Treatment of Abdominal Abscesses
Comparative Evaluation of Operative Drainage versus Percutaneous
Catheter Drainage Guided by Computed Tomography or Ultrasound
WILLARD C. JOHNSON, M.D., STEPHEN G. GERZOF, M.D., ALAN H. ROBBINS, M.D., DONALD C. NABSETH, M.D.
Computed tomography and, to a lesser extent, ultrasonog-
raphy provide detailed anatomic localization of intra-
abdominal abscesses that permit precise percutaneous place-
ment of catheters large enough to effect drainage. Using routes
similar to surgical approaches, the authors have used this
technique as definitive therapy for intra-abdominal abscesses.
To assess its efficacy, the results in the 27 patients treated
percutaneously over the last five years have been compared
with the results in the 43 patients treated by operative inter-
vention over the past ten years. In the percutaneous group,
complications (4%), inadequate drainage (11%), and duration
of drainage (17 days) were less than in the operative group
(16%, 21% and 29 days respectively). These results indicate
that percutaneous drainage is at least as efficacious as opera-
tive drainage and avoids the risks of a major operative
procedure.
HE CLASSIC TREATMENT of abdominal abscesses has
been operative drainage. However, in recent years,
improvement in ultrasonography (US) and computed
tomography (CT) provides accurate noninvasive recog-
nition of fluid masses in the abdominal cavity, and
facilitates needle aspiration that allows differentia-
tion of abscesses from seromas, hematomas, and
tumors, or even bowel loops.'-3 When needle aspira-
tion, guided by CT or US, yields purulent fluid and
a safe route is available, a logical presumption is to
percutaneously insert a catheter into the abscess
as a means of providing drainage and nonoperative
treatment.2
Since 1976, the authors have routinely used per-
cutaneous drainage in the treatment of abscesses at
this facility. In order to compare the efficacy of this
nonoperative percutaneous drainage technique as op-
posed to the classical operative technique, the authors
Presented at the Annual Meeting of the American Surgical
Association, Chicago, Illinois, April 22-24, 1981.
Reprint requests: Willard C. Johnson, M.D., Department of Sur-
gery, Boston Veterans Administration Medical Center, 150 South
Huntington Avenue, Boston, Massachusetts 02130.
0003-4932/81/1000/0510 $01.05 J. B. Lippincott Company
510
From the Departments of Surgery and Radiology,
Boston Veterans Administration Medical Center and
Tufts University School of Medicine,
Boston, Massachusetts
have retrospectively reviewed all cases of abdominal
abscesses treated both operatively and percutaneously
at the Boston Veterans Administration Medical
Center over the past ten years.
Methods
Abdominal abscesses were defined as either intra-
or extraperitoneal purulent fluid collections which were
located below the diaphragm and above the perineum.
All were confirmed by Gram stain and culture. Pan-
creatic abscesses and infected pseudocysts were not
included in this review, as they will be the subject
of a separate detailed evaluation. Diverticular, peri-
rectal, and abdominal wall abscesses were excluded,
as these patients were not considered candidates for
percutaneous drainage.
Cases of abdominal abscess were identified from
the operative, US and CT log books as well as the
computerized data base of discharge diagnoses. Each
patient was reviewed in terms of the following
parameters: cause of the abscess (spontaneous or
postoperative); size; bacteriologic findings; complica-
tions; inadequate drainage; duration of drainage;
death (septic or nonseptic); and dissemination of in-
fected material.
CT scans and sonograms were obtained with com-
mercially available equipment. Initially, CT scans were
performed with an Ohio Nuclear Delta 50 Scanner
with 2.5 minute scan time (five patients). Since 1978,
an Ohio Nuclear 2010 Scanner with a two-second scan
time has been used. Sonograms were performed with
the Picker 80L Gray-Scale Scanner.
VOl. 194.9 NO. 4 ABDOMINAL ABSCESSES 511

A K.-.4 K

CK141F c
FIG. 1. Angiocatheter technique. (A) Liver abscess-projected entry site (X) and drainage route (dotted line) are planned from the CT scan,
St = stomach, L = liver, P = pancreas. Ao = aorta, K = left kidney. The depth of the aspiration is transposed to aspiration needle as in
Figure IB. (B) A 20 gauge Teflon sleeve needle with a needle stop at the premeasured depth has been inserted over the planned route into the
abscess and a small sample is aspirated for immediate Gram stain. (C) After insertion of a guide wire into the abscess, the Teflon sleeve has
been removed and a dilator has been passed over the guide wire to widen the track. After removal of the dilator, an #8-French multiple side
hole pigtail catheter is inserted into the abscess which is now shown partially evacuated. The catheter is then securely sutured to the skin and
connected to a closed biliary bag drainage system.

Criteria for Percutaneous Drainage
Criteria for percutaneous drainage included: I) a
well-established unilocular fluid collection having
the variable CT and US signs of abscess,'-4 2) a safe
percutaneous access route, 3) joint evaluation by sur-
gical and radiology services, and 4) immediate opera-
tive backup for any complication or failure. Contra-
indications consisted of the absence of any of the
above. These criteria were subsequently expanded to
include some patients in whom percutaneous drain-
age was thought to be preferential to operative drain-
age (i.e., a recent myocardial infarction, poor
anesthetic risk, etc). The procedures were performed
by the department of Radiology.
Route Planning
After diagnostic scanning, drainage routes were
designed so that a straight line from the cutaneous
entry site to the abscess wall would avoid any vital
structures. Route planning included meticulous con-
sideration of the cutaneous entry site, angle and depth.
Generally, drainage routes followed established surgi-
cal approaches to an abscess in that particular loca-
tion. Extraperitoneal routes were preferred to trans-
peritoneal whenever possible. However, the latter
were used when the size or location of the abscess dis-
placed structures to provide a safe percutaneous
access.
Technique for Drainage
Once the abscess has been defined, one of two
techniques for catheter placement is used. These have
been previously described,4 and are summarized in
Figures 1 and 3. Prior to catheter placement, a 20-30
cm, 20 gauge, Teflon sleeve needle is inserted for
diagnostic aspiration. After sterile skin preparation,
under local anesthesia, through a 4 mm skin incision,
the needle is inserted and a small sample (5 cc or less)
is aspirated for immediate Gram stain and culture. If an
abscess is confirmed, insertion of a drainage catheter
proceeds immediately.
Angiocatheter Technique (Fig. I)
This technique was used to drain intraparenchymal
abscesses (Fig. 2), smaller abscesses and those in
close proximity to the bowel. This is a modification
of the Seldinger technique used in angiography. A
guide wire is inserted through the Teflon sleeve, fol-
lowed by a dilator and then a #8-French multiple
side hole pigtail catheter. The coiled pigtail tip mini-
mizes perforation of the far wall of the abscess and
resists accidental dislodgement. The abscess is then
manually evacuated by syringe suction and a repeat
scan is performed to exclude undrained fluid. The
catheter is then placed on closed gravity drainage
(biliary bag collection system).
Trocar Catheter Technique (Fig. 3)
This technique was predominantly used to drain the
larger abscesses where there was a wide safe access
window (Fig. 4). After positive diagnostic aspiration,
the Teflon sleeve of the aspiration needle is removed.
A #16-French Argyle trocar catheter with self-con-
tained trocar and multiple side holes (Sherwood Medi-
cal Industries, St. Louis, MO) traverses the same
route. After the trocar catheter enters the abscess,
the catheter is advanced over the stylet until it engages
the far wall. The abscess is then manually evacuated
 JOHNSON AND OTHERS Ann. Surg. * October 1981
512

FIG. 2. (A, left) CT scan of

the upper abdomen shows
a 6 cm abscess (arrows) in
the left lobe of the liver
(L) as in Figure JA. S
= stomach with orally ad-
ministered contrast, Sp
= spleen. (B, right) Fol-
low-up CT scan nine days
later shows the pigtail tip
of the drainage catheter
coiled within the former
abscess cavity as in Figure
IC. No residual fluid is
noted. S = stomach, Sp
= spleen.

by syringe suction, and managed as in the angio- with saline, chemical solutions, or antibiotics was dis-
catheter technique above. couraged. The catheters were removed when the clini-
cal response, cessation of drainage, and follow-up
Catheter Management scans indicated complete resolution of the abscess.
Because of the tendency to induce bacteremia,
Both catheters were securely sutured in place and sinograms were avoided, except when an enteric fistula
weremanaged like surgically placed drains. Irrigation was suspected.

FIG. 3. Trocar catheter

technique-lesser sac ab-
scess. (A) The safe drain-
age route (dotted line) has
been planned from the CT
scan. The depth of the ab-
scess is transposed to the
aspiration needle by means
of the clamp. P = pan-
creas, Sp = spleen, ST
= stomach, L = liver. (B)
After insertion of the as-
piration needle to the ap-
propriate depth, a small
sample of material is as-
pirated for immediate Gram
B stain. (C) The trocar cathe-
ter is cross-clamped at the
premeasured depth and is
inserted over the planned
route. Note that the cutting
tip of the trocar catheter
does not extend beyond
the near wall of the ab-
scess so as to avoid pene-
tration of the far wall. The
inner stylet is maintained
fixed in position and the
outer catheter is then ad-
vanced gently until it can be
felt to engage the far wall.
(D) After the abscess is
evacuated by syringe suc-
tion, the catheter is sutured
to the skin and placed
D on gravity drainage to a
closed biliary bag drainage
system.
Vol. 194 * No. 4 ABDOMINAL ABSCESSES 513

I_II

FIG. 4. (A) CT scan of the upper abdomen as in Figure 3A shows a 9 cm abscess (arrowheads) displacing the contrast-filled stomach (5)
anteriorly. The splenic flexure of the colon is displaced caudad and therefore is not seen in this CT scan plane. L = liver, P = pancreas, Sp
=spleen. (B) Follow-up CT scan four days following percutaneous drainage shows the tip of the trocar catheter (arrow) in the abscess cavity
with minimal residual fluid. Drainage ceased after nine days and the catheter was removed on the eleventh day. (C) CT scan 1 year later shows
no residual abscess. The splenic flexure of the colon (C) has returned to normal position. S = stomach.

Technique of Operative Drainage
There was no single operative protocol followed.
However, at this medical facility the concensus has
favored a direct operative approach similar to that rec-
ommended by DeCosse,5 as opposed to a generalized
laparotomy. This has increasingly been the case since
preoperative CT assessment frequently would localize
the area of disease and exclude synchronous disease.
Drainage was accomplished with sump catheters and/
or penrose drains. With large abscesses extending to
the abdominal wall, the operative wound was fre-
quently left open.
Results
Seventy patients were identified to be included in this
study, 43 in the operative group and 27 in the per-
cutaneous drainage group. In the percutaneotrs group,
14 abscesses (52%) followed a previous operative
procedure and 13 occurred spontaneously. In the
operative group of the 43 patients with abdominal
abscesses, 26 (60%) were following a previous opera-
tive procedure while 17 occurred spontaneously. The
details of each treatment group are presented in Tables
1 and 2.
The operative group included two patients with
abscesses which did not fit the criteria for percutaneous
drainage. One abscess was intraperitoneal in location
with surrounding bowel and had no safe drainage
route. The other abscess had multiple loculations.
Additionally, three patients had CT/US evaluation
that did not detect an abscess. Because of clinical sus-
picion, each underwent surgical exploration that re-
vealed an abscess. One was a patient with a left upper
quadrant phlegmon (not appreciated on our 22-minute
scanner). The second patient with ascites had a pelvic
abscess that had been assumed by CT to be an exten-
sion of his ascites. The third patient following a pelvic
lymphadenectomy had a CT diagnosis of a lympho-
cele however, at surgery he had a smaller lower
abdominal abscess. It should be stressed that none of
these patients had a diagnostic needle aspiration to
confirm the nonseptic nature of the process.
Successful Treatment
Treatment of an abscess was considered successful
if the abscess resolved quickly, was no longer a septic
focus, did not recur, and the drainage modality was
not contributory to death.
In the percutaneous drainage group, 24/27 (89%)
were scored as successful cases. Of those patients with
postoperative abscesses, 12/14 (86%) had successful
treatment, and in those with spontaneous abscesses
12/13 (92%) were successfully treated.
In the operative drainage group, 30/43 patients (70%)
were scored as successful cases. Of those patients
with spontaneous abscess, 14/17 (82%) were success-
ful, while in those with postoperative abscesses 10/16
(62%) were successfully treated.
Inadequate Drainage
Drainage of an abscess was considered inadequate
if an additional operation and/or percutaneous drain-
age was required to completely resolve the abscess, or
residual abscess was present at postmortem examina-
tion. All patients have been observed for a minimum of
six months to detect any late presentation of inade-
quate drainage.
514 JOHNSON AND OTHERS Ann. Surg. * October 1981

TABLE 1. Suimrnars of Patient Datai in Percutaneous Drainage

Primary
Method
for Route
Volume Catheter Plan In- Septic Non-
Ave Duration Technique Pig- Route Compli- adequate Related Septic
Location Cases Size* (Range) Drainage Trocar tail CT US E,T cations Drainage Death Death

Postop abscesses
subphrenic/ 7 8 660 20 2 5 5 2 5X2 Empyema
subhepatic (4- 14) )60-2200) (12-50)
midabdominal 4 6 437 22 1 3 3 1 1,3 3
intraperitoneal (3-10) (100-1000) 111-44)
peritransplant 2 10 250 17 2 0 1 1 02
(7-13) (12-21)
psoas 1 8 125 6 1 0 1 0 1/0
Spontaneous abscesses
midabdominal 2 6 437 22 0 2 2 0 0/2
intraperitoneal (3- 10) (100-1000) (11-44)
hepatic 4 5 65 15 0 4 2 2 0/4
(3-7.5) (15-125) (11- 19)
splenic 2 5 63 28 0 2 2 0 2/0
(4.6) (50-75)
renal 3 4 87 10 0 3 0 3 3/0
(75-100) (6- 12)

appendiceal 2 380 19 1 1 1 1 2/0

(75-100) (12-26)
Total 27 17 7 20 17 10 14/13 1 3 3 4

*Maximal axial diameter on CT (cm's). Average (range). T = Transpenrtoneal drainage catheter.

E = Extrapenrtoneal drainage catheter.

Three patients in the percutaneous group were con-
sidered inadequately drained. One patient had a large
spontaneous intraperitoneal abscess that had several
loculations, and several catheters were placed for
drainage. The patient died, and though permission for
autopsy examination was not obtained, clinically he
had remained septic and is scored as a failure. Review
of this case indicates that operative intervention,
likewise, may not have been curative. Additionally,
the patient did not fulfill our own criteria for per-
cutaneous drainage because of the multiple loculations,
but was considered to be unable to survive an exten-
sive laparotomy. A second patient developed two sub-
hepatic abscesses following a cholecystectomy and
common duct exploration. Nine days following per-
cutaneous drainage of each abscess, the patient
became febrile (40.2 C) and CT scan demonstrated
residual inflammatory mass in the area of one of the
abscesses. Sinographic examination revealed com-
munication with the common bile duct and antrum,
cause indeterminant. Despite the need for prolonged
catheter drainage and antibiotics, the inflammatory
process still resolved in 30 days after percutaneous
drainage without the need for surgery. One patient had
an operative splenectomy 24 hours following per-
cutaneous drainage when culture results revealed
clostridia. The operative specimen showed a well-
drained cavity without residual sepsis. He was
scored neither as a failure nor as inadequately
drained.
One patient had recurrent abscess formation after
both operative and percutaneous drainage. Initially
the psoas abscess, which was associated with locally
recurrent colonic cancer, was operatively drained. The
abscess recurred and the patient underwent percuta-
neous drainage with resolution of the abscess cavity
on CT. However one month later, a recurrence was
noticed and he had open drainage again. Three months
later, another recurrence was noticed, and repeat
operative drainage was performed, following which,
the patient had chronic purulent drainage for his re-
maining three months.
In the operative group, nine patients (2 1%) had in-
adequate drainage. Four occurred in the 14 patients
with postoperative subphrenic abscesses. Of these
four patients requiring an additional procedure, one
was treated by percutaneous catheter drainage, another
by additional operation, one had three further opera-
tive procedures before he died of sepsis, and the re-
maining patient had residual sepsis demonstrated at
postmortem examination. Inadequate drainage was
encountered in two of the 12 patients with postopera-
Vol. 194 * No. 4 ABDOMINAL ABSCESSES 515
TABLE 2. Summary of Patient Data in Operative Drainage
Duration of In- Septic Non-
Number Volume Drainage adequate Related septic
Abscess Location of Cases (cc) (days) Complications Drainage Death Death
Postop abscesses
subphrenic/ 12 440 42 Gastric fistula (2) 4 5
subhepatic (60-1000) (15-100)
midabdominal 14 212 27 Omental bleeding 2 4 2
intraperitoneal (20-600) (4-56) (1)
Spontaneous abscesses
midabdominal 6 237 31 Wound infection (2) 1 0
intraperitoneal (50-500) (5-52)
hepatic 2 160 14
(20-300)
appendiceal 5 * 13 Wound infection
(5-2 1)
perinephric 2 210 7 Wound infection 1
(40-500) (4-10)
psoas 2 * * 1
Total 43 29 7 9 9 2
* Data not available.

tive intra-abdominal abscesses; each had residual
sepsis found at autopsy examination. Inadequate
drainage occurred in three (18%) of the 17 patients
with spontaneous abscesses that were drained by an
operative procedure.
Enteric Communication
In the precutaneously drained group, five patients
had enteric communication to their abscess. Two of
these were associated with leakage from an operative
choledochostomy, two from a perforated gastric
ulcer, and one from a duodenal stump. Each of these
patients had resolution of the abscess and spontaneous
closure of the fistula without need for operative inter-
vention, though their drainage was somewhat pro-
longed (28 days).
Complications
Complications occurred in one patient (4%) treated
by percutaneous drainage. This was a patient who
developed an empyema following drainage of a left sub-
phrenic abscess. A closed thoracotomy was curative.
This complication occurred early in this study and was
probably related to the catheter traversing the pleural
space before entering the abscess cavity. Angulation
in the cephalocaudal axis with ultrasound guidance
to avoid traversing the diaphragm is now recommended.
Seven complications (16%) occurred in the opera-
tive group. In two patients, the drainage tube caused
gastric wall erosion, which may have contributed to
each of their deaths. Four patients developed wound
infections following operative drainage. One patient
had significant hemorrhage from an erosion in the
omentum caused by the drainage catheter.
Mortality Rate
In the percutaneous group, three ( 11%) septic related
deaths occurred. One occurred in the previously
described patient with an inadequately drained multi-
loculated abscess. The two other deaths were in
patients with pulmonary sepsis and multiple system
failure, which progressed despite adequate drainage
of the abscess. An additional four patients died from
nonseptic nondrainage related causes; variceal hemor-
rhage, CVA, acute myelogenous leukemia and
meningitis.
In the operative group, nine (21%) septic related
deaths occurred. Three of these occurred in patients
with inadequately drained abscesses. Six died from
septic but nonabscess related processes, (i.e., gastric
fistula, suture line dehiscence) and progressive mul-
tiple organ failure (four cases). Two patients died from
nonseptic related causes.
Bacteriology
Comparison of the spectrum of aerobic organisms
cultured show no difference between those patients
drained operatively or percutaneously (Table 3).
Anaerobic organisms were more frequently cultured in
the percutaneous group. However, this difference
516 JOHNSON AND OTHERS Ann. Surg. * October 1981
TABLE 3. Bacteriology drainage, the maximal axial dimension varied from 4
Postoperative Spontaneous to 14 cm, while drainage varied from six to 60 days.
Group Group To investigate the possible correlation of abscess size
Bacteria Op Cath Cath Op to duration of catheter drainage, a plot of the number of
days of drainage versus largest axial dimension meas-
Aerobic ured by CT was made (Fig. 5). A computer-derived
E. Coli 9 5 6 3
Klebsiella 7 1 5 2 line (y = a + bx, a = 4.61, b = 0.05) suggests that the
Staph 6 1 2 1 duration of drainage only weakly correlates to abscess
Proteus 3 2 3 size. Likewise the low correlation coefficient (R
S. fecalis 3 2 2
Aerogenes 2 = 0.372, p = 0.12) suggests that other variables
Pseudomonas 3 2 1 (abscess wall rigidity, etc.) may be more important.
Candida I
Enterobacteria 2
Citrobacterium 2 Discussion
Seratin 1
Fusobacteria 1 Following several years of use and gradual ac-
Anaerobic
Bacteroids 1 2 ceptance of computerized body tomography, this
Clostridia 1 1 modality is now credibly viewed by the clinician,
Staph 1 the radiologist and even regulatory agencies.6-" The
Multiple organisms
X2 4 2 3 1 realization has grown that body CT is inherently
X3 2 1 1 superior in displaying complex heterogenous lesions,
X4 1 such as abscesses. This is particularly true in the pres-
ence of gas, bone interference, distended bowel,
is most likely related to the fact that only within the obesity or postoperative wounds and drains which
past two to three years during which percutaneous severely limit ultrasound. Furthermore, information
drainage has preferentially been performed have anaer- is more easily obtained, reliably reproduced, and
obic techniques been emphasized. Multiple organisms understood by the clinican. Hence, CT has become our
were cultured in 17% of the patients in the operative
method of choice to identify and follow certain specific
drainage group and in 30% of the percutaneous group. problems such as intra-abdominal sepsis, lesions of
However, again this increase may be related to the pancreas;12 retroperitoneal lymphoma and abdom-
improved culturing techniques used in the per- inal aortic aneurysms.'3
cutaneous group. We have previously evaluated the accuracy of CT in
The spectrum of organisms present in spontaneous evaluating patients with a fever of unknown origin
abscesses was similar to that found in abscesses that for the identification of an intra-abdominal cause of
occurred following surgery. Exceptions occurred in fever. 14 In 46 such studies, the accuracy was 93% with a
two patients who had a S. aureus abscess following
sensitivity of 97% and a specificity of 91%. In contrast,
renal transplantation and in 3 patients with renal US was only 68% accurate with a sensitivity of 44% and
abscesses who cultured only E. coli. Fifteen per cent a specificity of 90%.
of the patients who developed spontaneous abscesses In this present review, which excluded diverticular
had multiple organisms. Most patients who had and pancreatic inflammatory processes, only three-
anaerobic organisms cultured, also had associated false-negative diagnoses were made in a five-year
aerobic organisms; the one exception was a patient with period, during which, approximately 200 patients have
a splenic abscess of Clostridium.
been evaluated for suspected abscesses. Aronberg,'5
and Koehler'6 have also presented data that suggest
Duration of Drainage that CT is the preferred diagnostic modality for the
evaluation of intra-abdominal abscesses. Though others
In the percutaneous group, the average period of have been less enthusiastic, their examinations were
drainage was 17 days. In those patients with spon- frequently performed on a "slow scanner" and did not
taneous abscesses it was 14 days, while in those pa- incorporate diagnostic needle aspiration.'7
tients with a postoperative abscess it was 20 days. In Percutaneous nonoperative catheter drainage is a sig-
the operative group, the average length of drainage was nificant departure from universally accepted but here-
29 days. The average was 20 days in the patient with a tofore unchallenged surgical methods of operative
spontaneous abscess and 34 days in patients with a incision and drainage for therapy of abdominal
postoperative abscess. abscesses. Established long before the advent of cross-
In this series of patients treated by percutaneous sectional imaging, these surgical principles remain
Vol. 194 * No. 4 ABDOMINAL ABSCESSES
1'
(1).
E4
FIG. 5. Plot of abscess size
against duration of percu-
taneous abscess drainage.
DURATION OF DRAINA4GE (days)
valid and, in fact, are generally followed in this new
technique. Indeed, most of our percutaneous drain-
age routes closely parallel recommended operative
approaches to abscesses in similar locations. Instead
of removing purulent material at surgery by sponging,
irrigation and suction, it is aspirated via catheter. In-
stead of maintaining drainage with operatively placed
penrose and sump drains, the percutaneously placed
catheters are retained and provide adequate drain-
age. Analysis of our experience suggests some
generalizations about percutaneous drainage pro-
cedures.
1) The majority (90%) of intra-abdominal ab-
scesses are amenable to percutaneous drainage tech-
niques because they are both unilocular and have a
safe percutaneous access route. The percutaneous
accessibility of an abscess is determined by its size
and location. The larger and more superficial the
abscess, the easier the percutaneous drainage.
2) Transperitoneal drainage routes can be used
when CT provides the anatomic detail necessary tor
avoid bowel.
3) The combination of CT for anatomic detail and
ultrasonography for simultaneous triplanar guidance
provides the easiest and safest method for catheter
insertion.
4) A concurrent enteric communication to the ab-
scess does not preclude percutaneous drainage, but
may be a special indication for percutaneous
drainage.
5) Percutaneous abscess drainage has several ad-
vantages over operative drainage. They include: a)
external drainage without risk of contamination or
spillage intra-abdominally or into the operative
517
wound, b) avoidance of surgery, general anesthesia,
and related perioperative complications; c) reduced
duration of drainage, d) probable saving of time and
expense; e) better patient acceptance, f) easier
nursing care, since frequent change of absorbent
bandages is replaced by the closed collection sys-
tem; g) earlier diagnosis and treatment, which may
account for decreased morbidity and mortality
rates, and h) a lower incidence of inadequate drain-
age. These last two factors are, in part, due to the
nature of noninvasive imaging, which defines the full
extent of the abscess prior to drainage, views the
entirety of the abdomen to exclude concommitant
abscesses and other abnormalities, and will demon-
strate undrained sepsis prior to removal of the drain-
age tube.
It should be stressed that whenever percutaneous
drainage is deemed inadequate, surgical drainage may
then be elected at any time. Indeed, percutaneous
abscess drainage may be planned as a temporizing
measure in any patient who is a poor operative risk,
but where some form of decompression or drainage is
desirable.
The issue of irrigation of the percutaneously-placed
drainage catheter is not resolved in this study. Only
rarely was irrigation used. When it was used, it was
because of physician preference. Blockage of the cathe-
ter (pigtail or trocar) was not a problem in this series of
abscesses, though it was in one patient where a pan-
creatic phlegmon was drained. Periodic 5 cc flushes
(once/day initially and then once every three to six
days, when draining is slow) of the catheter may be
appropriate to ascertain catheter patency. If the intent
of irrigation is to hasten resolution of the septic
518 JOHNSON AND OTHERS
process, this benefit needs to be questioned in light
of the observation (in this study) that systemic anti-
biotics and gravity drainage worked very well in most
all cases, and had shorter drainage times than in the
operative group. Likewise, irrigation may be detri-
mental in that it may prevent collapse of the cavity and
possibly contribute to bacteremia.
Clinical evaluation of the group of patients treated
by percutaneous catheter drainage suggested that these
abscesses were resolving faster than conventional
operative drainage. Figure 5 suggests that there is a
poor correlation between size and length of drainage.
We do not have a single explanation for this phenome-
non, but believe several variables may be important.
The early diagnosis by CT may allow early drainage
before a rigid wall has developed. Additionally,
diaphragmatic movement, and surrounding viscera,
exert external pressure upon the abscess cavity, which
results in a more rapid collapse of the cavity and
may partially account for the early resolution. This
suggests that the catheters could possibly be withdrawn
at an earlier time if CT demonstrated no residual
collection.
The results in this study indicated that the operative
group had a significant mortality rate (26%). While this
may seem high, it is quite similar to those reported in
other series.5 18'19 These studies as well as ours, sug-
gest that a major cause of this operative mortality
rate is undrained sepsis at sites undetected by the
initial operative intervention. In the past, this has
prompted the recommendation that all patients should
have a laparotomy at the time of operative drainage
to detect such "hidden" abscesses. Other surgeons
prefer to use an operative approach that will drain the
abscess without risk or contamination of adjacent
areas. The availability of CT helps to resolve this
dilemma, as the accuracy in our experience, of iden-
tification of abscesses in the abdomen is above 90%
(14), suggesting that exploratory laparotomy is no
longer necessary.
The favorable results in the percutaneously drained
patient may partially be explained by the availability
of CT which permitted an earlier diagnosis, earlier
drainage and appropriate antibiotics. Similarly, with
earlier recognition of the abscess, an operatively
treated patient may expect improved results, though
the risks associated with operative intervention,
wound or peritoneal contamination, enterotomy, and
anesthesia would still be present.
The use of percutaneous abscess drainage has been
reported from other centers. Kraulis reported on the
successful drainage of liver abscesses.20 Haaga suc-
cessfully treated 28 of 33 abscesses. He relates his
failures to the extent of the abscesses or the viscosity
Ann. Surg. * October 1981
of the pus.21 Mueller prefers to use a pediatric thoracic
trocar and reported successful results in a small group
of patients.22
It is impossible for us to directly assess the impact
upon the length of hospitalization by this method of
abscess drainage, because many patients were treated
as part of a more complex clinical setting. However,
the duration of drainage was usually 12 days less in the
percutaneous group than in the operative group, and
suggests that the total period of hospitalization should
probably be less. In addition, the avoidance of sur-
gery and anesthesia further contributes to make this a
very cost effective procedure.
We currently recommend an early evaluation with
computed tomography of patients with suspected
abdominal abscess. When an abscess is identified
and safe access for drainage is available, percutaneous
catheter drainage under CT or ultrasound guidance
is recommended as the initial mode of therapy.
Acknowledgments
The authors thank Anne Marie Romano, Anne Shea and Maura
Moore for their assistance in retrieving clinical data on these
cases.
References
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Vol. 194 * No. 4 ABDOMINAL ABSCESSES
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DISCUSSION
DR. CLAUDE E. WELCH (Boston, Massachusetts): These pioneer
efforts by this group have been astonishing in their effects. The
noise has even spread as far as the MGH, and I must say that our
radiologists have become enthusiastic about this particular matter.
I think we can all understand as surgeons our hesitaicy about
accepting it. We all know how many times we have gone into the
abdomen to find multilocular abscesses. We also know that many a
time we have had drains in for days or even weeks, and finally
some great gob of material comes out that my old chief, Dr. Allen,
used to call a codfish, and then the patient would get well. We
wondered how all these things could come out through little bits of
tubes.
Well, as time has gone on, I would like to give you the impres-
sion of our radiologic group, because they have now gotten to-
gether a group of some 45 patients treated this way. These figures
have not yet been published, but I was allowed to use them by our
radiologist, who has been collecting the data.
The cavity was evacuated in 42 of the 45 patients, and operation
was avoided in 42. It becomes very important, since it looks as
though the surgeons, shortly, will be playing a losing game as far
as this is concerned, to identify patients who would require sur-
gical drainage, rather than drainage by the method that you have
seen. I have three slides that I thought might illustrate some of the
factors that might be considered.
(slide) This boy had had nine upper abdominal operations for ulcer
disease, inability to empty his stomach after operation, inability to
empty his gastric remnant after nine operations, inability to empty
his stomach after several other operations. So, eventually, when he
came back to the hospital this time, he had been unable to eat
solid food for two years; he has been unable to get liquids down for
five months, and had been on total parenteral nutrition for that time.
This was, obviously, a challenge.
The operative procedure was performed in a situation that was
like operating in rock, and the operation was difficult. It was fol-
lowed by a fistula that can be seen here in the proximal stomach.
This is a lateral view. The stomach was removed to I cm of the
esophagus, and the jejunum brought up as a Roux-en-Y. This was to
avoid any emptying difficulties because of the stomach. A fistula
developed here.
(slide) On the next slide we have what developed after a short
period of time. Here is the CAT scan, and this is a blow-up of the CAT
scan down here. There are several areas of loculation, and in the
center of this spot is an abscess within the spleen itself.
(slide) On the next slide are shown the various catheters that
were put into these various areas: The subdiaphragmatic abscess
shown here, another catheter that was run into another locule,
and then the one run into the spleen, from which pus was aspirated.
This particular patient illustrated several of the reasons that these
drainages are not going to be successful by the tube. The failures
that have occurred in our hospital have all been in lesions that
have communicated with the gastrointestinal tract or with the kid-
ney. This, therefore, becomes one reason that this patient should
be operated upon.
519
in patients with intra-abdominal abscess. Surgery 1980; 88:
517-523.
19. Altemeier WA, Culberston WR, Fullen WD, Shock CD. Intra-
abdominal abscesses. Am J Surg 1973; 125:70-79.
20. Kraulis JE, Bird BL, Colapinto ND. Percutaneous catheter
drainage of liver abscesses: an alternative to open drain-
age? Br J Surg 1980; 67:400-402.
21. Haaga JR, Weinstein AJ. CT-guided percutaneous aspiration
and drainage of abscesses. Am J Roentgenol 1980; 35:1187-
1194.
22. Mueller BC. Discussion: Determinants of death in patients with
intra-abdominal abscesses Surgery 1980; 83:523.
Also multiple loculations are not so successful for aspiration.
Thick-walled abscesses are not likely to be as successful. Intra-
mesenteric abscesses between loops of intestine likewise pose
some difficulties. A splenic abscess might be considered for this
procedure.
Many of these factors were touched on in Dr. Johnson's manu-
script, but I think that we, as surgeons, need to outline this field
more carefully in our own minds.
This patient, incidentally, after recovering from this procedure
with an open drainage, was discharged eating solid foods and having
no difficulty with emptying of his esophagus into his jejunum. This
has a good deal to do with what Dr. Woodward's group discussed
in the previous paper.
DR. C. BARBER MUELLER (Hamilton, Ontario): This is a matter
of abdominal stereotaxis, and it certainly makes drainage more
precise and more clever. If the drainage of pus is the objective,
you can certainly get it done if you have a window.
Interestingly enough, the positive pressure in the abdominal
cavity assures egress if the tube is at all accommodating for ex-
ample, if the length and the diameter of the tube and the viscosity
of the fluid match each other. It makes it simple and exquisite in
its ease.
I do this in the CAT scan room, and have been doing it for about
22 years. The surgeon is able to find the correct window by scan-
ning the patient up and down until the exact spot is there, a red
line shows, and then with a pen or a paper clip I can make a mark on
the ,skin.
(slide) My tools are on this first slide, and they are not much dif-
ferent than the tools you saw used in Boston. In Canada we are
a little more simple. I have a sheath, a nylon stylette, needles,
various types of lumbar aortic puncture needles, or spinal needles.
The nicest one of all is the long Intracath, which has several
sizes, and is rigid to go in, but it is simple and flexible while in
there. I use several sizes of these Argyle thoracic catheters,
anywhere from the pediatric size up to the adult size.
I have a few slides that exemplify some of the problems.
(slide) This first patient is a boy with a intrahepatic abscess.
You see the size of the abscess, which has been drained by a
percutaneous puncture from his right lateral thoracic wall.
(slide) The next slide shows that Mother Nature occasionally
helps us, and that not only does the contrast material show the
decrease in the size of the abscess, but, actually, the material is
getting into the biliary tree. It outlines the gallbladder, the common
bile duct, and even the duodenum. So I think that all of the drain-
age, at least from the hepatic abscesses, is not solely out that
catheter.
(slide) This shows his fourth abscess of the liver, which we also
drained by percutaneous puncture. This patient is alive and now,
with epilepsy, back in the hospital two years later.
(slide) The next slide shows a woman with cirrhosis with a large
abscess in her liver, and after drainage (slide) this shows the size and