgical resection and histopathological analysis revealed the mass to be a parasitic leiomyoma, a very rare cause of inguinal hernia, especially in a postmenopausal woman.

Percutaneous management of enterocutaneous fistulae and abscess-fistula complexes.

Abscess-fistula complexes and enterocutaneous fistulae are due to postoperative, spontaneous, and inflammatory etiologies. Conservative, percutaneous, endoscopic, and surgical treatment options are available options. Interventional radiologists have an array of different treatment strategies, often starting with percutaneous drainage of associated intra-abdominal abscesses. This review article details different percutaneous management strategies, focusing on percutaneous catheter strategies for abscess-fistula complexes along with tract closures strategies for enterocutaneous fistulae.

Abscess-Fistula Complexes: A Systematic Approach for Percutaneous Catheter Management.

PURPOSE: To describe a systematic catheter management approach for treatment of abscesses with enteric fistulae by abscess evacuation and selective fistula tract cannulation in a series of patients with postprocedural abscess-fistula complexes. MATERIALS AND METHODS: This single-center retrospective study included 27 patients (17 male; mean age, 51.3 y) who underwent percutaneous drainage of postprocedural abscess-fistula complexes from January 2005 to September 2013. There were 15 low-output and 12 high-output fistulae. Intra-abdominal abscesses were evacuated by percutaneous drainage. Multiple catheters were used for collections with viscous fluid or size ≥ 6 cm in diameter. High-output fistulae and recurrent low-output fistulae had additional catheter cannulation of the enteric hole to facilitate the creation of a controlled enterocutaneous tract. There was no preexisting cutaneous tract before catheter insertion in 23 fistulae. RESULTS: Abscess-fistula complex resolution occurred in 24 patients (88.9%). Of the 3 cases of failure, 2 patients required surgical repair of the fistula, and 1 patient died. Mean number of drainage procedures was 7.0, and mean catheter duration was 76.1 days. There was no significant difference in catheter duration of low-output and high-output abscess-fistula complexes (P = .34); however, high-output patients underwent significantly more procedures (9.1 vs 6.1, P = .025). There were 15 fistulae that were cannulated (11 high-output and 4 low-output fistulae). Cannulated abscess-fistula complexes had significantly longer catheter duration (102.5 d vs 53.2 d, P = .04) and underwent significantly more procedures (8.4 vs 5.4, P = .04). CONCLUSIONS: The catheter management strategy was successful in resolving most abscess-fistula complexes in this series.

Torsed hepaticoileostomy-an unusual complication of Bile Duct injury repair.

We present a 42-year-old male with strictured bilioenteric anastomosis after bile duct injury repair. The patient improved after percutaneous biliary drainage and balloon dilation of the stricture. Persistent bile reflux around the catheter insertion site prompted a cholangiogram that suggested an error in the enteric limb. Surgical exploration revealed that a torsed ileal loop was used for bilioenteric anastomosis. This error was repaired surgically. The patient had immediate and long-term resolution of symptoms.

Severe gastric variceal bleeding successfully treated by emergency splenic artery embolization.

Bleeding from gastric varices due to splenic vein obstruction is extremely rare in children, but it can be catastrophic. Reported herein is the case of a teenager with splenic vein thrombosis and chronic decompensated liver disease from autoimmune hepatitis who presented with massive gastric variceal bleeding. Standard medical management did not control the bleeding. Due to decompensated liver disease and continuous active bleeding, emergency partial splenic artery embolization was preferred over splenectomy or a shunt procedure. Bleeding was successfully controlled by partial splenic artery embolization by decreasing the inflow of blood into the portal system. It is concluded that emergency partial splenic artery embolization is a safer alternative life-saving procedure to manage severe gastric variceal bleeding due to splenic vein obstruction in a patient with high surgical risk. To our knowledge, only one other patient with similar management has been reported in the pediatric age group.

Biliary spills and collections: causes, diagnosis, and multidisciplinary management.

PURPOSE: To evaluate the role of image-guided percutaneous interventions in patients with bile leaks and bile collections managed by a multidisciplinary team. MATERIAL & METHODS: Selection criteria included those patients from February 1999 to August 2007 who had bile leaks and bile collections in whom an image-guided procedure was performed. Ultrasound (US), computed tomography (CT), and nuclear medicine studies were used for diagnostic imaging. Patients were evaluated and managed in a multidisciplinary fashion by gastroenterologists, surgeons, and interventionists. Parameters measured in the study were drainage indications, cause and location of the biliary injury, location and size of bile collections, volume of fluid drained, fluid microbiology results, duration of catheterization, and patient outcome. Patients were followed up by the interventionist on daily rounds while inpatients and at the interventional clinic as outpatients. RESULTS: There were 31 patients who underwent image-guided percutaneous interventions as part of the management of bile leaks and bile collections. Causes of biliary injuries were surgical procedures, 18 patients (laparoscopic cholecystectomy, 11 patients; hepatectomy, 7 patients); abdominal trauma, 8 patients; percutaneous biliary procedures, 3 patients; liver abscess, 1 patient; gallbladder rupture, 1 patient. Bile collections were localized in 23 patients and diffuse in 8 patients. Localized collections were extrahepatic in 17 patients and intrahepatic in 6 patients. The size of the bile collections ranged from 4 to 12 cm (mean, 8 cm) in maximum diameter. The volume of fluid drained ranged from 25 mL to 4300 mL (mean, 915 mL). Microbiology studies showed sterile bile in 24 patients and bacterial infections in 7 patients. Duration of catheterization ranged from 3 days to 202 days (mean, 36 days). Of the 31 patients, 28 (90%) were cured from their condition and 3 (10%) patients died. Image-guided percutaneous interventions were able to resolve bile leaks and bile collections in 24 (86%) patients while 4 (14%) required additional procedures (endoscopic, 3 patients; surgery, 1 patient). CONCLUSION: Under multidisciplinary management, image-guided interventions are effective for resolution of most bile spills and collections. Additional endoscopic and surgical procedures are necessary when the percutaneous approach fails.

Management of postoperative chylothorax utilizing percutaneous CT-guided drainage.

This case presentation describes a patient who developed postoperative chylothorax after transhiatal esophagectomy for achalasia that was successfully managed by percutaneous drainage. A review of chylothorax causes and treatment options are presented. The effectiveness of percutaneous drainage for treatment of chylothorax is discussed. This minimally invasive method is a valuable alternative to open surgical or thoracoscopic drainage.