Percutaneous Appendicular Abscess Drainage

Overview

An appendicular abscess is a pus collection around an inflamed appendix (appendicitis). It is a life-threatening complication of untreated appendicitis (burst appendix) and appendectomy (postoperative). This may cause lower right-sided abdominal pain, fever, nausea, vomiting, and diarrhea. The abscess can be diagnosed through blood tests and imaging tests such as X-rays, CTs, and MRIs. An appendicular abscess is initially treated with antibiotics, which is later accompanied by drainage (the abscess is punctured, and the pus is drained). Percutaneous drainage of the appendicular abscess is the most widely used minimally invasive procedure to provide permanent relief and prevent recurrence. 

What are the Treatment options for Appendicular Abscesses?

Appendicular abscesses are usually treated according to their size and severity of the condition. It includes medication, incision and drainage, and surgical intervention.

Medications 

• Medication is a first-line treatment for smaller appendicular abscesses measuring less than 0.4 cm deep.
• These include antibiotics prescribed for 1 to 2 weeks, depending on the abscess size.
• Antibiotics are also used postoperatively after drainage and surgical intervention to prevent secondary infection.

Incision and drainage (percutaneous)

• This is a relatively non-invasive (does not involve extensive incisions or bleeding) procedure performed under image guidance, either ultrasound or CT (Computed Tomography) guided.
• This method involves a small nick or a puncture over the skin underlying the appendicular abscess once the location is traced through ultrasound or CT-guided images. 

Surgical intervention 

This is usually done through an appendectomy, where one or more incisions (cuts) are made to gain access to the abscess and surgically drained to remove the pus, in addition to the complete removal of the inflamed appendix. It is performed through the following methods:

Open appendectomy

• An open appendectomy involves a single large incision that de-roofs the abscess (cutting through the layer of skin and tissue) to gain access.
• The abscess is drained, and the lining is completely scrapped out, leaving behind a catheter (a thin tube-like device) for further drainage of residual pus.

Laparoscopic appendectomy

• This minimally invasive procedure involves 2 to 3 keyhole-sized incisions over the skin underlying the abscess to insert a special device called a laparoscope (consists of a light source and camera).
• The camera captures the images and guides the surgeon to insert other tiny surgical instruments to drain the appendicular abscess.

What is Meant by Percutaneous Appendicular Abscess Drainage?

Percutaneous (through the skin) appendicular abscess drainage is a non-invasive procedure to drain the pus in the abscess. Percutaneous drainage involves locating the appendicular abscess through ultrasound or CT-guided images that determine the exact location. A small prick or puncture over the skin is made by your surgeon using a thin-needle syringe directly into the appendicular abscess. The pus is aspirated or suctioned out through the syringe and sent for pathological testing to rule out any malignancy (cancer-forming ability). A catheter is inserted into the drained surgical site for 1 to 2 weeks to drain any residual pus. 

Percutaneous drainage is performed through two techniques, namely:

• The Seldinger technique- Performed for high-rise, deep-seated, difficult-to-access appendicular abscess that involves a blind insertion of the catheter into the abscess. 
• The Trocar technique- Performed for larger superficial abscesses. Here a special cannula (hollow tube) known as a trocar is used to insert the catheter.

When is a Percutaneous Appendicular Abscess Drainage Recommended?

An appendicular abscess is usually formed when untreated, infected appendix bursts. The burst content from the appendix consists of dead and necrotic tissues, microorganisms, and certain blood components (WBCs) formed as an inflammatory response to the infection. Percutaneous drainage helps drain the infected fluid and relieves symptoms. 

Percutaneous drainage is recommended:

• When medications such as antibiotics fail to treat the abscess.
• To relieve the symptoms associated with the abscess, like lower right-sided abdominal pain, high-grade fever, body aches, chills, nausea, vomiting, and diarrhea. 
• When the abscess is more than 3 cm in diameter. 
• For multiple appendicular abscesses.
• For appendicular abscess that is multiloculated.

How to Prepare for Percutaneous Appendicular Abscess Drainage?

Consult your surgeon if you repeatedly experience any related symptoms of an appendicular abscess. Your surgeon will evaluate your symptoms and other findings through a detailed medical history. This includes:

• Presence of any pre-existing medical conditions like diabetes (increased blood sugar levels), hypertension (high blood pressure), asthma, blood disorders, and other diseases related to the heart, lungs, or kidneys.
• Allergy to any medication, anesthesia, etc., to avoid complications during or after the procedure. 
• List of medications being taken, such as anticoagulants (blood thinners), anti-inflammatory or antihypertensive drugs, antidepressants, or other herbal and vitamin supplements. 
• History of any previous surgery, trauma, or radiation therapy.
• Presence of pregnancy to avoid fetal exposure to harmful radiations.

Your surgeon will advise diagnostic tests like blood analysis, ultrasound, CT, or MRI (Magnetic Resonance Imaging) scans on an emergency basis. to check the presence of infection and to determine the size and exact location of the appendicular abscess.

It is important to be well prepared before the drainage procedure for a successful outcome and speedy recovery by following the guidelines given by your surgeon.

• You must discontinue medications like blood thinners, etc., and other herbal supplements 2 weeks before the procedure to prevent the risk of bleeding during and after the procedure.
• You must avoid smoking and consumption of alcohol at least a week before the surgery since they may delay the wound healing. 
• You must fast 8 to 12 hours before the abscess drainage as the procedure will be performed under general anesthesia. Fasting helps to prevent the aspiration of food particles into the lungs.

How Does a Percutaneous Appendicular Abscess Drainage Work?

Percutaneous drainage is an image-guided procedure that is performed by a surgical team comprising an interventional radiologist (a doctor especially trained to carry out image-guided, minimally invasive procedures to diagnose or treat diseases related to the organs of the body) and a general surgeon (a doctor who specializes in the surgical treatment of any disease in your body).

• You will be taken to the operating room, and the nurse will prep you for the procedure.
• The area of needle penetration will be disinfected with an antiseptic solution to remove the surface contaminants.
• Your nurse will connect monitors to track your vitals like BP (blood pressure), pulse, heart rate, and oxygen level.
• An IV (intravenous) line will be inserted through your vein to administer the anesthetic solution to sedate you. The type of anesthesia (local or general) will depend on the size and severity of the appendicular abscess.
• Your surgeon will use image guidance either through ultrasound or a CT scan to locate the appendicular abscess.
• A small prick or puncture on the skin overlying the appendicular abscess will be made, and your surgeon will insert a thin needle through the puncture.
• A catheter will be placed into the appendicular abscess to allow for the drainage of the infected fluid.
• This procedure is usually completed in 20 minutes to 1 hour.

What to Expect After a Percutaneous Appendicular Abscess Drainage?

After the percutaneous appendicular abscess drainage, you will be moved to the recovery room, where your vitals will be monitored.

• Once your vitals are stable, you will be shifted to the ward. 
• You will be in the hospital for a day or two, depending on your recovery progress.
• The amount of drain will be periodically monitored through the fluid collected in the catheter bag. 
• When discharged from the hospital, you will be prescribed painkillers and antibiotics to manage post-op pain and prevent infection.
• Regular follow-ups will be done on an outpatient basis, where your surgeons will evaluate the drained surgical site through ultrasound images to monitor the healing.
• Once your surgeon and radiologist are satisfied that healing is complete, the catheter is removed ( after a week or two).
• Complete recovery after the percutaneous drainage may take around 2 weeks. 

What are the Benefits and Risks of Percutaneous Appendicular Abscess Drainage?

Image-guided percutaneous appendicular abscess drainage is a non-invasive, safe, and effective procedure with the following benefits and risks. 

Benefits

• Percutaneous drainage does not require any surgical incision or cut. 
• Minimal/no scarring near the site of needle penetration.
• There is reduced or minimal bleeding.
• Shorter operating time with quick recovery.
• You can resume your job and other activities early.
• There are minimal postoperative precautions that need to be followed.

Risks 

• Since the procedure penetrates the skin, there is a risk of infection.
• Allergic reactions due to anesthesia used with associated symptoms such as skin rash, hives, redness, itching, facial edema (swelling of the face), nausea, vomiting, dizziness, confusion, headaches, and breathing difficulties.
• Numbness and tingling sensation due to damage to the nearby nerves during the needle penetration.
• A slight risk of blood clot formation that may eventually lead to the formation of a hematoma (swelling beneath the skin due to blood clots)
• Hemorrhage (increased bleeding) near the needle penetration. 
• Risk of catheter displacement or blockage that may require manipulation or replacement of the catheter.

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