422 AJR:194, February 2010

cases. For reasons that remain unclear, how-
ever, a substantial minority (| 10–25%) of
patients with perforated acute appendicitis
may not respond to initial nonsurgical treat-
ment with percutaneous drainage, leading to
prolonged hospitalization, repeated percu-
taneous procedures, multiple follow-up CT
examinations, and in some cases, urgent ap-
pendectomy [9, 10]. The results of the few
studies [6, 9, 10] conducted in attempts to
identify factors predictive of the outcome of
percutaneous drainage in patients with per-
forated acute appendicitis have been conflict-
ing. This lack of agreement generates uncer-
tainty in the clinical care of these patients,
leading to wide variations in clinical practice
among surgeons at different institutions and
even among surgeons at the same institution.
The purposes of this study were to retrospec-
tively investigate the effectiveness and safety
Percutaneous Abscess Drainage in
Patients With Perforated Acute
Appendicitis: Effectiveness, Safety,
and Prediction of Outcome
Daniele Marin
1

Lisa M. Ho
1

Huiman Barnhart
2

Amy M. Neville
1

Rebekah R. White
3

Erik K. Paulson
1
Marin D, Ho LM, Barnhart H, Neville AM, White
RR, Paulson EK
1
Department of Radiology, Duke University Medical
Center, Box 3808, Durham, NC 27710. Address
correspondence to Erik K. Paulson
(pauls003@mc.duke.edu).
2
Department of Biostatistics and Bioinformatics, Duke
University Medical Center, Durham, NC.
3
Department of Surgery, Duke University Medical Center,
Durham, NC.
Gast roi ntesti naI l nagi ng · Ori gi naI Research
AJR 2010; 194:422–429
0361–803X/10/1942–422
© American Roentgen Ray Society
A
cute appendicitis is a common
clinical problem with an incidence
of approximately 1 case per 1,000
persons per year [1]. Although
immediate appendectomy is the treatment of
choice of patients with uncomplicated acute
appendicitis, there is no consensus on the opti-
mal treatment of the approximately 2–6% of
patients whose condition becomes manifest at
a later stage with appendiceal perforation with
or without appendiceal abscess [2–4].
Imaging-guided percutaneous drainage
in combination with broad-spectrum IV an-
tibiotics is an effective, minimally invasive
treatment of patients with acute appendici-
tis complicated by perforation and abscess
[5–8]. This approach manages the initial in-
flammatory process and is followed by either
elective interval appendectomy or conserva-
tive nonoperative management in selected
Keywords: abdominal abscess, effectiveness,
percutaneous drainage, perforated acute appendicitis
DOI:10.2214/AJR.09.3098
Received May 26, 2009; accepted after revision
July 30, 2009.
OBJECTIVE. The purposes of this study were to retrospectively investigate the effective-
ness and safety of CT-guided percutaneous drainage in the treatment of patients with acute
appendicitis complicated by perforation and to identify CT findings and procedure-related
factors predictive of clinical and procedure outcome.
MATERlAL5 AND METHOD5. From March 2005 through December 2008, 41 con-
secutively registered patients (24 men, 17 women; age range, 18–75 years) underwent CT-
guided percutaneous drainage for the management of acute appendicitis complicated by per-
foration and abscess. Three board-certified radiologists independently reviewed preprocedure
CT images. Patients were assigned to one of three risk categories on the basis of the CT find-
ings. Success and failure of percutaneous drainage were defined on a per-patient (i.e., clinical
outcome) and per-procedure (i.e., technical outcome) basis. Immediate, periprocedure, and
delayed complications were recorded. The association between candidate predictive vari-
ables, including demographic characteristics, preprocedure CT findings, and procedure-relat-
ed factors and clinical or technical outcome was assessed with logistic regression models.
RE5ULT5. Fifty-two CT-guided procedures were performed on 41 patients. Percutane-
ous drainage had clinical and technical success rates of 90% (37 of 41 patients, 47 of 52 pro-
cedures) with no procedure-related complications. In seven patients (19%) clinical success
required repeated drainage procedures. A large, poorly defined periappendiceal abscess and
an extraluminal appendicolith on preprocedure CT images were independent predictors of
clinical failure of percutaneous drainage.
CONCLU5lON. CT-guided percutaneous drainage is both effective and safe in the
treatment of patients with acute appendicitis complicated by perforation and abscess. The
clinical and technical success rates are high.
Marin et al.
Abscess Drainage for Acute Appendicitis
Gastrointestinal Imaging
Original Research
AJR:194, February 2010 423
Abscess Drainage for Acute Appendicitis
of CT-guided percutaneous drainage in the
care of patients with acute appendicitis com-
plicated by perforation and to identify CT
findings and procedure-related factors pre-
dictive of clinical and procedure outcome.
Materials and Methods
This retrospective single-center HIPAA-com-
pliant study was approved by our institutional re-
view board. The requirement for informed con-
sent was waived.
Patient Selection
We reviewed the interventional procedure log
for CT-guided percutaneous abscess drainage of
the abdomen or pelvis performed from March 2005
through December 2008. Among 843 procedures,
59 consecutive procedures on 48 patients were re-
ported as being performed for acute appendicitis
complicated by perforation and abscess (Fig. 1).
For each of these patients, we reviewed medical re-
cords (radiology, surgery, pathology, and discharge
summary) to confirm the diagnosis of acute appen-
dicitis with perforation. Seven of the 48 patients
were excluded because of a history of Crohn’s dis-
ease (five patients) or concomitant tuboovarian ab-
scess (two patients). The other 41 patients (mean
age, 38 years; range, 18–75 years) composed our
study cohort, which included 24 men (mean age,
40 years; range, 18–75 years) and 17 women (mean
age, 29 years; range, 20–50 years).
The final diagnosis of perforated appendici-
tis was based on a clinical history of fever, leu-
kocytosis, and right lower quadrant abdominal
pain corroborated by at least one of the following
CT findings [11, 12]: focal defect in an enhancing
appendiceal wall, periappendiceal abscess, peri-
appendiceal phlegmon, extraluminal air, and ex-
traluminal appendicolith. In 24 patients who un-
derwent interval appendectomy a mean of 74 days
(range, 0–210 days) after the primary drainage
procedure, a final diagnosis of appendiceal per-
foration was confirmed when appendiceal perfo-
ration was macroscopically evident (n = 5), when
transmural inflammatory cell infiltrate with necro-
sis was found at pathologic examination (n = 12),
or both (n = 7). In two of these patients, pathologic
examination showed perforated acute appendicitis
was associated with mucocele secondary to muci-
nous cystadenoma.
Preprocedure CT and Drainage Procedure
Diagnostic CT was performed with an MDCT
scanner (LightSpeed 16, GE Healthcare) with the
following parameters: detector configuration, 16
× 0.625 mm; effective section thickness, 5 mm;
reconstruction interval, 5 mm; gantry rotation
time, 0.5 second; beam pitch, 1.75; 100–350 mA
depending on the patient’s body habitus; 140 kVp.
Patients ingested 450 mL of a 2% barium sulfate
suspension (Readi-Cat 2, E-Z-EM) 1–2 hours be-
fore scanning. After IV administration of 150 mL
of nonionic contrast medium (iopamidol, Isovue
300, Bracco), scanning was performed from the
dome of the diaphragm through the pubic sym-
physis during the portal venous phase as deter-
mined with bolus tracking and automated trigger-
ing technology. In addition to the transverse source
images, a set of coronal images of the abdomen and
pelvis (effective section thickness, 3 mm; recon-
struction interval, 3 mm) were reconstructed by the
technologist at the operator’s console.
After referral from the surgical team, each pa-
tient gave written informed consent before the
drainage procedure. All patients were treated with
broad-spectrum antibiotics before the drainage
procedure. All the procedures were performed or
closely supervised by one of 12 attending radiolo-
gists with 4–20 years of experience in imaging-
guided percutaneous drainage and interventional
procedures. A senior resident or fellow assisted
with the procedure.
Before each procedure, diagnostic CT examina-
tions were reviewed for planning of an appropri-
ate route. Catheter size (Flexima APD or APDL,
Boston Scientific) was determined by the attending
radiologist. Abscess drainage was performed with
CT or CT fluoroscopic guidance (CT/i equipped
with SmartView, GE Healthcare) and Seldinger
technique [13]. After catheter placement, the col-
lections were aspirated as completely as possible,
and samples were sent for microbiologic analysis.
The catheters were attached to Jackson-Pratt bulb
drains (Medi-Vac, Cardinal Healthcare), which
generate 30–50 mm Hg of suction. The inpatient
nursing service ensured catheter patency by flush-
ing the catheter lumen with 10–15 mL of 0.9% ster-
ile saline three times per day. The decision for cath-
eter removal was based on the following criteria:
clinical improvement (normal body temperature
and WBC count, no clinical symptoms), drainage
output of 10 mL/d or less, and CT findings of com-
plete resolution of the target fluid collection.
Data Collection
Preprocedure CT findings and risk catego-
rization—Three board-certified radiologists with
18, 10, and 3 years of experience in abdominal
imaging independently reviewed the preproce-
dure CT images of each patient on a PACS work-
station (Centricity 2.1, GE Healthcare). Readers
were aware that the patients had been referred for
known or suspected perforated appendicitis, but
they were unaware of the clinical data and final
Fig. 1—Flowchart shows study
enrollment.
424 AJR:194, February 2010
Marin et al.
outcome (see later, Effectiveness). Because we
were not attempting to determine the diagnostic
accuracy of CT, disagreement was resolved by
consensus. Readers assessed contrast-enhanced
CT images of each patient for visualization of the
appendix and the presence of a periappendiceal
abscess (defined as a fluid collection adjacent to
the appendix with attenuation of 0–20 HU), peri-
appendiceal phlegmon (defined as areas of 20-HU
or greater attenuation in the fat tissue surround-
ing the appendix), extraluminal gas or appendi-
colith, and small-bowel obstruction. If an abscess
was identified, readers also documented the size
(defined as the single largest transverse diameter)
and margins (either well-circumscribed or poorly
defined) of the fluid collection.
In an attempt at stratification according to se-
verity of inflammatory disease and size and com-
plexity of abscess, patients were assigned to one of
three risk categories on the basis of the CT find-
ings. Based on a classification system described
by Jeffrey et al. [6], the categories were 1, periap-
pendiceal phlegmon or abscess smaller than 3 cm
(n = 17) (Fig. 2A); 2, well-circumscribed periap-
pendiceal abscess larger than 3 cm (n = 10) (Fig.
2B); and 3, large, poorly defined periappendiceal
abscesses extending to distant locations, such as
the pelvic cul-de-sac, the interloop spaces, or be-
yond the peritoneal cavity (n = 14) (Fig. 2C).
Procedure details—Details of each drainage
procedure were recorded by one abdominal imag-
ing research fellow who retrospectively reviewed
the interventional radiology data sheets, which
were prospectively completed by the attending ra-
diologist after the procedure: procedure reports and
intraprocedure CT images. Data collected included
the approach for catheter placement, number and
diameter of catheters, volume and character of as-
pirate (purulent or not purulent), and results of mi-
crobiologic culture. For patients who underwent re-
peated procedures, technical details were recorded
individually for each procedure. Documentation of
the duration of catheter placement was not report-
ed because of inconsistent data from patients who
were discharged after the drain placement and un-
derwent outpatient follow-up.
Effectiveness—The same abdominal radiol-
ogy research fellow who recorded the procedure
details assessed the outcome of drainage therapy
by retrospectively reviewing electronic medical
records (radiology, surgery, pathology, and dis-
charge summary) for each patient. Success and
failure were defined per patient (i.e., clinical out-
come) and per procedure (i.e., technical outcome).
Clinical success was defined as patient recovery
after single or multiple procedures with or with-
out interval elective appendectomy. Clinical fail-
ure was defined as progressive deterioration with
worsening clinical signs and symptoms of infec-
tion after single or multiple drainage procedures
that ultimately necessitated urgent appendectomy.
Technical success was defined as complete res-
olution of an abscess as determined at follow-up
CT along with negligible catheter output. A proce-
dure was considered a failure if the operator was
unable to place a drain, if no fluid was aspirated
A
C
Fig. 2—Three-category CT scale of perforated acute appendicitis.
A, 32-year-old man with right lower quadrant abdominal pain, tenderness, and
mild leukocytosis (category 1, periappendiceal phlegmon or abscess smaller
than 3 cm). Transverse CT image shows well-circumscribed, 2.5-cm abscess
with thickened wall (straight arrows) in right lower quadrant and 0.5-cm extruded
appendicolith (curved arrow). Examination of specimen from elective laparoscopic
appendectomy 150 days after drainage procedure showed chronic appendicitis.
B, 32-year-old man with acute onset of lower abdominal pain radiating to
periumbilical region for 12 hours (category 2, well-circumscribed periappendiceal
abscess larger than 3 cm). Transverse CT image shows well-circumscribed
5-cm pelvic abscess (arrows) with air–fluid level (asterisk). Patient was treated
successfully with percutaneous drainage and antibiotic therapy only.
C, 26-year-old woman with 6 hours of generalized abdominal pain, tenderness,
and leukocytosis (category 3, large, poorly defined periappendiceal abscesses
extending to distant locations). Transverse CT image shows large, poorly-defined
pelvic abscess (arrows) extending from periappendiceal region to pouch of
Douglas. After initial attempt at percutaneous drainage, patient underwent urgent
open appendectomy because follow-up CT showed interval increase in abscess.
B
AJR:194, February 2010 425
Abscess Drainage for Acute Appendicitis
after successful catheter placement, or if follow-
up imaging more than 1 day after the procedure
showed enlargement of the abscess that necessi-
tated either secondary drainage or urgent appen-
dectomy. Repeated drainage procedures because
of development of a new abscess in a different lo-
cation were not deemed technical failure and were
evaluated separately. Abscesses that became evi-
dent after surgical appendectomy were excluded
from our analysis. Immediate, periprocedure, and
delayed complications were recorded per treatment
and were classified in accordance with suggested
reporting criteria [14].
Predictive variables—Candidate predictive
variables selected included demographic charac-
teristics (age and sex), preprocedure CT findings
(risk category and presence of extraluminal gas or
appendicolith and small-bowel obstruction), and
factors related to the first procedure (approach for
catheter placement, number and diameter of cath-
eters, volume and character of aspirate, and results
of microbiologic culture). The association between
these variables and clinical or technical outcome
was assessed with logistic regression models. Be-
cause of the small number of patients who under-
went multiple procedures, only the first procedure
was considered in the association analysis. Vari-
ables in the univariate analysis with p < 0.20 were
entered into multivariate logistic regression analy-
sis in a search for independent factors predictive of
outcome. Backward-forward and stepwise proce-
dures were used for model selection with entry and
stay level of 0.10. Because of the exploratory nature
of the analyses with a small sample size, p d 0.1
was considered to indicate statistical significance.
All statistical analyses were performed with statis-
tical software (SAS version 9.1.3, SAS Institute).
ResuIts
Preprocedure CT Findings, Risk Category, and
Procedure Details
Table 1 summarizes the demographic
characteristics, preprocedure CT findings,
and procedure details for patients in differ-
ent risk categories. In 39 of the 41 patients
(95%), perforated acute appendicitis became
manifest as a periappendiceal abscess (mean
size, 4.1 cm; range, 0.8–10.5 cm) at the initial
CT examination. The abscess was associated
with an extraluminal appendicolith in 16 of
the patients (39%). In no patient were mul-
tiple abscesses present throughout the abdo-
men or pelvis. Unequivocal identification of
the appendix was possible in 24 of the 41 pa-
tients (59%). In 37 of the 41 patients (90%),
percutaneous drainage was preferentially
performed through a direct transabdominal
approach with a single catheter greater than
10-French. Except for two patients in whom
percutaneous drainage was performed de-
spite the absence of fluid collections at pre-
procedure CT, 5–350 mL of fluid was aspirat-
ed during the drainage procedure. Aspiration
revealed purulent fluid in most of the patients
(34 of 41, 83%).
Effectiveness
Fifty-two CT-guided procedures were per-
formed on 41 patients, including a single pro-
cedure on 33 patients, two procedures on six
patients, three procedures on one patient, and
four procedures on one patient. Percutaneous
A
C
Fig. 3—18-year-old woman with right lower quadrant pain and fever.
A, Transverse contrast-enhanced CT scan shows 5-cm well-circumscribed
abscess (straight arrows) in right lower quadrant, inflammatory changes in
adjacent fat tissue (category 2), and 1-cm extruded appendicolith (curved arrow).
B, CT fluoroscopic image (140 kV, 10 mA, 5-mm section thickness) shows 18-gauge
needle (curved arrow) in pelvic abscess (straight arrows). After stepwise dilation,
14-French pigtail catheter (not shown) was placed in abscess.
C, Follow-up CT scan 15 days after drainage procedure shows successful abscess
drainage (arrow) with no residual fluid. No interval appendectomy was performed.
B
426 AJR:194, February 2010
Marin et al.
drainage was clinically successful for 37 of
the 41 patients (90%; 95% CI, 81–99%), in-
cluding 16 of the 17 patients (94%) in cat-
egory 1, all 10 patients in category 2, and 11
of 14 patients (79%) in category 3 (Fig. 3).
In 30 of the 37 patients (81%), success was
achieved after a single drainage procedure;
seven patients (19%) needed repeated drain-
age procedures because of follow-up imag-
ing findings of a new abscess in a different
location (six patients) or enlargement of a pe-
riappendiceal abscess (one patient).
In four of the 41 patients (10%), percutane-
ous drainage was deemed a clinical failure,
and urgent appendectomy was performed. In
two of these patients (both category 3), includ-
ing one patient for whom catheter placement
required transgression of the ascending colon,
follow-up CT (2 and 4 days after procedure)
showed enlargement (from 4 to 6 cm and from
5 to 8 cm) of a periappendiceal abscess despite
successful catheter placement during the initial
drainage procedure (Fig. 4). Although we do
not advocate transcolonic percutaneous drain-
age, this approach was discussed with both the
patient and the surgeon before the procedure.
In one patient (category 3) the operator was
unable to advance the tip of the catheter into
the target fluid collection using a direct trans-
abdominal approach. In the other patient (cat-
egory 1), urgent appendectomy was performed
because of the development of small-bowel ob-
struction 2 days after the drainage procedure.
In this patient, an adhesion was removed at the
point of transition during surgery. For three
of four patients with clinical failure, catheters
were still in place when the patient’s condition
deteriorated.
Technical success was achieved in 47 of 52
drainage procedures (90%), including 18 of
19 procedures (95%) on patients in category
1, all 11 procedures on patients in category 2,
and 18 of 22 procedures (81%) on patients in
category 3. The technical success rate for the
first procedure was 88% (36 of 41 patients;
95% CI, 78–98%). Although five procedures
(10%) in five patients were deemed technical
failures, clinical success was achieved in three
patients after a course of antibiotic therapy ei-
ther alone (two patients) or in combination
with secondary percutaneous drainage (one
patient). Causes of technical failure included
inability to place a drain into the target fluid
collection despite multiple attempts in two pa-
tients and increased size of an abscess as doc-
umented at follow-up CT in three patients. No
complications were observed during or imme-
diately after any drainage procedure.
Predictive Variables
The results of the univariate analysis for
comparison of the predictive variables (de-
mographic characteristics, preprocedure CT
findings, procedure-related factors) with
clinical and technical outcome are summa-
rized in Table 2. The multivariate analysis
showed that risk category 3 (odds ratio, 0.07;
90% CI, 0.01–0.67; p = 0.05) and extralumi-
nal appendicolith (odds ratio, 0.09; 90% CI,
0.09–0.83; p = 0.07) were independent pre-
dictors of clinical failure of percutaneous
drainage (Table 3) (Fig. 5). Use of a direct
transabdominal approach for catheter place-
ment was an independent predictor of techni-
cal success of percutaneous drainage (odds
ratio, 14.73; 90% CI, 1.545–140.48; p =
0.05), and female sex was associated with a
TABLE 1: Denographic Characteristics, Preprocedure CT Findings, and
Procedure DetaiIs on Patients 5tratified to Risk Categories
Characteristic
Risk Category
Total (n = 41) 1 (n = 17) 2 (n = 10) 3 (n = 14)
Sex (no.)
Men 13 (76) 7 (70) 4 (29) 24 (59)
Women 4 (24) 3 (30) 10 (71) 17 (41)
Age (y)
Mean 42.0 42.2 29.9 37.9
SD 15.0 20.4 12.1 16.3
Range 23–75 15–73 16–57 18–75
Abscess size (cm)
Mean 2.5 4.5 5.3 4.1
SD 0.4 1.6 2.1 2.0
Range 0.8–3 3.5–7 4–10.5 0.8–10.5
Phlegmon (no.) 8 (47) 3 (30) 7 (50) 18 (44)
Extraluminal gas (no.) 10 (59) 5 (50) 7 (50) 22 (54)
Extraluminal appendicolith (no.) 7 (41) 5 (50) 4 (29) 16 (39)
Small-bowel obstruction (no.) 1 (6) 0 1 (7) 2 (5)
No. of procedures
Single 14 (82) 9 (90) 10 (71) 33 (80)
Multiple 3 (18) 1 (10) 4 (29) 8 (20)
Technical approach (no.)
Transabdominal 16 (94) 10 (100) 11 (79) 37 (90)
Transgluteal 1 (6) 0 2 (14) 3 (7)
Transcolic 0 0 1 (7) 1 (3)
No. of catheters
0 (aspiration) 2 (12) 0 0 2 (5)
1 14 (82) 10 (100) 13 (93) 37 (90)
2 1 (6) 0 1 (7) 2 (5)
Catheter size (no.)
> 10 French 10 (59) 9 (90) 7 (50) 26 (63)
d 10 French 7 (41) 1 (10) 7 (50) 15 (37)
Volume of aspirate (mL)
Mean 36.6 67 33.9 43.1
SD 50.6 100.8 24.8 60.8
Range 0–200 15–350 0–70 0–350
Note—Values in parentheses are percentages calculated with numerators in the rows and denominators in the
column headings.
AJR:194, February 2010 427
Abscess Drainage for Acute Appendicitis
A
Fig. 4—26-year-old woman with right lower quadrant pain.
A, Transverse contrast-enhanced CT scan shows 3.5-cm well-circumscribed abscess (arrows) immediately posterior to cecum (C) with inflammatory changes in adjacent
fat tissue (category 2). Abscess would have been difficult to approach percutaneously because of interposed intestine, pelvic bones, and adnexa.
B, After discussion with referring surgeon, abscess was drained by intentional transgression of ascending colon. CT fluoroscopic image (140 kV, 10 mA, 5-mm section
thickness) shows 18-gauge needle (curved arrow) in pelvic abscess (straight arrows). Despite excellent position of drainage catheter (not shown), follow-up CT showed
enlargement of abscess that necessitated urgent appendectomy.
B
A
C
Fig. 5—19-year-old woman with right lower quadrant pain and fever.
A, Transverse contrast-enhanced CT scan shows 5.8-cm poorly defined abscess
(black straight arrows) in right lower quadrant of abdomen with inflammatory
changes in adjacent fat tissue (category 3), 1-cm-diameter extruded appendicolith
(curved arrow), and thickened and enhanced wall of adjacent sigmoid colon (white
straight arrows).
B, CT fluoroscopic image (140 kV, 10 mA, 5-mm section thickness) shows 0.38
guidewire (curved arrow) coursing through 18-gauge needle (straight arrow) in
pelvic abscess. After stepwise dilation, 10-French pigtail catheter (not shown)
was placed in abscess.
C, Follow-up CT scan 5 days after procedure shows newly developed 4-cm
abscess (arrows) in right paracolic gutter immediately lateral to ascending colon
(C). After continued clinical deterioration, open appendectomy was performed.
B
428 AJR:194, February 2010
Marin et al.
lower rate of technical success (odds ratio,
0.12; 90% CI, 0.01–0.99; p = 0.1) (Table 3).
Discussion
Our results show that percutaneous drain-
age is effective and safe in the treatment of
patients with acute appendicitis complicat-
ed by perforation and abscess. Both clinical
and technical success rates were 90% (37 of
41 patients and 47 of 52 procedures), and no
procedure-related complications occurred.
In patients with a well-circumscribed peri-
TABLE 2: Bivariate Association Between Patient Denographics, Preprocedure
CT Findings, and Procedure-ReIated Factors and CIinicaI and
Technical Outcome
Variables
Clinical Outcome Outcome of First Procedure
Success
(n = 37)
Failure
(n = 4) p
Success
(n = 36)
Failure
(n = 5) p
Sex (no.) 0.18 0.09
Men 23 (62) 1 (25) 23 (64) 1 (20)
Women 14 (38) 3 (75) 13 (36) 4 (80)
Age (y) 0.24 0.24
Mean 38.9 28.3 39.1 29.6
SD 16.7 7.9 17.1 3.6
Risk category (no.) 0.11 0.05
1–2 26 (70) 1 (25) 26 (72) 1 (20)
3 11 (30) 3 (75) 10 (28) 4 (80)
Extraluminal gas (no.) 21 (57) 1 (25) 0.25 20 (56) 2 (40) 0.52
Extraluminal appendicolith (no.) 13 (35) 3 (75) 0.16 13 (36) 3 (60) 0.32
Small bowel obstruction (no.) 2 (6) 0 (0) NA 2 (6) 0 (0) NA
No. of procedures 0.77
Single 30 (81) 3 (75)
Multiple 7 (19) 1 (25)
Technical approach (no.) 0.02 0.04
Standard 35 (95) 2 (50) 34 (94) 3 (60)
Nonstandard 2 (5) 2 (50) 2 (6) 2 (40)
No. of catheters (no.) NA NA
1 33 (90) 4 (100) 34 (94) 5 (100)
2 2 (5) 0 (0) 2 (6) 0 (0)
Catheter size (no.) 0.56 0.26
> 10 French 24 (65) 2 (50) 24 (67) 2 (60)
d 10 French 13 (35) 2 (50) 12 (33) 3 (40)
Volume of aspirate (no.) 0.77 NA
> 50 mL 7 (19) 1 (25) 8 (22) 0 (0)
d 50 mL 30 (81) 3 (75) 28 (78) 5 (100)
Character of aspirate (no.)
a
0.31 NA
Purulent 32 (86) 2 (50) 30 (83) 2 (50)
Nonpurulent 4 (11) 1 (25) 5 (14) 1 (25)
Microbiologic culture (no.)
a
NA NA
Polymicrobial 34 (92) 3 (75) 34 (90) 3 (75)
Monomicrobial 2 (6) 0 (0) 2 (6) 0 (0)
Note—Values in parentheses are percentages calculated with numerators in the rows and denominators in the
column headings. NA = not applicable for data with zero frequency.
a
No fluid was in two patients.
appendiceal abscess (categories 1 and 2), the
clinical and technical success rates of percu-
taneous drainage increased to 92% and 96%.
Our data compare favorably with the results
of previously published studies [5–8] and
confirm the effectiveness of percutaneous
drainage in combination with broad-spec-
trum antibiotics in the treatment of patients
with acute appendicitis complicated by per-
foration and abscess. There is compelling ev-
idence that among these patients, immediate
appendectomy is associated with substan-
tially higher risk of complications, including
hemorrhage, fistula formation, wound infec-
tion, prolonged ileus, and adhesions [4].
Another clinically important finding of
our study is that besides the high clinical suc-
cess rate (81%, 30 of 37 patients), which was
achieved after a single drainage procedure,
percutaneous drainage was clinically success-
ful in seven of eight patients (88%) who un-
derwent repeated procedures, most commonly
because of the development of a new abscess
at a location distant from the primary site of
infection. These results, which are consistent
with the 92% clinical success reported by
McCann and colleagues [15] in a study with
patients with acute appendicitis complicated
by multiple abdominal abscesses, emphasize
the importance of secondary drainage in the
treatment of patients with perforated acute
appendicitis in whom new intraabdominal ab-
scesses develop after the first drainage proce-
dure. At the same time, our data highlight the
need for close clinical and CT follow-up af-
ter percutaneous drainage for early detection
and prompt management of persistent or new-
ly developed abscesses.
In our study, initial nonsurgical manage-
ment with percutaneous drainage failed to
control the acute inflammatory process in four
of 41 patients, resulting in a 10% clinical fail-
ure rate. In accordance with results of previous
analyses [6, 9], we found that a large, poorly
defined periappendiceal abscess (category 3)
and extraluminal appendicolith were the two
most specific predictors of unfavorable clinical
outcome of percutaneous drainage. This find-
ing, which remained significant after adjust-
ments for other potential prognostic factors,
has two important clinical implications. First,
it reinforces the current clinical practice of per-
forming urgent appendectomy on patients with
perforated acute appendicitis that becomes ev-
ident at a later stage with more generalized,
potentially life-threatening signs and symp-
toms of peritoneal infection. Second, it cor-
roborates the hypothesis that patients with an
AJR:194, February 2010 429
Abscess Drainage for Acute Appendicitis
extraluminal appendicolith after appendiceal
perforation have a poorer prognosis, including
increased risk of recurrent abscess and other
complications [16]. The presence of an appen-
dicolith can act as a nidus for continuous in-
fection and abscess formation. This notion jus-
tifies the need for elective interval removal of
a dropped appendicolith with either surgery or
CT-guided percutaneous extraction and stone
basket catheters [16, 17].
In our study, percutaneous abscess drainage
through a direct transabdominal approach was
associated with a significantly higher prob-
ability of procedure success. In a minority of
patients, however, an alternative approach, in-
cluding a transgluteal route in three patients
and intentional transgression of the ascending
colon in one patient, was necessary because of
the presence of deep-seated, less accessible ab-
scesses. These approaches were not associated
with major periprocedure complications, such
as hemorrhage or injury to the sciatic nerve but
resulted in both clinical and procedure fail-
ure in two of four cases (50%). Although this
finding did not reach statistical significance, it
needs to be emphasized that many authorities
have discouraged transgression of the small or
large bowel for drainage of deep-seated ab-
scesses [18]. In our patient who needed colonic
transgression, the risks of this approach were
discussed with both the patient and the refer-
ring surgeon before the procedure.
Besides its retrospective nature, potential
limitations of our study merit consideration.
First, the relatively small sample size probably
limited the statistical power to detect associa-
tions between CT findings and technique-relat-
ed factors and the outcome variables. Second,
we restricted our analysis to patients with con-
clusive diagnostic criteria for perforated acute
appendicitis at CT [11, 12]. This approach
might have introduced selection bias because
it is possible that some patients with atypical
clinical or CT manifestations of perforated
acute appendicitis might have been excluded
from the study. In addition, because we includ-
ed only patients with perforated acute appen-
dicitis who were referred to our interventional
radiology service for a percutaneous drainage
procedure, we cannot compare the effective-
ness of percutaneous drainage with that of oth-
er treatments, such as immediate appendecto-
my and antibiotic therapy alone. Our results
also reflect the experience of a single tertiary
referral center with a high volume of percuta-
neous drainage procedures. It remains to be
determined whether our results can be gener-
alized to smaller community hospitals. Final-
ly, our work was focused on adults; we believe
similar results can be achieved in the treatment
of children with perforated appendicitis.
CT-guided percutaneous drainage is both
effective and safe in the care of patients with
acute appendicitis complicated by perforation
and abscess, having clinical and technical
success rates of 90%. In patients with prepro-
cedure CT findings of large, poorly defined
periappendiceal abscesses or extraluminal ap-
pendicoliths, percutaneous drainage is associ-
ated with a less favorable clinical outcome.
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TABLE 3: MuItivariate Association Between Candidate Predictive VariabIes
and Clinical and Technical Outcomes
Variable
Clinical Outcome Outcome of First Procedure
Odds Ratio 90% CI p Odds Ratio 90% CI p
Sex NI 0.12 0.01–0.99 0.10
Risk category (3 vs 1 or 2) 0.07 0.01–0.67 0.05 NI
Extraluminal appendicolith 0.09 0.09–0.83 0.07 NI
Technical approach NI 14.7 1.55–140.48 0.05
Note—NI = not included and not significant at 0.10 level.
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AJR:194. effective section thickness. For each of these patients. pathologic examination showed perforated acute appendicitis was associated with mucocele secondary to mucinous cystadenoma. All the procedures were performed or closely supervised by one of 12 attending radiologists with 4–20 years of experience in imagingguided percutaneous drainage and interventional procedures. periappendiceal abscess. and samples were sent for microbiologic analysis. Boston Scientific) was determined by the attending radiologist. 0. The other 41 patients (mean age. range. which included 24 men (mean age. when transmural inflammatory cell infiltrate with necrosis was found at pathologic examination (n = 12). Patient Selection We reviewed the interventional procedure log for CT-guided percutaneous abscess drainage of the abdomen or pelvis performed from March 2005 through December 2008. 20–50 years).Abscess Drainage for Acute Appendicitis of CT-guided percutaneous drainage in the care of patients with acute appendicitis complicated by perforation and to identify CT findings and procedure-related factors predictive of clinical and procedure outcome.9% sterile saline three times per day. Cardinal Healthcare). Catheter size (Flexima APD or APDL. range. 5 mm. gantry rotation time. surgery. 100–350 mA depending on the patient’s body habitus. Before each procedure. GE Healthcare) with the following parameters: detector configuration. Among 843 procedures. All patients were treated with broad-spectrum antibiotics before the drainage Data Collection Preprocedure CT findings and risk categorization—Three board-certified radiologists with 18. After IV administration of 150 mL of nonionic contrast medium (iopamidol.75. but they were unaware of the clinical data and final Fig. 16 × 0.625 mm. periappendiceal phlegmon. Seven of the 48 patients were excluded because of a history of Crohn’s disease (five patients) or concomitant tuboovarian abscess (two patients). and CT findings of complete resolution of the target fluid collection. GE Healthcare). the collections were aspirated as completely as possible. 12]: focal defect in an enhancing appendiceal wall.1. February 2010 423 . no clinical symptoms). The catheters were attached to Jackson-Pratt bulb drains (Medi-Vac. After catheter placement. a final diagnosis of appendiceal perforation was confirmed when appendiceal perforation was macroscopically evident (n = 5).5 second. each patient gave written informed consent before the drainage procedure. and 3 years of experience in abdominal imaging independently reviewed the preprocedure CT images of each patient on a PACS workstation (Centricity 2. Isovue 300. 140 kVp. Materials and Methods This retrospective single-center HIPAA-compliant study was approved by our institutional review board. diagnostic CT examinations were reviewed for planning of an appropriate route. procedure. 0–210 days) after the primary drainage procedure. The requirement for informed consent was waived. A senior resident or fellow assisted with the procedure. 18–75 years) and 17 women (mean age. In 24 patients who underwent interval appendectomy a mean of 74 days (range. and discharge summary) to confirm the diagnosis of acute appendicitis with perforation. reconstruction interval. Bracco). pathology. In addition to the transverse source images. E-Z-EM) 1–2 hours before scanning. The decision for catheter removal was based on the following criteria: clinical improvement (normal body temperature and WBC count. After referral from the surgical team. GE Healthcare) and Seldinger technique [13]. and ex- Preprocedure CT and Drainage Procedure Diagnostic CT was performed with an MDCT scanner (LightSpeed 16. reconstruction interval. and right lower quadrant abdominal pain corroborated by at least one of the following CT findings [11. 5 mm. extraluminal air. 3 mm. leukocytosis. 3 mm) were reconstructed by the technologist at the operator’s console. The final diagnosis of perforated appendicitis was based on a clinical history of fever. 38 years. which generate 30–50 mm Hg of suction. 1—Flowchart shows study enrollment. or both (n = 7). Abscess drainage was performed with CT or CT fluoroscopic guidance (CT/i equipped with SmartView. 59 consecutive procedures on 48 patients were reported as being performed for acute appendicitis complicated by perforation and abscess (Fig. 18–75 years) composed our study cohort. 1). a set of coronal images of the abdomen and pelvis (effective section thickness. 1. The inpatient nursing service ensured catheter patency by flushing the catheter lumen with 10–15 mL of 0. 40 years. Readers were aware that the patients had been referred for known or suspected perforated appendicitis. range. 10. In two of these patients. 29 years. scanning was performed from the dome of the diaphragm through the pubic symphysis during the portal venous phase as determined with bolus tracking and automated triggering technology. Patients ingested 450 mL of a 2% barium sulfate suspension (Readi-Cat 2. drainage output of 10 mL/d or less. we reviewed medical records (radiology. traluminal appendicolith. beam pitch.

2—Three-category CT scale of perforated acute appendicitis. patient underwent urgent open appendectomy because follow-up CT showed interval increase in abscess. B C outcome (see later. and mild leukocytosis (category 1. 2. Patient was treated successfully with percutaneous drainage and antibiotic therapy only. If an abscess was identified. 2. such as the pelvic cul-de-sac. which were prospectively completed by the attending radiologist after the procedure: procedure reports and intraprocedure CT images. 32-year-old man with right lower quadrant abdominal pain. number and diameter of catheters. periappendiceal phlegmon or abscess smaller than 3 cm). well-circumscribed periappendiceal abscess larger than 3 cm). Readers assessed contrast-enhanced CT images of each patient for visualization of the appendix and the presence of a periappendiceal abscess (defined as a fluid collection adjacent to the appendix with attenuation of 0–20 HU). technical details were recorded individually for each procedure.5-cm extruded appendicolith (curved arrow). and leukocytosis (category 3. the interloop spaces. A. or beyond the peritoneal cavity (n = 14) (Fig. clinical outcome) and per procedure (i. tenderness. C. if no fluid was aspirated 424 AJR:194. A procedure was considered a failure if the operator was unable to place a drain. Transverse CT image shows well-circumscribed. Data collected included the approach for catheter placement.e. and small-bowel obstruction. tenderness.. February 2010 . disagreement was resolved by consensus. Transverse CT image shows large. periappendiceal phlegmon (defined as areas of 20-HU or greater attenuation in the fat tissue surrounding the appendix). pathology. extraluminal gas or appendicolith. 26-year-old woman with 6 hours of generalized abdominal pain. poorly defined periappendiceal abscesses extending to distant locations). Transverse CT image shows well-circumscribed 5-cm pelvic abscess (arrows) with air–fluid level (asterisk). Documentation of the duration of catheter placement was not reported because of inconsistent data from patients who were discharged after the drain placement and underwent outpatient follow-up. periappendiceal phlegmon or abscess smaller than 3 cm (n = 17) (Fig. A Fig. Effectiveness—The same abdominal radiology research fellow who recorded the procedure details assessed the outcome of drainage therapy by retrospectively reviewing electronic medical records (radiology.. Examination of specimen from elective laparoscopic appendectomy 150 days after drainage procedure showed chronic appendicitis. well-circumscribed periappendiceal abscess larger than 3 cm (n = 10) (Fig. readers also documented the size (defined as the single largest transverse diameter) and margins (either well-circumscribed or poorly defined) of the fluid collection. Success and failure were defined per patient (i.5-cm abscess with thickened wall (straight arrows) in right lower quadrant and 0. For patients who underwent repeated procedures. After initial attempt at percutaneous drainage. patients were assigned to one of three risk categories on the basis of the CT findings. poorly-defined pelvic abscess (arrows) extending from periappendiceal region to pouch of Douglas. Clinical success was defined as patient recovery after single or multiple procedures with or without interval elective appendectomy. Effectiveness). Technical success was defined as complete resolution of an abscess as determined at follow-up CT along with negligible catheter output. Based on a classification system described by Jeffrey et al. and results of microbiologic culture. poorly defined periappendiceal abscesses extending to distant locations. surgery. Clinical failure was defined as progressive deterioration with worsening clinical signs and symptoms of infection after single or multiple drainage procedures that ultimately necessitated urgent appendectomy. Procedure details—Details of each drainage procedure were recorded by one abdominal imaging research fellow who retrospectively reviewed the interventional radiology data sheets. 2C). and 3. [6]. B. the categories were 1.e.Marin et al. 32-year-old man with acute onset of lower abdominal pain radiating to periumbilical region for 12 hours (category 2. and discharge summary) for each patient. large. large. In an attempt at stratification according to severity of inflammatory disease and size and complexity of abscess. 2A). Because we were not attempting to determine the diagnostic accuracy of CT. volume and character of aspirate (purulent or not purulent). 2B). technical outcome).

three procedures on one patient. Unequivocal identification of the appendix was possible in 24 of the 41 patients (59%). In no patient were multiple abscesses present throughout the abdomen or pelvis. 14-French pigtail catheter (not shown) was placed in abscess. Aspiration revealed purulent fluid in most of the patients (34 of 41. After stepwise dilation. February 2010 425 . Variables in the univariate analysis with p < 0. range. 0. Abscesses that became evident after surgical appendectomy were excluded from our analysis. Backward-forward and stepwise procedures were used for model selection with entry and stay level of 0. Because of the exploratory nature of the analyses with a small sample size. percutaneous drainage was preferentially performed through a direct transabdominal approach with a single catheter greater than 10-French. Because of the small number of patients who underwent multiple procedures. 3—18-year-old woman with right lower quadrant pain and fever. preprocedure CT findings. B.20 were entered into multivariate logistic regression analysis in a search for independent factors predictive of outcome. and delayed complications were recorded per treatment and were classified in accordance with suggested reporting criteria [14]. periprocedure.3.8–10. two procedures on six patients. Immediate. In 39 of the 41 patients (95%). No interval appendectomy was performed. Follow-up CT scan 15 days after drainage procedure shows successful abscess drainage (arrow) with no residual fluid. perforated acute appendicitis became manifest as a periappendiceal abscess (mean size. and factors related to the first procedure (approach for catheter placement. 5-mm section thickness) shows 18-gauge needle (curved arrow) in pelvic abscess (straight arrows). inflammatory changes in adjacent fat tissue (category 2). and results of microbiologic culture).10. Risk Category. and 1-cm extruded appendicolith (curved arrow).1 was considered to indicate statistical significance.5 cm) at the initial CT examination. p 0. 83%). Effectiveness Fifty-two CT-guided procedures were performed on 41 patients. Predictive variables—Candidate predictive variables selected included demographic characteristics (age and sex). including a single procedure on 33 patients. A. All statistical analyses were performed with statistical software (SAS version 9. only the first procedure was considered in the association analysis. and four procedures on one patient. C after successful catheter placement. The abscess was associated with an extraluminal appendicolith in 16 of the patients (39%). Repeated drainage procedures because of development of a new abscess in a different location were not deemed technical failure and were evaluated separately. preprocedure CT findings (risk category and presence of extraluminal gas or appendicolith and small-bowel obstruction). Percutaneous AJR:194. and procedure details for patients in different risk categories. CT fluoroscopic image (140 kV. In 37 of the 41 patients (90%). number and diameter of catheters. C. volume and character of aspirate. Preprocedure CT Findings. 10 mA. 5–350 mL of fluid was aspirated during the drainage procedure. Except for two patients in whom percutaneous drainage was performed despite the absence of fluid collections at preprocedure CT. and Procedure Details Table 1 summarizes the demographic characteristics.Abscess Drainage for Acute Appendicitis A B Fig.1 cm. Transverse contrast-enhanced CT scan shows 5-cm well-circumscribed abscess (straight arrows) in right lower quadrant. SAS Institute). or if followup imaging more than 1 day after the procedure showed enlargement of the abscess that necessitated either secondary drainage or urgent appendectomy. The association between these variables and clinical or technical outcome was assessed with logistic regression models. 4.1.

0 15.6 3. seven patients (19%) needed repeated drainage procedures because of follow-up imaging findings of a new abscess in a different location (six patients) or enlargement of a periappendiceal abscess (one patient).3 2. and female sex was associated with a Risk Category Characteristic Sex (no. all 10 patients in category 2. For three of four patients with clinical failure. In the other patient (category 1).3 18–75 13 (76) 4 (24) 7 (70) 3 (30) 4 (29) 10 (71) 24 (59) 17 (41) 1 (n = 17) 2 (n = 10) 3 (n = 14) Total (n = 41) Note—Values in parentheses are percentages calculated with numerators in the rows and denominators in the column headings.545–140.8 0–70 43.9 16. of procedures Single Multiple Technical approach (no. follow-up CT (2 and 4 days after procedure) showed enlargement (from 4 to 6 cm and from 5 to 8 cm) of a periappendiceal abscess despite successful catheter placement during the initial drainage procedure (Fig.) Extraluminal gas (no.09. Although five procedures (10%) in five patients were deemed technical failures.6 0–200 67 100. urgent appendectomy was performed because of the development of small-bowel obstruction 2 days after the drainage procedure. 0. In two of these patients (both category 3). 1. preprocedure CT findings. this approach was discussed with both the patient and the surgeon before the procedure. percutaneous drainage was deemed a clinical failure.67. and 11 of 14 patients (79%) in category 3 (Fig.8–3 8 (47) 10 (59) 7 (41) 1 (6) 4.1 4–10. drainage was clinically successful for 37 of the 41 patients (90%.4 15–73 29. 90% CI. 90% CI. The multivariate analysis showed that risk category 3 (odds ratio.48. catheters were still in place when the patient’s condition deteriorated.5 1.5 0. and urgent appendectomy was performed. p = 0. 90% CI.) Transabdominal Transgluteal Transcolic No.1 16–57 37.1 60.6 50. and 18 of 22 procedures (81%) on patients in category 3.0 0. In four of the 41 patients (10%). 3). all 11 procedures on patients in category 2.4 0.) No. clinical success was achieved in three patients after a course of antibiotic therapy either alone (two patients) or in combination with secondary percutaneous drainage (one patient).5 7 (50) 7 (50) 4 (29) 1 (7) 4. 0. Use of a direct transabdominal approach for catheter placement was an independent predictor of technical success of percutaneous drainage (odds ratio. including 18 of 19 procedures (95%) on patients in category 1. February 2010 .09–0. success was achieved after a single drainage procedure. 5). Although we do not advocate transcolonic percutaneous drainage.1 2.05). Causes of technical failure included inability to place a drain into the target fluid collection despite multiple attempts in two patients and increased size of an abscess as documented at follow-up CT in three patients. In 30 of the 37 patients (81%).9 12.8–10.) Men Women Age (y) Mean SD Range Abscess size (cm) Mean SD Range Phlegmon (no. 95% CI.73.07) were independent predictors of clinical failure of percutaneous drainage (Table 3) (Fig. 14. 0. 0. an adhesion was removed at the point of transition during surgery. procedure-related factors) with clinical and technical outcome are summarized in Table 2. In one patient (category 3) the operator was unable to advance the tip of the catheter into the target fluid collection using a direct transabdominal approach. The technical success rate for the first procedure was 88% (36 of 41 patients.8 0–350 10 (59) 7 (41) 9 (90) 1 (10) 7 (50) 7 (50) 26 (63) 15 (37) 2 (12) 14 (82) 1 (6) 0 10 (100) 0 0 13 (93) 1 (7) 2 (5) 37 (90) 2 (5) 16 (94) 1 (6) 0 10 (100) 0 0 11 (79) 2 (14) 1 (7) 37 (90) 3 (7) 1 (3) 14 (82) 3 (18) 9 (90) 1 (10) 10 (71) 4 (29) 33 (80) 8 (20) 2. 81–99%). 426 AJR:194. p = 0.5 18 (44) 22 (54) 16 (39) 2 (5) 42. No complications were observed during or immediately after any drainage procedure.9 24.5–7 3 (30) 5 (50) 5 (50) 0 5. including one patient for whom catheter placement required transgression of the ascending colon.) Small-bowel obstruction (no.Marin et al.2 20.) Extraluminal appendicolith (no. p = 0. 95% CI.8 15–350 33.0 23–75 42. 4). Predictive Variables The results of the univariate analysis for comparison of the predictive variables (demographic characteristics.07.05) and extraluminal appendicolith (odds ratio. In this patient.83. including 16 of the 17 patients (94%) in category 1.) > 10 French 10 French Volume of aspirate (mL) Mean SD Range 36.01–0. of catheters 0 (aspiration) 1 2 Catheter size (no. 78–98%). Technical success was achieved in 47 of 52 drainage procedures (90%).

Transverse contrast-enhanced CT scan shows 3. Follow-up CT scan 5 days after procedure shows newly developed 4-cm abscess (arrows) in right paracolic gutter immediately lateral to ascending colon (C). B. 10 mA. 10 mA. follow-up CT showed enlargement of abscess that necessitated urgent appendectomy. A B C AJR:194. After continued clinical deterioration. CT fluoroscopic image (140 kV. 4—26-year-old woman with right lower quadrant pain. February 2010 Fig. Transverse contrast-enhanced CT scan shows 5. A. Abscess would have been difficult to approach percutaneously because of interposed intestine. 5—19-year-old woman with right lower quadrant pain and fever. pelvic bones. After discussion with referring surgeon. B. 5-mm section thickness) shows 18-gauge needle (curved arrow) in pelvic abscess (straight arrows).Abscess Drainage for Acute Appendicitis A B Fig. Despite excellent position of drainage catheter (not shown). CT fluoroscopic image (140 kV. C. and adnexa.8-cm poorly defined abscess (black straight arrows) in right lower quadrant of abdomen with inflammatory changes in adjacent fat tissue (category 3). abscess was drained by intentional transgression of ascending colon. A. 1-cm-diameter extruded appendicolith (curved arrow). 427 .38 guidewire (curved arrow) coursing through 18-gauge needle (straight arrow) in pelvic abscess. open appendectomy was performed. 5-mm section thickness) shows 0.5-cm well-circumscribed abscess (arrows) immediately posterior to cecum (C) with inflammatory changes in adjacent fat tissue (category 2). and thickened and enhanced wall of adjacent sigmoid colon (white straight arrows). 10-French pigtail catheter (not shown) was placed in abscess. After stepwise dilation.

In accordance with results of previous analyses [6. 30 of 37 patients). has two important clinical implications.18 23 (64) 13 (36) 1 (20) 4 (80) 0.) Standard Nonstandard No. which remained significant after adjustments for other potential prognostic factors.) Men Women Age (y) Mean SD Risk category (no. emphasize the importance of secondary drainage in the treatment of patients with perforated acute appendicitis in whom new intraabdominal abscesses develop after the first drainage procedure. Second. 9]. Discussion Our results show that percutaneous drainage is effective and safe in the treatment of patients with acute appendicitis complicated by perforation and abscess. our data highlight the need for close clinical and CT follow-up after percutaneous drainage for early detection and prompt management of persistent or newly developed abscesses.99. and adhesions [4]. of procedures Single Multiple Technical approach (no. 90% CI. These results. p = 0.09 Note—Values in parentheses are percentages calculated with numerators in the rows and denominators in the column headings.) 1 2 Catheter size (no.6 0. There is compelling evidence that among these patients. aNo fluid was in two patients. Both clinical and technical success rates were 90% (37 of 41 patients and 47 of 52 procedures).6 3. fistula formation. lower rate of technical success (odds ratio.24 39. the clinical and technical success rates of percutaneous drainage increased to 92% and 96%.) Extraluminal appendicolith (no. potentially life-threatening signs and symptoms of peritoneal infection.02 34 (94) 2 (6) 3 (60) 2 (40) NA 0. 0. which are consistent with the 92% clinical success reported by McCann and colleagues [15] in a study with patients with acute appendicitis complicated by multiple abdominal abscesses. 428 AJR:194. wound infection.04 26 (70) 11 (30) 21 (57) 13 (35) 2 (6) 1 (25) 3 (75) 1 (25) 3 (75) 0 (0) 0.11 26 (72) 10 (28) 20 (56) 13 (36) 2 (6) 1 (20) 4 (80) 2 (40) 3 (60) 0 (0) 0.Marin et al.9 0.12. In patients with a well-circumscribed periappendiceal abscess (categories 1 and 2).1) (Table 3). initial nonsurgical management with percutaneous drainage failed to control the acute inflammatory process in four of 41 patients. In our study.25 0.05 Success (n = 37) Failure (n = 4) p 0.77 38.1 29.52 0.31 30 (83) 5 (14) 2 (50) 1 (25) NA 24 (65) 13 (35) 2 (50) 2 (50) 0.) No.7 28. At the same time. and no procedure-related complications occurred. This finding.77 8 (22) 28 (78) 0 (0) 5 (100) NA 33 (90) 2 (5) 4 (100) 0 (0) 0. First. including hemorrhage.)a Purulent Nonpurulent Microbiologic culture (no.) > 50 mL 50 mL Character of aspirate (no. of catheters (no.) Small bowel obstruction (no. Another clinically important finding of our study is that besides the high clinical success rate (81%.1 17.32 NA 23 (62) 14 (38) 1 (25) 3 (75) 0.)a Polymicrobial Monomicrobial 34 (92) 2 (6) 3 (75) 0 (0) 32 (86) 4 (11) 2 (50) 1 (25) NA 34 (90) 2 (6) 3 (75) 0 (0) 7 (19) 30 (81) 1 (25) 3 (75) 0. February 2010 .56 24 (67) 12 (33) 2 (60) 3 (40) NA 35 (95) 2 (5) 2 (50) 2 (50) NA 34 (94) 2 (6) 5 (100) 0 (0) 0.) > 10 French 10 French Volume of aspirate (no. resulting in a 10% clinical failure rate. prolonged ileus. Our data compare favorably with the results of previously published studies [5–8] and confirm the effectiveness of percutaneous drainage in combination with broad-spectrum antibiotics in the treatment of patients with acute appendicitis complicated by perforation and abscess. it corroborates the hypothesis that patients with an Technical Outcome Clinical Outcome Variables Sex (no.3 7. NA = not applicable for data with zero frequency. it reinforces the current clinical practice of performing urgent appendectomy on patients with perforated acute appendicitis that becomes evident at a later stage with more generalized.26 30 (81) 7 (19) 3 (75) 1 (25) 0. percutaneous drainage was clinically successful in seven of eight patients (88%) who underwent repeated procedures.16 NA 0. 0.9 16. which was achieved after a single drainage procedure.01–0. immediate appendectomy is associated with substantially higher risk of complications. most commonly because of the development of a new abscess at a location distant from the primary site of infection.24 Outcome of First Procedure Success (n = 36) Failure (n = 5) p 0. we found that a large.) 1–2 3 Extraluminal gas (no. poorly defined periappendiceal abscess (category 3) and extraluminal appendicolith were the two most specific predictors of unfavorable clinical outcome of percutaneous drainage.

Roach JP. Wherry DC. Lundagårds J. Maher MM.01–0. National Cancer Institute Website. Radiology 2003. Chui CH. 246:142–147 13. National Center for Health Statistics. Ridgeway P. Ziegler MM. version 3. et al. Nilsson PE. Federle MP. 139. 169:1619–1622 6. ctep. Karrer FM. Geoghegan T.cancer. the relatively small sample size probably limited the statistical power to detect associations between CT findings and technique-related factors and the outcome variables. Gervais D. Jeffrey RB Jr. Surg Infect (Larchmt) 2004. Abrishami M. J Pediatr Surg 2007. Meza MP.10 level. This approach might have introduced selection bias because it is possible that some patients with atypical clinical or CT manifestations of perforated acute appendicitis might have been excluded from the study. CT fluoroscopy-guided interventional procedures: techniques and radiation dose to radiologists. Snow A. Reblock KK. percutaneous abscess drainage through a direct transabdominal approach was associated with a significantly higher probability of procedure success. 38:661–668 16. Cancer Therapy Evaluation Program. Velmahos GC. Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study. Besides its retrospective nature. 42:934–938 10. Allshouse MJ. we restricted our analysis to patients with conclusive diagnostic criteria for perforated acute appendicitis at CT [11. Although this finding did not reach statistical significance. Takase K.12 NI NI 14. Nadler EP. Kao TC. 220:161–167 14. Partrick DA. 167:13–16 7. potential limitations of our study merit consideration. having clinical and technical success rates of 90%. Radiology 1988. Radiology 2008. the risks of this approach were discussed with both the patient and the referring surgeon before the procedure. Complicated appendicitis in children: a clear role for drainage and delayed appendectomy. Mueller PR. National Center for Health Statistics Series 13. et al. Periappendiceal inflammatory masses: CT-directed management and clinical outcome in 70 patients. less accessible abscesses. Muller M. because we included only patients with perforated acute appendicitis who were referred to our interventional radiology service for a percutaneous drainage procedure.7 1. In our study. First. Gibeily GJ. Chait PG. Filler R. In our patient who needed colonic transgression. Jamieson DH. AJR 2008. Kalra MK. Finally. Singh AK. 24:717–735 and Clinical and Technical Outcomes Clinical Outcome Variable Sex Risk category (3 vs 1 or 2) Extraluminal appendicolith Technical approach Odds Ratio NI 0. McCann JW. Colhoun E. Imageguided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy. Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences. such as immediate appendectomy and antibiotic therapy alone. 60:80–83 18. Accessed May 1. 12]. 17:725–729 AJR:194. 1. an alternative approach. Hahn PF. Surg Endosc 2003. This notion justifies the need for elective interval removal of a dropped appendicolith with either surgery or CT-guided percutaneous extraction and stone basket catheters [16. et al.55–140. Buckley O. Bledsoe SE.09 NI 0. GA: National Center for Health Statistics 2. 194:769– 772 8. Sheafor DH. including increased risk of recurrent abscess and other complications [16]. we cannot compare the effectiveness of percutaneous drainage with that of other treatments. Enterline DS. AJR 1997. Barnhart DC. Atlanta. J Pediatr Surg 2005. Published December 12.05 90% CI 0. extraluminal appendicolith after appendiceal perforation have a poorer prognosis. Vaughan KG. CT-guided percutaneous drainage is both effective and safe in the care of patients with acute appendicitis complicated by perforation and abscess.07 90% CI p Outcome of First Procedure Odds Ratio 0. including a transgluteal route in three patients and intentional transgression of the ascending colon in one patient. percutaneous drainage is associated with a less favorable clinical outcome. Kaneda I. 5:349–356 11. Predictors of outcome for children with perforated appendicitis initially treated with non-operative management. 168:264–269 9. Horrow JC. et al.07 0. Bruny JL. Vijayraghavan G. In a minority of patients. 69:829–832 3. The inaccessible or undrainable abscess: how to drain it. In patients with preprocedure CT findings of large. Gaines BA. Late-presenting appendicitis: a laparoscopic approach to a complicated problem. Tsuboi M. Radiology 2001.09–0. 2003. Ross MN. Brown CV. These approaches were not associated with major periprocedure complications. Interventional drainage of appendiceal abscesses in children. Manning DB.Abscess Drainage for Acute Appendicitis 5. Differentiation of perforated from nonperforated appendicitis at CT.html. Vaid Y. it needs to be emphasized that many authorities have discouraged transgression of the small or large bowel for drainage of deep-seated abscesses [18]. 2009 15. Eur J Radiol 2006. Goh BK.gov/reporting/ctc. Harmon CM. Appendiceal abscess: immediate operation or percutaneous drainage? Am Surg 2003. poorly defined periappendiceal abscesses or extraluminal appendicoliths. The usefulness of CT guided drainage of abscesses caused by retained appendicoliths. Maroo S.83 0. Dropped appendicolith: CT findings and implications for management. Second. Eur J Surg 2002. Common terminology criteria for adverse events. Gervais DA. our work was focused on adults. White DS. 1996.10 Note—NI = not included and not significant at 0.0. no. et al.48 0. Am J Surg 2007. Torreggiani WC. Our results also reflect the experience of a single tertiary referral center with a high volume of percutaneous drainage procedures. Aprahamian CJ. Horrow MM. however. Yap TL. In addition. 40:1134–1137 4. Wales P.05 0. such as hemorrhage or injury to the sciatic nerve but resulted in both clinical and procedure failure in two of four cases (50%). Lasson A. Tolentino CS. February 2010 429 .01–0.99 p 0. Paulson EK. RadioGraphics 2004. Perforated and nonperforated appendicitis: defect in enhancing appendiceal wall—depiction with multi-detector row CT. we believe similar results can be achieved in the treatment of children with perforated appendicitis. was necessary because of the presence of deep-seated. 190:707–711 17. Lorén I. It remains to be determined whether our results can be generalized to smaller community hospitals. 17]. Ford HR.67 0. Pediatr Radiol 2008. The presence of an appendicolith can act as a nidus for continuous infection and abscess formation. 227:46–51 12. Appendiceal abscesses: primary percutaneous drainage and selective interval appendicectomy. Ambulatory and inpatient procedures in the United States.

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