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Drainage 7.7.1

Abscesses

Percutaneous abscess drainage is a relatively straight forward technique with a wide field of indications, the most common being peri-appendiceal abscesses and Crohn's abscesses (Norman 2001; HubbarD and Fellows 1993; Safrit et al. 1987). The aim of the procedure is either to gain time in order to reduce surgery related morbidity and to be able to perform a one-stage operation or to obtain complete cure. The latter has been described in patients with Crohn's disease, making surgery at the time unnecessary (Safrit et al. 1987). The only contraindications for percutaneous drainage are uncorrectable coagulopathy and the inability to approach the collection without transgressing major vessels, bowel loops, solid organs or the pleural cavity (Lang et al. 1986). Studies performed in adult patients show a high success rate of up to 90% and low mortality rates (Lang et al. 1986).

Depending on the location of the abscess the intervention can be performed using ultrasound, sometimes in combination with fluoroscopy or CT guidance. Ultrasound will be used for larger and superficial abscesses whereas CT will be used for smaller and more deeply located collections (Maher et al. 2004). In case of multiple abscesses or loculated abscesses, more than one drain should be placed ensuring complete drainage of all locations. In case of deep pelvic abscesses or a perirec-tal abscess, a transrectal approach can be chosen (Fig. 7.9), performing abdominal ultrasonography to visualize the abscess. Under ultrasound guidance a finger is placed within the rectum up to the level of the abscess. A trocar is guided upwards along this finger and the abscess is punctured. With the trocar in place, a guidewire and subsequently a pigtail can be inserted into the abscess. In children this procedure has been reported to be as effective as a percutaneous or a surgical approach and better tolerated (Pereira et al. 1996).

Although some radiologists will use the trocar technique, which encompasses placing a catheter mounted on a sharp trocar into the abscess, a safer and more elegant way is the use of the Seldinger technique (Norman 2001). The Seldinger technique entails puncturing the skin with a thin (22- to 20-G) or thick (18- to 19-G) needle and placing the tip of the needle within the collection. When a thin needle is used one will need to upgrade to a system capable of accepting a 0.038-in. guidewire. Commercial kits are available for this purpose, one of which is the Neff-set (Cook, Bloomington, IN) (Fig. 7.7). Once the needle is in place, a stiff guidewire is placed within the collection and a catheter is advanced into the collection. Smaller calibre catheters (7-8.5 F)will only be used in liquefied collections, whereas thicker, more viscous collections will require a 12- to 14-F catheter. In general, self-retaining pigtail catheters (Cook, Bloomington, IN) will be used, as they have a lower risk of inadvertent dislocation (Fig. 7.8). We also always secure the drain to the skin, either by using a suture or by the supplied retention device. Decompression of the abscess is generally attained using a syringe attached to the catheter. Some radiologists advocate flushing the abscess cavity with saline. However, care should be taken to use less fluid than was drained, as an increased pressure within the cavity can result in bacteraemia and sepsis (Gervais et al. 2004). Towbin et al. (1991) report the use of contrast medium to identify catheter position and possible connections between the abscess and surrounding structures.

The drain is attached to a bag and left to drain by gravity. Ward nurses are supplied with written instructions from the radiologist responsible for the intervention on how to care for the catheter. The drain is removed once the patient's symptoms have resolved and no drain production is noted. In the case of a complex abscess a control study, CT (or in

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