CT-guided special approaches of drainage for intraabdominal and pelvic abscesses: One single center's experience and review of literature

Abstract

Background: To explore the safety and efficacy of several special approaches of drainage for deep inaccessible intraabdominal and pelvic abscesses.

Methods: By searching of our institutional database, the clinical and radiologic information of all patients with special approaches of abscesses drainage was collected, consisting of etiology, diameter of abscess, duration of drainage, major complications, rates of success, failure and death, and pre-procedure, intra-procedure and post-procedure computed tomography scans.

Results: A total of 124 patients are eligible for the criterion in our center between January 2010 and January 2018. The mean diameter of abscess was 5.6 cm (range 3.0-9.8 cm) and mean duration of drainage was 10.3 days (range 4-43 days). Pain was complained in 6 patients (4.8%) and hemorrhage was observed in one patient. Complete resolution of the abscess following drainage was observed in 115 patients (92.7%). A total of 9 patients (7.3%) failed to percutaneous abscess drainage and 3 patients died of catheter-unrelated diseases. Transintestinal afferent loop of drainage was firstly attempted in six patients and complete resolution of abscess was achieved in five patients.

Conclusion: Special approaches, including transgluteal, presacral space, transhepatic, multiplane reconstruction (MPR)-assisted oblique approach and transintestinal afferent loop approach for those deep inaccessible intraabdominal and pelvic abscesses are safe and feasible.

Figure 1

Transgluteal approach. (A) Axial CT scans revealed that 8 × 9 cm abscess (blue arrow) is detected in the excavation rectovesicalis. (B) Axial CT scans (prone position) showed a 17-gage coaxial needle (red arrow) advanced progressively into the abscess cavity (blue arrow) through the piriformis (green arrow). (C) Axial CT scans obtained 2 weeks after the removal of drainage catheter revealed that abscess cavity completely collapsed.

Figure 2

Drawing of female pelvis (midsagittal view) shows the anatomy of the presacral space. A = Urinary bladder, B = Uterus, C = Vagina, D = Anus, E = Rectum, F = Sacrum.

Figure 3

Presacral space approach. (A) CT scans revealed that 5 × 7 cm abscess (light orange arrow) is located between bladder and sacrum (the rectum had been resected). (B) When the patient was in prone position, intraprocedural CT scans demonstrated that the tip of needle (red arrow) advanced into presacral abscess (light orange arrow) during procedure. (C) CT scans obtained 3 days after the procedure revealed that abscess cavity (light orange arrow) obviously shrinked.

Figure 4

Transhepatic third segment approach. (A) Axial CT scans showed an abscess (light orange arrow) with size of 6 × 8 cm was detected in the lesser peritoneal sac. (B) Axial CT scans showed drainage catheter (red arrow) get through the third segment of liver parenchyma into the abscess cavity and abscess cavity completely collapsed ten days after the placement of drainage catheter.

Figure 5

Transhepatic sixth segment approach. (A) Axial CT scans showed that an abscess (light orange arrow) with size of 3 × 4 cm was detected in previous region of pancreatic head and spread to the porta hepatis. (B) Axial CT scans showed drainage catheter (red arrow) get through the sixth segment of liver parenchyma into the abscess cavity and abscess cavity completely collapsed 12 days after the placement of drainage catheter.

Figure 6

MPR-assisted pararenal space approach. (A) Axial CT scans showed an abscess (light orange arrow) with size of 7 × 8 cm was detected on top of pancreatic body and tail and surrounded by spleen and stomach. (B) MPR technique showed that a cross-sectional entrance along interstitial space of spleen and kidney (green arrow) into the abscess cavity (light orange arrow). (C) CT scans obtained 1 week after the procedure showed that drainage catheter (red arrow) advanced along the proposed access route and the abscess cavity collapsed.

Figure 7

(A) Drawing of pancreaticoduodenectomy anatomy (coronal view): a: anastomosis of pancreas and intestine; b: anastomosis of bile duct and intestine; c: afferent intestinal loop; d: anastomosis of stomach and intestine; e: efferent intestinal loop. (B) Drawing of transintestinal afferent loop approach (coronal view): light orange arrow: abscess; green arrow: afferent intestinal loop; red arrow: drainage catheter.

Figure 8

Transintestinal afferent loop approach. (A) Axial CT scans showed that an abscess (light orange arrow) with size of 5 × 6 cm was detected in previous region of pancreatic head and was surrounded by intestinal afferent loop (green arrow). (B) Axial CT scans obtained 3 days after the placement of drainage catheter showed that the tip of catheter (red arrow) was inside abscess cavity. (C) Drainage catheter pyrography obtained 1 week after the procedure confirmed that the drainage catheter (red arrow) got through the jejunum (green arrow) into the abscess cavity (light orange arrow). (D) Axial CT scans 10 days after removal of drainage catheter showed that abscess cavity completely collapsed.