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Interventional drainage of appendiceal abscesses

in children. AJR Am J Roentgenol
ARTICLE in AMERICAN JOURNAL OF ROENTGENOLOGY JANUARY 1998
Impact Factor: 2.74 DOI: 10.2214/ajr.169.6.9393176 Source: PubMed

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Interventional
Appendiceal
Douglas H. Jamieson1
Peter 6. Chait2
Robert Filler3

OBJECTIVE.

This

study

age and IV antibiotics

MATERIALS
with one or more
center.

The

received
were

aspirations.

Four

gery. One patient

CONCLUSION.

presents

managing

abscesses

4480 Oak St. Vancouver, B. C.V6H 3V4, Canada. Address

correspondence to 0. H. Jamieson.
2Department of Diagnostic Imaging, The Hospital for Sick
Children, 555 University Ave., Toronto, Ontario M5G 1X8,
Canada.

3Department of Pediatric Surgery, The Hospital for Sick

Children, Toronto, Ontario M5G 1X8, Canada.
AJR1997;169:1619-1622

populations
reported

American Roentgen Ray Society

AJR:169, December

1997

has
both

in

and

dominal

real-time

Our study
a 4-year

gery

period.

and

for

sonographic
Management

radiology.

patient

outcome

in our

close

of sur-

divisions
patients

over

were

1 year.

The

study

group

fol-

successful
validates

our management.

terventional

service

1991

sur-

was

drain-

in children.

obtained

46

patients

with

information
by

about

review

of

their

and our intervention

database.
outpatient
notes and corresponto at least

1 year

after

hospi-

All patients

underwent

sonography

as a diagnos-

tic study and as an aid to planning

for

abscess

drainage.

catheter

In

24

place-

patients

IV

abdominal CT was performed to

aid diagnosis
and beuer define the location of abscesses.
Cl was especially
useful when sonographic
access was restricted
and when multiple
collections
were noted or suspected (Figs. lA and lB).
All procedures
were done in the interventionalangiographic
suite that was equipped
with C-arm
fluoroscopy and an XP 128 sonography
unit (Acuson, Mountain
View, CA) with 3.5-, 5-, and 7-MHz
One

remaining
local

patient

received

45 patients

anesthetic.

For

anesthetic;

the

received

an IV sedative

and

patients

weighing

20 kg, we used 3 mg/kg

general

less

of IV pentobarbital

than

sodium

(Nembutal;
Abbott,
Toronto,
Canada)
and I mg/kg
ofIV meperidine
hydrochloride
(Demerol; Abbott).
For patients weighing more than 20 kg, we used 0.1
mg/kg ofIV diazepam (Diazemuls;
Pharmacia
and
Don

Mills.

Canada)

and

1 mg/kg

of IV

meperidine hydrochloride.
Lidocaine hydrochloride
1% (Xylocaine;
Astra Pharma, Mississauga,
Can-

and Methods
March

required

tal discharge.

Upjohn,

Between

1 year.

image-guided

abscesses

records

probes.

treated

required

the
All

up for at least

per-

transab-

guidance.

46 patients

between

lowed

but

with

patients

contrast-enhanced

We used

[91.

diagnosis

procedures

included

collaboration

used

was

CT

and

eral surgical service

treated
appendiceal
abscess. Pertinent

in the

ear-

IV seda-

the insertion
of 34
catheters,
and five

(9 1%) justifies

ment

surgical

using

up for at least

treatment

for appendiceal

medical

referral

of their

spontaneously.

on ap-

[7. 8]. In a third,

in the European

all drainage

Materials

0361-803X/97/1696-1619

radiologist
practice

initial

46 children
care

suite

followed

Charts, including
dence, were reviewed

intraabdominal

[1-6]. Two studies

drainage
reported

sonography

formed

Hospital,

and

adult
study

to their

drain-

drainage

intervention
were

resolved

these

children

largely

sonography

B. Cs Childrens

in

by an interventional

literature,

of Radiology,

that

ap-

American
radiology
literature
relied
on CT-guided
drainage and included

her,

1995,

at a tertiary

interventional

of 42 patients

greatly

North

seen

underwent

management

procedures

of

drainage

adults and children

pendiceal
abscess

1Department

respond

fistula

treatment

abscesses

a well-accepted

become

after revision

not

antibiotics.
Percutaneous

1991 and March

All patients

our experience

drainage

of interventional

in children.

were

in the radiology

intraabdominal

using interventional

Received February 28, 1997; accepted

May28, 1997.

did

a colonic

as appropriate

pendiceal

Iv

abscesses

underwent
64 procedures.
These included
the insertion
of 25 transrectal
drainage

Successful

his report

and

anesthetic.

patients

developed

age and IV antibiotics

in

the outcome

of appendiceal

performed

a general

The 46 patients
drainage
catheters,

to validate

undertaken

IV antibiotics

All procedures

RESULTS.
percutaneous

of
in Children

AND
METHODS.
Between March
intraabdominal
appendiceal
abscesses

tion and, in one patient,

needle

was

for the treatment

children

collections.

Drainage
Abscesses

and

March

in conjunction

1995

the

in-

with the gen-

ada)

to a maximum

anesthesia.

A nurse

of0.5

mi/kg

was

with appropriate

used

for local

training

and

1619

Jamieson

et al.

Fig. 1.-li-year-old
boywith
multiple intraabdominal
abscesses
after surgeryfor
ruptured appendix.
A and B, IV contrast-enhanced
CT scans reveal (A) lobulated rim-enhancing left flank abscess
(asterisk)
and (B)
rim-enhancing abscess (asterisk) in pelvis. Note contiguity between pelvic abscess and left anterior rectal wall.
C, Abdominal radiograph
shows percutaneously
placed drainage catheter in left flank and transrectally
inserted
drainage catheter in optimal position, slightly left of midline.

the

attending

radiologist

and monitored

imetry,

administered

sedation.

blood

the sedative

All patients

pressure,

and

ECG

had

pulse

equal

ox-

monitoring

dur-

ing the sedation.

Deep

pelvic

drained

collections

through

were

transrectal

preferentially
approach

Transabdominal
sonography
through
window of the bladder allowed
direct
of a rectally
ing

the

inserted

abscess.

stiff

An

plastic

the

abscess

(Fig.

2).

lections

under

were

ance

using

punctured
a 16-

collections

Chiba

needle,

(Cook:

Bloomington,

ment

of a 0.035-inch

safest

route

tamination

1620

sonographic
under

or

and

guidance

sheathed

Neff

IN) was

used

was

of a second

body

place-

shortest

to avoid

compartment,

structures,

to confirm

The

chosen

system

to allow

the

drainage
included

or

the pus.

guidance

guidewire

(Cook),

place-

of a fixed

appropriate

catheter,

and

8- to 14-

French fixed-loop
all-purpose
drainage catheters.
We attempted to drain the abscess completely
and
monitored drainage by sonography
[1 1]. We were
reluctant

pletely

drain

(Figs.

1C and
drainage

to place

multiple

multiple

or multilocular

4). Catheters
and

were

catheters
were

flushed

line every

6 hr to maintain

patency.

removed

when

pus

no

when less than

5-10

was

was

Sinograms

a solid

lent.

Collections

that

small

aspirated

larger
only.

in place
2-3

were

caliber

admitted

by the
and

attending

IV antibiotic

general
treatment,

which
continued
for a minimum
of 5 days after
drainage. Antibiotic protocols varied in this study
group. The three main protocols were, first, 3-6 mg/
kg of gentamicin
sulfate
per day and 30 mg/kg of
metronidazole
per day; second, 3-6 mg/kg of gentamicin sulfate per day, 30 mg/kg of metronidazole
per day, and 150-200
mg/kg of ampicillin
per day;
and third, 3-6 mg/kg of gentamicin
sulfate per day,
150-200 mg/kg of ampicillin
per day, and 15-25
mg/kg ofclindamycin
per day.

draining
were

Results

were

and
fluid

obtained

persistent

drainage

were

for observation

for

ml of sa-

Catheters

longer

was

cess with

left

ml of serosanguineous

per day.

draining

to com-

surgeon

collections

with

drainage

an

of guidewire

dilators

of the drainage

if catheter

and

Patients

method

catheter
(Fig. 3). Standard
equipa 0.035-inch
guidewire
or the stiffer

only

Pus

contrast

This

and placement

dilatation,

size

iodinated

to replace

con-

or the bowel.
diagnosis,

loop
ment

free

with a 22-gauge

guidewire.

of drainage

guidneedle.

Introducer

tract

not

col-

sonographic

18-gauge
a

was

tip into

abscess

were accessed

organ, neurovascular
aspirated

needle

of water-soluble

fluoroscopic

ment,

for the

tip indent-

trocar

assisted

Amplatz

acoustic

of the enema

intraabdominal

Deeper

was

direct

Superficial

the

visualization

enema

I 8-gauge

advanced through the lumen

[10].

volume

medium was used

or difficult

catheters

or fecuto ac-

were

Forty-six
tional

patients

procedures.

presented

after

underwent

14 had no previous

patients
who
had delayed

patients

an appendectomy

all but one had perforation

and

64 interven-

Thirty-two
evident
surgery.

did not undergo

elective
surgery

had

(of whom
at surgery),
Seven

of the

appendectomy
to attempt

AJR:169, December

re-

1997

Interventional

Drainage

of Appendiceal

Abscesses

in Children

F-

F 2.-8cabscest
orappendiceal rupture. Fs line sagittal sonogram of retrovesical abscess
shows
18-gauge trocar needle (arrow)
entering collection from anterior rectal wall. Puncture
was performed during direct real-time imaging.

boy with pelvic abscesses

after ruptured appendix. Lateral fluoroscopic
image shows two transrectally placed drainage catheters. After lower drain was placed,
sonographic evaluation indicated higher locu-

Fig. 3.-15-year-old

Fig. 4.-3-year-old

girl with pelvic abscess after appendectofluoroscopic

image shows injected
contrast
mateabscess
and drainage
catheter
advancing
over
guidewire into collection.
my. Lateral
rial within

lation had not cleared.

Second
transrectal
drain was immediately
inserted into higher col-

lection to ensure complete

moval
of the appendix
or the appendiceal
remnant.
In the other seven patients,
no further surgery

was done and the diagnosis

presumptive,

being

based

on clinical

abscess

both

at

cedures
ously

presentation

and

in age from

1 to 15

age, 9 years 4 months).

at

included
drainage

performed
placed

The pro-

34 percutanecatheters,
25

placed drainage
catheters,
aspirations.
Thirteen
patients
(28%)

and
had

Iransrectally

five
more

than

the time
tients

one drainage

of initial

(15%)

tional

catheter

ics

ment

length

1-7

intervention,

catheters

drainage

after

abscess

and underwent

improvement
of peritonitis.

new
im-

and

IV antibiotdecision

had

surgery

age

procedure,

Three

before

their

and

of the four
had

for

patients

both

in

had the
for an

sepsis was note-

not

patients
drain-

undergone

gram

confirmed

was

clinically

drainage
moved.

The patient

that appeared
a colonic

well

tube

fistula.

and

AJR:169, December

1997

that were

[9]. Our complication

cess

rate

2%.

No complications

patient

1 year without

The

After

1 week

and the tube

has been

was

followed

and
a

the
re-

up for

event.

10%

would
catheters,
procedural

to

abscess

catheters

or perform

the
pa-

dures to drain new or recurrent

not

of patients.

We succeeded
This

in avoiding
rate compares

second

proce-

well with

other

(5%)

of

was re-

intraabdominal

have had complication

but 3% [1]

major

complications.

additional

We

placement

minor return
bacteremia

of blood,

Reported

major

to be

transgression

into

hemothorax,

or minor
unexpected

of
postor a

complications

the

thorax

or empyema

with
sev-

and

tubes;

vessel [1]; transgression

formation; malpositioned
accidental
tube removal.
Minor

complications
orrhage,
ance
CT

could

wound

None

in 91%

for one
[7], and for

ering of a mesenteric
into the bowel; fistula

collections.
operation

for

consider

pneumothorax,
approach

study

significant
hemorrhage;
postprocedural
with disseminated
intravascular
coagu-

lopathy;

interventional

rate
suc-

reported

drainage
studies

success
an 85%

rate was a low

were

drainage

complication.
sepsis

Our

Large

[4]

not

include

Discussion

ap-

rates of 10% for all complications

patient

with

abscess

fluid collection

a sino-

discharged

left in place.

had stopped
The

had persistent

feculent;

drainage

ruptures

had

study one complication

(2%).

with

by CT had a

had a 90%

of 27 patients

[8].

complication

In one of these two patients,

had appendiceal

patients

a study

another

one catheter-related

derwent

tients

abscess

and

ported

Only

drainage
is aggressive.
We attempt
to drain
collections
completely
at the initial procedure,
and we are not reluctant
to place multiple

was detected
only after
drainage procedure.
Two

guided

ously.

The two patients

in the
a detected appendicolith
un-

the appendicolith
interventional

in all age groups

drainage

appendiceal

previous
surgery.
study group with
surgery.

[8],

abscess

success rate [7], a study of 20 periappen-

diceal

21 and 23 days.
wound

study of 21 patients
pendiceal
91%

drainage.

hospitalized

62% [4] to 84%

drainage
proce-

worthy
at the time of discharge
or follow-up,
and no catheter tract failed to close spontane-

drainage
to

in position
two

of pus.

dures in adults and an 88% [5] success rate for

abdominal
drainage
procedures
in children.
A

drain7 days).

of abscess

were

studies,
which have reported
[1] success rates for abdominal

or develop-

interventional

one

time:

was detected

The

after

septicemia

catheter-related

tube drainage

surgery.

patient

No

pa-

where

with

these patients

extended

undergone

(mean,

The

at the time

of addi-

drainage

in the

Both

4 days).

group

septicemia

seven

and

for placement

returned

had

of hospitalization

(mean,

days

at

operate
on these four patients
was made by
the surgical staff on the basis of lack of clinical

The

inserted

collections
had developed
or reaccumulated.
Four patients
(9%) did not clinically
prove

had not.

the study
ranged

patients

(mean

years

patients

and the other

age ranged from 3 to 23 days

Drainage
catheters
remained

follow-up.
The

one of these

surgery

was
assess-

ment and lack of other cause for intraabdominal

sealed;

evacuation

of
was

include

of our procedures
initial
available

self-limiting

hem-

and undue pain.

sepsis,
needle

required
placement,

to us.

We

CT guidalthough

used

a free-

1621

Jamieson

handed

technique

phy

to

directly

The

time

using

real-time

sonogra-

an indication

visualize

needle

insertion.

collections,

spent acquiring

paid by its versatility

up a CT scanner

needle

with

CT-guided
real-time

placement,

dures

successful

ularity.

All

and

well
sump

drainage

of deep

patients

should

detect
with

must

pop-

have

been

and shorter
or sur-

abscesses

[10].

patients

with

infection

of

diffuse

to surgery

collection

a patient

Sonographic
times

findings

loculated

well-defmed

require

can be diagnosed

us-

IV contrast

24 patients
(52%),
we
to confirm
the diagnosis.
of a round,
and

oval,

with

structure
walls

contents

sicker
ment.

possibly

which

gas indicate

may

contain

abscess.

ported

These

appear-

needle

the fluid

infected
The

or purulent
two

patients

fled appendicolith
strong argument

underwent
can be made

debate.
is

with

identi-

early surgery. A
to exclude
these

patients
from interventional
drainage
procedures.
We believe that further
assessment
of
this subgroup
of patients
is required
because

1622

of fluid
surgery

drainage

collections

or

to temporize

the expectation

in our study

that

seven

appendiceal

or

of cure.
group who

Long-term

tomy

and

outcome

patients

appendectomy

Successful
with

elective

not

only

appendec-

undergoing

delayed

of 42
one

(91 %)

significant

justifies

of 46

catheter

image-guided

drainage
and IV antibiotics
as our management of choice
for appendix-related
abscess
in children.

current

G,

concepts.

Radio!-

follow-up.

1992;l84: 167-179

Radio!ogy

5. Towbin
RB, Strife JL. Percutaneous
aspiration,
drainage,
and biopsies in children. Radio!ogy
1985;
157:81-85

GR, Edwards

E, Wittich
diagnostic

DK, et al.

and therapeutic

tional radiologic
procedures
ence in 100 patients. Radio!ogy

interven-

in children:
experil987;162:60l-605

7. van Sonnenberg E, Wittich GR, Casola

Periappendiceal
abscesses:
percutaneous
age. Radiology
1987; 163:23-26

G, et al.
drain-

CS, Federle M} Laing FC.

ofpeiiappendiceal
abscesses:
review of2O patients.AJR 1987;149:59-62
9. Bagi P, Dueholm
5, Karstrup
S. Percutaneous
drainage of appendiceal
abscess:
an altemative
to
conventional
treatment.
Dis Colon Rectum
1987;
8. Jeffrey

RB Jr, Tolentino

Percutaneous

drainage

30:532-535

10. Pereira JK, Chait PG. Miller SE Deep pelvic abscesses in children: transrectal drainage under radiologic
guidance.
Radiology
1996;l98:393-396
1 1. Jeffrey

RB Jr. Wing

nographic

FC. Real-time

so-

of percutaneous
abscess
AiR
1985; 144:469-470
DH, Schein M, Condon RE. Management

drainage.

12. Wittmann

ofsecondaiy
13. Janik

VW, Laing

monitoring

JS,

peritonitis.Ann
Em

SH,

Surg

Shandling

Stephens CA. Nonsurgical

pendiceal

mass

1996;224:l0-18
B,

Simpson

management

in late presenting

children.

1980; 15:574-576
GS, Mueller PR. Abdominal

JS,
of apJ Pe-

diatr Surg
14.

Gazelle
diol

Cliii

North

15. Malangoni
ardson

MA,
JD.

Am

Shumate

Factors

intra-abdominal

abscess.

Ra-

1994;32:9l3-932
CR, Thomas

influencing

abscesses.

HA, Rich-

the treatment

Am J Surg

of

1990;159:

167-171

is pending.

treatment
(2%)

of pa-

evaluation

delayed

drainage:

Casola

BW. Percuta-

RE, Deyoe

scesses:

patients
were
rupture and abof some

HB,

RB, Goodacre

Percutaneous

was

interventional
The interest-

is a matter

laparotomy

undergoing

children

col-

1984;151:343-347

L, Cronan
JJ, Dorfman
GS.
drainage of 335 consecutive
abresults of primary drainage
with 1-year

4, Lambiase

to de-

surgery, the surgical procedure

tients

complication

surgical

monitoring

for the individual

patient.
benefit from percutaneous

without

without

re-

of patient

with

patient

than

has been

interventional

ing observation
cured
of their

elective
study

drainage

cooperation

whether

drainage

scess

[2, 9].
in our

close

and diligent

laparotomy
is best
These patients
may
delay

are

rather

this category

not compromised
by the prior
placement
of drainage
catheters.

gas,

whether

abscess
Treating

[17].

surgical

underwent

for abscess
after initial

confirms

leagues

with

abscess

Percutaneous

and have greater

physiologic
derangeA slightly
improved
outcome
in exill patients

H. Radio!ogy
E, DAgostino

6. van Sonnenberg

abscesses

reasonably

ances are not absolutely

specific
[2, 14], but aspiration
of contents
puncture

or

E, Ferrucci iT Percuof 250 abdominal

abscess and

ogy 1991;181:617-626

Interventional

multilocular

complex

of varying

and CT
fmdings
of a rim-enhancing
walled structure
with usually
low-density
content and, again,

echogenicity,

of low

physiologically

[15-17].

For the four patients

some-

effective,

with

interventional

with

drainage.

and CT after

administration.
For
used both techniques

has re-

or multilocular
abscesses
is
In our experience,
patients

termine

fluid

the patient

drainage ofcomplex
more controversial.

tremely

and a suspected
from

drainage

I. Radio!ogy

NA, Sanchez

neous

of illness

severity

and less disruptive

than is surgical

collections.

abscess
1984;15l:

PR, van Sonnenberg

Halasz

in situ for an

remained

as efficient,

accepted

fl. Per-

of 250 abdominal

drainage
fluid collections.

IV antibiotics
are greater determinants
of
of hospital stay than is the surgical or in-

morbidity,

E, Mueller

taneous

hospitaliza-

is well

gravitational

and

PR, Femicci

drainage

3. van Sonnenberg

a 1-week

catheters

337-341
2. Mueller

is to

removal.

averaged

patients

ceived
length

tibiotics

sonography

appendicolith

cutaneous
and fluid

appendicolith.

drainage

average of4 days. The clinical

on presentation
and whether

requires

ing both

the

to

of patients is at high
clinical assessment and

if interventional

tion, although

an inflammatory
mass or phlegmon.
Phlegmon requires observation
with or without anloculated

remove

Clearly,
this subgroup
risk and requires
close
observation

1. van Sonnenberg

and then to proceed

better

those patients

[9, 13]; abscesses

to

References

abscess

to clinically

terventional procedure
performed.
The interventional drainage of unilocular
or simple abscesses

percutaneous

be separated

defervescent,

laparotomy

to drain

the patient

procedures
were
no complications.

pelvic

and divert

A patient

abscess

of

selection
for initial
interventional
is important,
and clinical
triage

peritonitis

become

Our

proce-

of greater

less analgesic

than either

out

may be present
to allow

precede

required,

drainage

of abscesses

stays

Patient
drainage

had
allow

to require

hospital

[12].

and

catheters

drainage

shown
gical

transrectal

tolerated

Transrectal

transrectal

in-

proceguidance

access

and deserving

25

in ac-

extended

the plane of axial scanning

is often
which can be technically
demanding.

We have found

re-

collections.
In a busy
of great advantage
is

terventional
procedures.
dures
do not provide
during

is well

and effectiveness

cessing intraabdominal
radiology
department,
not tying

this skill

et al.

16. Hemming

A, Davis

sus percutaneous
scesses.
17. Levison
score,
erative
Obstet

NL,

drainage

Robins

E. Surgical

of intra-abdominal

verab-

Am J Surg 1991;16l
:593-595
MA, Zeigler D. Correlation
ofApache
drainage

technique

intra-abdominal

and outcome
abscess.

Surg

II

in postopGynecol

1991;172:89-94

AJR:169,

December

1997