|Year : 2021 | Volume
| Issue : 2 | Page : 66-71
Experience with percutaneous drainage of body fluids in a tertiary center in Benin City
Blessing O Igbinedion1, Festus Ehigiamusoe1, Esongboriaimen Mabel Agbebaku2
1 Department of Radiology, College of Medical Sciences, University of Benin, Benin City, Edo State, Nigeria
2 Department of Radiology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Submission||10-Jul-2021|
|Date of Decision||19-Aug-2021|
|Date of Acceptance||21-Sep-2021|
|Date of Web Publication||30-Nov-2021|
Esongboriaimen Mabel Agbebaku
Department of Radiology, University of Benin Teaching Hospital, Ugbowo, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Background: Percutaneous drainage is the evacuation of body fluids either using needle aspiration or by catheter placement under imaging guidance. Abnormal collections in the body which may be idiopathic, postinfectious, posttraumatic, or postsurgical (iatrogenic) can be free (e.g., ascites) or loculated (e.g. cysts and abscesses). Most cases of significant fluid accumulation require evacuation. Interventional radiology offers treatment and even cure to such patients who may be too ill to withstand surgery or not able to afford the cost of open surgery. The aim of this article is to review the common percutaneous drainage procedures done in the Radiology department of the University of Benin teaching hospital. Materials and Methods: A retrospective analysis of percutaneous drainage requests to the department of radiology of the hospital from January 2017 to march 2020 was performed. Data on age, gender, clinical diagnosis, the radiologic findings, procedures, and instrumentation utilized were retrieved and analyzed using IBM SPSS version 23. Results: A total of 49 patients' data were recruited for this study; 40 (81.6%) were female. The most common indication for intervention was liver abscess (14.3%), followed by liver cyst, endometriosis, obstructive jaundice, and pelvic abscess. The IV cannula/sheath was the most widely used instrument, followed by the pigtail catheter. All patients had their procedures done under antibiotic cover and the cases of hepatic cysts had albendazole added to their drug regimen. Conclusion: Despite the limited availability of resources for interventional radiology, basic procedures like cyst and abscess drainages can be successfully carried out using available materials and catheters.
Keywords: Abscess, body fluid, catheter, cyst, drainage, percutaneous, ultrasound
|How to cite this article:|
Igbinedion BO, Ehigiamusoe F, Agbebaku EM. Experience with percutaneous drainage of body fluids in a tertiary center in Benin City. J Radiat Med Trop 2021;2:66-71
|How to cite this URL:|
Igbinedion BO, Ehigiamusoe F, Agbebaku EM. Experience with percutaneous drainage of body fluids in a tertiary center in Benin City. J Radiat Med Trop [serial online] 2021 [cited 2022 May 28];2:66-71. Available from: http://www.jrmt.org/text.asp?2021/2/2/66/331522
| Introduction|| |
Interventional radiology is a subspecialty in radiology which involves the use of minimally invasive targeted treatment options to manage various medical conditions under image guidance. It is less invasive than conventional open surgery and does not routinely require general anesthesia. Image-guided drainage is one of the most commonly performed interventional radiology procedures and its application range from drainage of breast cysts, relief of severe hydronephrosis, and distended obstructed gallbladder to drainage of pelvic abscess and collections. Percutaneous abscess drainage is one of the most common and rewarding procedures performed by interventional radiologists.
Interventional radiology is especially key in the management of critically ill patients who may be too ill to undergo surgery with its attendant morbidities. In the past three decades, percutaneous fluid drainage has had a profound effect on the management of the critically ill patient population and is arguably one of the most important procedures performed by radiologists. Success is almost always immediate with evidence of aspiration of effluent which may be clear, bloody, purulent, sanguineous, or serosanguineous. The success rate of these procedures is 100% as they are done under direct image guidance. Guidance may be ultrasound, computed tomography, magnetic resonance imaging, or fluoroscopically guided. Of the aforementioned imaging modalities, ultrasound guidance is the most commonly employed as it is real-time imaging, cheap, readily available, and does not employ ionizing radiation.
The type of instruments used would depend largely on the site, size, consistency, and location of the fluid. Other factors to be considered include availability of IR material, its cost, skills, and preference of the IR as well as the predicted rapidity of fluid reaccumulation. There may be need to place a sterile catheter for continuous drainage for conditions which cause fluid reaccumulation such as septated fluid, chronic abscess, large volume abscess/fluid, malignant ascites, or obstructed biliary tree. The use of catheter for drainage is especially useful with the management of hepatic hydatid cyst in which treatment includes puncture, aspiration, injection, and reaspiration (PAIR) therapy. The PAIR approach to hydatid cyst management has shown reduction of cyst size in 100% of patients making it reliable.
Not much has been done by way of documentation with respect to fluid drainage by IR in South-South Nigeria. The aim of this study is to review some of the image-guided drainages that were done at a tertiary center in Benin using available materials and to document the indications and some of the challenges faced.
| Materials and Methods|| |
This was a retrospective descriptive study of consecutive patients diagnosed with body or tissue fluid collections (such as cysts and abscesses) from different departments of UBTH over a 39-month period (January 2017 to March 2020) that were sent for IR fluid drainage. Departmental approval was sought and granted. No patient identifying data was collected.
All patients with clinical diagnosis of body fluids for drainage had ultrasound scans done by the authors to confirm and localize the collection and determine its suitability for percutaneous drainage. Other available radiologic and nonradiologic investigations done were also reviewed. All procedures were performed under local anesthetic cover and aseptic technique.
Two of the authors are consultant radiologists and have postfellowship training in IR. All the procedures were performed by them or under their supervision. The third author is a resident with keen interest in IR and assisted in some of the procedures.
Data obtained included the age, sex, location of collection, indication, method of drainage, volume of aspirate drained, and outcome. Data were analyzed for measures of central tendency using IBM-SPSS (Statistical Package for Social Sciences; Chicago, Illinois, USA) version 22. The results were presented with charts and tables.
| Results|| |
A total of 49 patients' data aged between 2 and 78 years were utilized in this study; the average age was 41.1 years. Of these, 40 (81.6%) were female and 9 (18.4%) were male. Thirteen out of the 49 patients had liver pathologies. The most common indication for intervention was liver abscess (14.3%), followed by liver cyst, endometriosis with free intraperitoneal fluid collection [Figure 1], obstructive jaundice, and pelvic abscess. In females, endometriosis and pelvic abscess were common [Table 1]. [Table 2] and [Table 3] show tabulations of the fluid drained.
|Figure 1: Longitudinal B-mode sonograme showing free intraperitoneal collection. (image credit: Department of radiology, UBTH)|
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The methods of intervention included ultrasound-guided percutaneous drainage, percutaneous insertion of catheter, cyst aspiration and ablation using alcohol, and occasionally tetracycline. The intra-abdominal and pelvic collections were found to be of larger volumes compared to subcutaneous and extra-abdominal collections. Abdominal interventions accounted for over half of all interventions with the liver being the organ most intervened on 55.1%.
Documented instruments used in this study include 16 and 18G IV cannula/sheath (49%), pig-tail catheter (34.7%), Chiba needle (5.4%), needle/stylet assemblage (10.2%), and Abram's needle (2.0%). [Table 4] shows the materials used.
The various effluents yielded ranged from sanguineous, serous, purulent, serosanguineous, and bilious to clear. Most of the effluents collected were sent for microscopy, culture, and sensitivity, while cytology was included for suspected malignancies.
Two of the cases suspected to be hydatid were confirmed by a microbiologist and all the cases required continuous drainage for a minimum of 4 weeks. Eleven patients achieved complete cure in one intervention, while 10 required multiple interventions. Some of the patients were lost to follow up while three mortalities were documented days after the procedures. These mortalities were related to the primary disease (malignancy) and not from the procedure. One complication requiring hospital admission was recorded; this was a case of septic shock in a patient being managed for obstructive jaundice due to choledochal cyst.
| Discussion|| |
Before the advent of image-guided percutaneous drainages, abscesses were mostly managed by open surgical intervention such as incision and drainage ((I & D) and antibiotic therapy, while ascites has also been managed using external drain. These procedures were either done blind by the patients' bed side or at surgery. Interventional radiology has improved the success rate of bed side fluid drainages with little or no damage to adjacent structures; this includes a reduction in the rate of bowel transection during these procedures. Generally, percutaneous drainage of abnormal fluid collections is greatly influenced by the location of the collection, as ease of accessibility of the collection determines how successful the procedure will be. The best route will be one that avoids as many intervening structures as possible. Similar to our study, other studies have reported the use of large gauge cannulas, drainage catheters such as the pigtail catheter and the Foley's catheter. It can be safely said that percutaneous ultrasound-guided drainage of abdominal abscesses is a viable alternative to open surgical drainage.
In our study, the large bore IV cannula (16 and 18G) was the most widely used tool as this is the most readily available/accessible in the hospital and it comes at a much cheaper cost compared to the specialized drains. There was, however, limitations with this instrument as draining deep collections were challenging due to the short length of the cannula. The IV cannula is still very important because the ready availability and relatively low cost of this instrument, makes it easy to plan procedures without unnecessary delay. The size 10F pigtail catheters from a nephrostomy set were mostly used for continuous percutaneous drainages especially in the management of large liver cysts (>10 cm). The choice of catheter size was guided by the nature of the collection as more viscid collections will require larger caliber catheters. In comparison to a similar study done in the reference center about 5 years earlier which reported heavy reliance on the IV cannula/sheath, this shows some improvement in instrument procurement. A study done in Lagos State University Teaching hospital (LASUTH) also reported use of catheter as well as needles in management of hepatic abscess. Misauno et al. of University of Jos also reported the use of needles in managing intra-abdominal abscesses.
The common techniques for percutaneous drainage include the Seldinger and the Trochar method. Seldinger technique has the advantage of verification of successful access into a collection prior to creation of a larger bore for the cannula, but has higher risk of cross contamination during catheter exchange, while the trochar technique is advantageous when draining larger and more superficial collections with minimal risk of infection spread. In our study, continuous drainage catheters were placed using the Seldinger technique, while single episode instant drainages were done using the direct trochar method.
The cases of hepatic cysts suspected to be hydatid were managed using the PAIR approach with the pigtail catheter as the employed drain. The success rate in terms of cyst size reduction was 100%. This is similar to the findings in the study by Rajesh et al. which reported reduction in cyst size over a period of 3–6 months in 100% of patients with hydatid who were managed using the PAIR approach. A study done in LASUTH on percutaneous drainage of hepatic abscesses, showed success using both percutaneous needle aspiration and percutaneous catheter drainages with no adverse complications noted. Other treatment options include operative treatment, radiofrequency ablation, laparoscopic resection and chemotherapy which serve as an adjunct to other treatment options. In this study, all patients with hepatic cyst suspected to be Hydatid had Albendazole tablets added to their drug regimen before and after intervention.
The possible complications include septic shock (1%–2%), bacteremia requiring significant new intervention (2%–5%), hemorrhage requiring transfusion (1%), superinfection (includes infection of sterile fluid collection) (1%), bowel transgression requiring intervention (1%), pleural transgression requiring intervention (abdominal interventions) (1%), pneumothorax, hemothorax, and pleural effusion requiring further intervention (2%–10%). Only one case of septic shock was recorded in our study; this was in a patient with infected obstructed biliary fluid which puts our severe complication rate at 0.02% which is reasonably low. The patient was resuscitated with intravenous fluid, anti-histamines, and observed overnight at the accident and emergency unit. She recovered fully and was discharged.
Hepatic pathologies were the commonest indication for intervention accounting for 34.7% of the cases reviewed with hepatic abscess [Figure 2] accounting for a significant proportion (41.2%). Hepatic abscess were more in males than females, but the female patients had a higher average age at diagnosis (47 years) compared to the males (34 years). Other studies have also shown that liver abscesses are more common in males than females and the older the age of the patient, the less likely that the abscess is from trauma.,, All the patients who had hepatic cysts were female suggesting a higher incidence in females. Similarly, the study by Mgbor et al. in Enugu Nigeria, reported a higher number of cases of hepatic cysts among females compared to males. Three patients had recurrence of cyst after three drainages, one underwent surgery at which omental packing was performed, one refused surgery while the other was lost to follow up. Gynecological intervention accounted for 30% of indication among females.
|Figure 2: Transverse B-mode sonogram of the liver showing a hepatic abscess. (image credit: Department of radiology, UBTH)|
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There were major challenges with accessibility of materials. IR catheters are not readily available for purchase, and there are few representatives within the country to help facilitate purchase. This problem is compounded by the low awareness that IR services are available. This low availability has a double pronged effect; fewer patients are sent for basic procedures and fewer materials are requested, thus making the turnover of IR procedures much lower than is expected. A significant number of patients were lost to follow up and this was another major challenge making it difficult to document the full outcome of treatment.
The practice of IR in Nigeria is still in its infancy and there are no didactic training programs for Nigerian radiology residents or early career consultants interested in pursuing a career in IR. There is need to commence training of doctors (residents and consultants) in the field of IR as well as embark on large scale sensitization of other specialists, patients and IR equipment representatives on the availability, capability of and growth potential of IR in Nigeria. There is also need to set up well stocked IR clinics and wards for better patient care and follow up
| Conclusion|| |
The field of IR in Nigeria is still in its early form; however, basic body interventions can be done even in the absence of highly specialized equipment, using the available resources. Capacity building in this field is greatly advocated.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]