The American Journal of Surgery 184 (2002) 148 153

Scientific paper

Can failure of percutaneous drainage of postoperative abdominal

abscesses be predicted?
Stephane Benoist, M.D., Ph.D.a, Yves Panis, M.D., Ph.D.a*, Virginie Pannegeon, M.D.a,
Philippe Soyer, M.D., Ph.D.b, Thierry Watrin, M.D.a, Mourad Boudiaf, M.D.b,
Patrice Valleur, M.D.a
a

Department of Surgery, Service de Chirurgie Generale et Digestive, Hopital Lariboisie`re, 2, Rue Ambroise Pare, 75475 Paris Cedex 10, France
b
Department of Radiology, Lariboisie`re Hospital, Paris, France
Manuscript received December 5, 2001; revised manuscript April 29, 2002

Abstract
Background: Percutaneous drainage (PD) of complex postoperative abscesses associated with a variety of factors such as multiple location
or enteric fistula remains a matter of debate. Accordingly, this retrospective study was designed to determine the predictive factors for failure
of PD of postoperative abscess, in order to better select the patients who may benefit from PD.
Methods: From 1992 to 2000, the data of 73 patients who underwent computed tomography (CT)-guided PD for postoperative
intra-abdominal abscess, were reviewed. PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. The
possible association between failure of PD and 27 patient-, abscess-, surgical-, and drainage-related variables were assessed using univariate
and multivariate analysis.
Results: Successful PD was achieved in 59 of 73 (81%) patients. The overall mortality was 3% but no patient died after salvage surgery.
Multivariate analysis showed that only an abscess diameter of less than 5 cm (P 0.042) and absence of antibiotic therapy (P 0.01) were
significant predictive variables for failure of PD.
Conclusions: CT-guided PD associated with antibiotic therapy could be attempted as the initial treatment of postoperative abdominal
abscesses even in complex cases such as loculated abscess or abscess associated with enteric fistula. 2002 Excerpta Medica, Inc. All
rights reserved.
Keywords: Percutaneous drainage; Radiological guidance; Intra-abdominal abscess; Postoperative abscess

Despite advances in surgical techniques and antibiotic therapy, postoperative development of intra-abdominal abscesses remains a serious and potentially fatal complication
in abdominal surgery with a mortality rate often ranging up
to 30% [1,2]. Early recognition and localization, followed
by prompt, and appropriate drainage, are essential factors
for intra-abdominal abscesses to be treated successfully
[3,4]. For many years, surgical drainage has been considered as the best therapeutic option in postoperative abdominal abscesses, although it was associated with a high mortality rate of 20% to 40% [57]. During the 2 last decades,
major changes have occurred in the treatment of abdominal
abscesses. With refinements in imaging technology, which
* Corresponding author. Tel.: 00-33-1-4995-8258; fax: 00-33-14995-9102.
E-mail address: yves.panis@lrb.ap-hop-paris.fr

improve early detection and accurate localization of postoperative intra-abdominal fluid collection, ultrasonographyor CT-guided percutaneous drainage (PD) has been successfully developed [8 10]. Several retrospective studies
showed that percutaneous approach is as effective as surgical drainage, and can lead to substantial improvement in
prognosis [7,1113]. Therefore, despite the lack of randomized study comparing percutaneous to surgical drainage of
postoperative abdominal abscesses drainage, PD has become a widely accepted treatment for accessible postoperative abscess and especially in case of unilocular abscess
[7,11,13,14]. Recently, with improved radiological experience, PD of complex abscesses (ie, loculated, poorly defined
collections, abscesses communicating with enteric fistulas,
and interloop abscesses) is commonly performed [15,16].
However, for such complex abscess, there is no definite
consensus regarding the use of PD as the initial treatment.

0002-9610/02/$ see front matter 2002 Excerpta Medica, Inc. All rights reserved.
PII: S 0 0 0 2 - 9 6 1 0 ( 0 2 ) 0 0 9 1 2 - 1

S. Benoist et al. / The American Journal of Surgery 184 (2002) 148 153

Accordingly, we performed this retrospective study in order

to determine the predictive factors for failure of PD of
postoperative abdominal abscess, to better select the patients with postoperative abdominal abscess who may benefit from PD as the initial treatment.

Patients and methods

Patients
From January 1992 to June 2000, the data of all patients
who have symptomatic postoperative intra-abdominal collection in our unit were reviewed. All collections were
diagnosed by CT scan. An abscess was defined as a collection of pus or infected fluid collection identified by CT
scan-guided needle aspiration and systematically confirmed
by positive microbiological culture. A CT scan-guided PD
was only attempted as initial procedure if abscess was
accessible to PD without risk of injuries of the pleural space
or abdominal organ, if diagnosis of diffuse peritonitis was
not suspected and in absence of septic chock at presentation.
In this setting, during the same period, 50 patients with
inaccessible abscess or diffuse peritonitis were drained surgically [17,18]. Furthermore, 10 patients with sterile fluid
collections were also excluded from the study. Seventythree patients who fulfilled these selection criteria were
treated by PD and formed the basis for this study. The study
group comprised 31 women and 42 men, with a mean age of
55 17.4 years (range 16 to 84). The different types of
initial surgical procedure are summarized in Table 1. In 26
patients, the initial operation was performed in an emergency setting.
An abscess was defined as simple when there was a
single unilocular cavity without evidence of an enteric connection on CT scan. Abscesses were defined as complex
when either a multilocular cavity or multiple abscesses were
present or when an enteric fistula communicating with the
abscess cavity was demonstrated. According to this definition, abscess was single in 52 patients (71%) and complex
in 21 (29%). In 24 patients, a fistula tract was present: a
biliary fistula was observed in 8 cases, a pancreatic fistula in
8 cases, and an enteric fistula in 8 cases. The mean size of
abscess was 7.2 2.6 cm (range 2 to 15 cm). The mean
interval between surgery and the diagnosis of intra-abdominal abscess by CT scan was 19 16 days (range 4 to 48).
Percutaneous drainage procedure
All the procedures were performed under local anesthesia and CT scan guidance. The catheter was inserted using
a modified Seldinger technique. Commonly a 18-gauge needle catheter was inserted percutaneously into the abscess. A
variable amount of aspirated contents was sent for Gram
stain, culture, and biochemical assays. After dilatation, a
multiple side hole catheter (Flexima Regular Medi-Tech;

149

Table 1
Type of initial surgical procedure in 73 patients undergoing
percutaneous drainage of postoperative intra-abdominal abscess
No. of
patients
Colorectal surgery
Rectal resection
Left colonic resection
Right colonic resection
Subtotal colectomy with ileo-rectal anastomosis
Total proctocolectomy with pouch-anal anastomosis
Hartmans procedure
Colorectal anastomosis after Hartmans procedure
Appendectomy
Hepatic and biliary surgery
Hepatic resection
Hepatic resection with common bile duct resection
Choledocoduodenal anastomosis
Cholecystectomy
Pancreatic and splenic surgery
Pancreaticoduodenectomy
Distal pancreatectomy
Bypass surgery
Splenectomy
Gastric surgery
Total gastrectomy
Partial gastrectomy
Small bowel resection
Adrenalectomy
Mesh repair for incisional hernia

32 (44)
3
7
6
5
3
1
1
6
18 (25)
10
2
2
4
12 (16)
5
5
1
1
6 (8)
4
2
2 (3)
2 (3)
1 (1)

Values in parentheses are percentages.

Boston Scientific, Massachusetts), size ranging from 8F to

16F, was left within the abscess cavity. Large drain was
chosen when viscous material was encountered. Sixty patients (81%) had a single drain placed, 12 patients (7%) had
two drains, and 2 patients (2%) had three drains. Aspirated
contents were pus in 48 cases (66%), infected hematoma in
16 cases (22%), infected bile in 6 cases (8%), and clear but
infected fluid in 3 cases (4%). Microbiologic culture showed
negative Gram stained organism in 70 cases, anaerobic in 40
cases, Enterococcus faecalis in 20, and Staphylococcus aureus in 7. In 44 cases, two or more organisms were detected.
Catheters were irrigated three times daily with 10 mL sterile
saline. Volume of drainage fluid was measured daily. Sixty
patients (82%) were maintained on broad-spectrum antibiotics. These were initially chosen empirically and were
subsequently changed, if necessary, to provide specific coverage based on culture and sensitivity results. The indication
of empiric antibiotic therapy was left to the discretion of
primary surgeon. Fifty patients were treated by empirical
double combination therapy (piperacillin-tazobactam and
gentamicin in 45 and a third-generation cephalosporin and
gentamicin in 15), and 10 patients by triple combination
therapy (ampicillin-clavulanat, metronidazole, and gentamicin).
In all patients, catheters were removed when drainage
had completely ceased and serial CT scan showed evidence

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S. Benoist et al. / The American Journal of Surgery 184 (2002) 148 153

of collapse or significant size reduction of the abscess cavity.

PD was considered to be successful if the patients intraabdominal infection resolved without the need for additional surgery. Drainage was considered as failure in case of
persisting clinical sepsis and when urgent or emergency
surgery was needed.
Statistical analysis
To determine the predictive factors for failure of PD,
patients were divided into two groups, based on whether or
not subsequent surgical drainage was required. Patients who
were successfully treated by PD, constituted the success
group and those, who required salvage surgical drainage,
the failure group.
Univariate analysis was used to examine the relationships between failure of PD and the 27 following variables:
age, sex, overweight (body mass index 27), diabetes mellitus, cirrhosis, cardiopulmonary disease (including coronary artery disease, history of myocardial infarction and
valvular heart disease), steroid treatment, American Society
of Anesthesiologists (ASA) classification, previous laparotomy, type of initial surgery, emergency or elective surgery,
benign or malignant disease, abscess characteristics included number, size, complexity, associated fistula, localization, type of aspirated content, volume of drainage at day
1, and type and number of organisms cultured, interval
between initial surgery and drainage, number of drain, size
of drain, antibiotic therapy and duration of antibiotic therapy, leukocytes blood count, and fever on the day of diagnosis of abscess. Quantitative data were expressed as
mean SD (range).
Comparisons between groups were analyzed by the chisquare test with Yates correction and the Mann-Whitney U
test for quantitative and qualitative variables, when appropriate. All variables associated with drainage failure with
P 0.20 in univariate analysis were examined consecutively by multivariate analysis using forward stepwise logistic regression. Significance was defined as p 0.05.
Statistical analysis was performed using biomedical software (SPSS, for Windows, 6.0, Chicago, Illinois).

Results
Successful catheter drainage was achieved in 59 of 73
(81%) patients. Five of them required repeated drainage. PD
failed in 14 patients (19%) for whom subsequent surgical
drainage was required. The indications for surgical drainage
were persistent sepsis in 5 patients, persisting fistula despite
effective drainage in 2, and recurrence of abscess with
sepsis after drain removal in 7. In patients with failed PD,
the mean interval of time from the initial PD to surgical
drainage was 11 9 days (range 1 to 30).
The overall mortality rate was 3% (2 patients). One

patient died of multiple system organ failure secondary to

pulmonary infection 2 months after successful PD of subphrenic abscess after partial gastrectomy for bleeding duodenal ulcer. A CT scan provided evidence of complete
collapse of abscess cavity. The other patient, who had
proved successful PD of subphrenic abscess after bypass
surgery for unresectable pancreatic tumor, died from massive tumor bleeding 1 month after surgery. No patient in the
failure group died after reoperation for surgical drainage.
One complication related to PD was observed in 1 patient in
the success group. This patient had transient respiratory
failure after drainage of peripancreatic abscess following
left colonic resection for diverticulitis. The mean duration of
catheter drainage in the success group was 13 12 days
(range 3 to 80). In the success group, drains were left in
place for a mean of 8.6 3.3 days for patients without
fistula tract and significantly longer for a mean of 23 17.6
days in patients with fistula (P 0.001). The mean hospital
stay after drainage of postoperative abdominal abscess was
17 11 days (range 6 to 59) in the success group and 24
13 days (range 10 to 60) in the failure group (P 0.05). In
the failure group, no patient required additional drainage
procedure for reaccumulated abscess after surgical drainage.
Univariate analysis showed four variables associated
with an increased risk of PD failure (Tables 2 and 3): gastric
resection as initial surgery (P 0.02), an abscess diameter
of less than 5 cm (P 0.01), the absence of antibiotic
therapy (P 0.02) and a mean duration time of antibiotic
therapy of less than 7 days (P 0.05). Multivariate analysis
showed that an abscess diameter of less than 5 cm and the
absence of antibiotic therapy only were significant predictive variables for failure of PD (Table 4).

Comments
Whatever the technique of drainage used, postoperative
intra-abdominal abscess remains a dreaded complication
[19]. PD could settle this problem, thus obviating additional
surgery. However, PD has to be considered only for located
abscess but is not indicated in case of diffuse peritonitis,
which requires a surgical approach [17,18].
Ultrasonography and CT scan allow an early diagnosis of
postoperative abscess and imaging-guided PD has thus been
used extensively in the treatment of postoperative abdominal abscess [20 22]. However, controversy remains regarding percutaneous treatment of complex abscesses associated
with a variety of factors such as multiple location, enteric
fistula. Several authors consider that abscess can benefit
from PD only in selected cases [19,2325]. Furthermore,
some authors reported that the mortality rate of salvage
laparotomy for failed PD could be extremely high, ranging
up to 50%, which is higher than those usually reported after
surgical drainage used as the initial procedure [19,26,27].
Our study, which includes patients with complex postoper-

S. Benoist et al. / The American Journal of Surgery 184 (2002) 148 153
Table 2
Univariate analysis of patient characteristics related to failure of
percutaneous drainage of postoperative intra-abdominal abscess in 73
patients

Age (years)
Sex (female/male)
Overweight (BMI 27)
Cardiopulmonary disease
Diabetes mellitus
Cirrhosis
Previous laparotomy
Steroid treatment
ASA status 2
Malignant disease
Initial surgery as emergency
Type of initial surgery
Colorectal surgery
Hepatic and biliary surgery
Pancreatic and splenic surgery
Gastric surgery
Others
Interval between surgery and
percutaneous drainage (days)
Leukocytes blood count
15,000
Fever 38.5C

Success
group
(n 59)

Failure
group
(n 14)

P
value

55 17
26/33
10 (17)
6 (10)
5 (8)
2 (3)
6 (10)
3 (5)
13 (22)
23 (39)
19 (32)

53 18
5/9
2 (14)
1 (7)

1 (7)
2 (14)
4 (28)
7 (50)
7 (50)

0.75*
0.73
0.85
0.84
0.66
0.81
0.80
0.48
0.79
0.71
0.38

25 (42)
17 (29)
11 (19)
2 (3)
4 (7)
20 15

7 (50)
1 (7)
1 (7)
4 (29)
1 (7)
26 23

0.71
0.18
0.58
0.013
0.64
0.22*

40 (68)

10 (71)

0.88

52 (88)

12 (86)

0.81

Values in parentheses are percentages.

* Mann-Whitney U test.
On the day of percutaneous drainage.
BMI body mass index; ASA American Society of Anesthesiologists.

ative abdominal abscess, showed that CT-guided PD was

successful in the majority of cases (81%). Multivariate analysis revealed that the absence of antibiotic therapy and an
abscess diameter of less than 5 cm were the only two
independent factors for failure of PD. In addition, the mortality rate of salvage surgical drainage for failure of PD was
nil. Therefore, we consider that PD associated with antibiotic therapy could be attempted as the initial treatment of
postoperative abscesses even in complex cases such as loculated abscess or associated with enteric fistula.
Our success rate of PD is lower than those usually reported by many authors [8,1214,21,28,29]. However, most
of previously published series included patients who have
not only postoperative abscess, but also abscess secondary
to diverticulitis or Crohns disease, which both constitute a
different situation. If we only consider the results of PD of
postoperative abscess, our success rate compares favorably
with those reported by others, ranging from 43% to 80%
[9,10,19,25,30 33].
The most appropriate management of postoperative abscess is not clearly defined in the literature. In particular,
indications and contraindications for PD are not well established so far. Ideally, this should be addressed by a prospective randomized trial, which is, however, not yet avail-

151

Table 3
Univariate analysis of abscess and drainage characteristics related to
failure of percutaneous drainage of postoperative intra-abdominal
abscess in 73 patients

Multiple abscesses
Size of abscess 5 cm
Complex abscess*
Associated fistula
Localization of abscess
Subphrenic
Subhepatic
Paracolic gutter
Pancreatic lesser sac
Type of aspirated content
Pus
Hematoma
Bile
Clear fluid
Initial volume of drainage
(mL)
Multiple cultured organism
Multiple drains
Size of drain 12F
Antibiotic therapy
Duration of antibiotic
therapy 7 days

Success
group
(n 59)

Failure
group
(n 14)

P
value

14 (24)
12 (20)
16 (27)
17 (29)

3 (21)
10 (71)
5 (36)
7 (50)

0.82
0.0008
0.69
0.23

24 (41)
18 (31)
25 (42)
5 (8)

4 (28)
3 (21)
6 (42)
2 (14)

0.61
0.78
0.83
0.85

38 (64)
13 (22)
5 (8)
3 (5%)
169 146

10 (71)
3 (21)
1 (8)

225 288

0.79
0.82
0.86
0.9
0.28

35 (59)
12 (20)
15 (25)
52 (88)
11/52 (21)

9 (64)
2 (14)
3 (21)
8 (57)
5/8 (62)

0.5
0.87
0.92
0.019
0.047

Values in parentheses are percentages.

* Abscesses were defined as complex when either a multilocular cavity
or multiple abscesses were present or when an enteric fistula communicating with the abscess cavity was demonstrated.
Several abscesses had multiple localization.
Mann-Whitney U test.
On the day of percutaneous drainage.

able. Knowledge of the predictive factors for failure of PD

of postoperative intra-abdominal abscess may be helpful in
selecting the patients who may benefit from this procedure.
Several authors have identified by univariate analysis predictive factors for failure of PD, including enteric fistula,
multiple or loculated abscess, large size of abscess, presence
of necrotic tissue and pancreatic localization [4,7,8,10,15,
20,21,27]. To our knowledge, our study is the first one, in
which predictive factors were determined by multivariate

Table 4
Multivariate analysis of predictive factors for failure of percutaneous
drainage of postoperative intra-abdominal abscess in 73 patients

Gastric surgery
Hepatic and biliary surgery
Size of abscess 5 cm
No antibiotic therapy
Duration of antibiotic therapy
7 days

Odds
ratio

95%
Confidence
intervals

P
value

2.09
1.87
7.45
3.82
1.36

0.7810.5
0.538.6
3.0113.88
1.788.21
0.4327.4

0.18
0.27
0.01
0.037
0.55

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S. Benoist et al. / The American Journal of Surgery 184 (2002) 148 153

analysis. Although the present work is one of the largest

series of patients with postoperative abdominal abscess
treated by PD, the small number of patients make analysis
of variables responsible for failure tenuous. It would be
probably interesting to check if similar result would be
observed in a larger cohort of patients.
If the efficiency of empiric antibiotic therapy has been
demonstrated in cases of postoperative diffuse peritonitis
[34], to our knowledge, there is no data about the role of
antibiotic therapy in specific case of postoperative intraabdominal abscesses treated by PD. Several authors [4,8,
12,15,21,25] use it routinely as a part of treatment while
others do not use it or neglect to notice it [3,11,12,19]. The
current data support their systematic use for a prolonged
period. Initially it should cover usual digestive organisms,
ie, anaerobic and negative Gram stained, and subsequently
adapted to culture results.
In our study, we found, surprisingly, that a small abscess
diameter appeared as an independent predictive factor for
failure of PD. Conversely, previous studies reported large
size of abscess as a cause of failed PD [14,15]. Several
hypotheses may be raised to explain our result. First, small
abscess may be more difficult to localize and less accessible
for insertion of drain. Second, small abscess may be more
prone to drain displacement resulting in incomplete drainage [33]. This hypothesis is further supported by the fact
that the 10 patients with small abscess in the failure group
were reoperated for persistent sepsis or sepsis recurrence
after drain removal, probably because of incomplete drainage. Some authors have reported that small abscess after
appendicectomy could be successfully managed with antibiotics alone [35,36]. However, in our study, if we only
focus on patients with an abscess diameter of less than 5 cm,
the use of antibiotic therapy was similar in the success (8 of
12, 75%) and failure group (7 of 10, 70%). We consider that
antibiotics alone are not sufficient for the treatment of small
but symptomatic postoperative abscess. In our study, a
lower but still clinically significant rate of success were seen
in patients with small abscess (12 of 22 patients; 55 %).
Furthermore, mortality rate was nil in patients who required
subsequent surgical drainage after failure of PD. Therefore,
for patients with small abscess, we consider that when an
abscess seems easily accessible on CT scan, PD could be
reasonably attempted and surgical drainage should be indicated only in patients without clinical improvement within
24 to 48 hours after PD.
Mortality and morbidity rates are two important issues to
be addressed before determining the best therapeutic option
for treatment of postoperative abdominal abscess. In our
study, overall mortality rate was 3%, which is similar to the
rate usually reported, ranging from 0% to 16% [3,4,10 12,
21,27]. In addition in our study, 2 patients died from causes
, which were not related to PD with no missed abscesses. As
in other reports [4,11,13,21,31], the rate of complications
directly attributable to PD was low in our study (ie, less than
10%). In particular no enteric fistula resulting from drain

misplacement occurred. Moreover, mortality and morbidity

rates favorably compared with those usually reported after
surgical drainage [5,6,37].
In conclusion, the results of our study suggest that, in
absence of diffuse peritonitis, CT scan-guided PD of postoperative intra-abdominal abscesses could be indicated in
first instance whenever feasible as a safe and relatively
atraumatic procedure with few complications. It should be
associated with a prolonged intravenous antibiotic therapy
as a part of treatment. Neither the presence of multiloculated
abscesses, multiple abscesses, nor intestinal fistulas precludes the use of PD.

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