422 AJR:194, February 2010

cases. For reasons that remain unclear, how-

ever, a substantial minority (| 1025%) 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 conict-
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; 194:422429
0361803X/10/1942422
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 26% of
patients whose condition becomes manifest at
a later stage with appendiceal perforation with
or without appendiceal abscess [24].
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
[58]. This approach manages the initial in-
ammatory 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 ndings 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, 1875 years) underwent CT-
guided percutaneous drainage for the management of acute appendicitis complicated by per-
foration and abscess. Three board-certied radiologists independently reviewed preprocedure
CT images. Patients were assigned to one of three risk categories on the basis of the CT nd-
ings. Success and failure of percutaneous drainage were dened 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 ndings, 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 dened 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
ndings 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 conrm the diagnosis of acute appen-
dicitis with perforation. Seven of the 48 patients
were excluded because of a history of Crohns dis-
ease (ve patients) or concomitant tuboovarian ab-
scess (two patients). The other 41 patients (mean
age, 38 years; range, 1875 years) composed our
study cohort, which included 24 men (mean age,
40 years; range, 1875 years) and 17 women (mean
age, 29 years; range, 2050 years).
The nal 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 ndings [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, 0210 days) after the primary drainage
procedure, a nal diagnosis of appendiceal per-
foration was conrmed when appendiceal perfo-
ration was macroscopically evident (n = 5), when
transmural inammatory cell inltrate 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 conguration, 16
0.625 mm; effective section thickness, 5 mm;
reconstruction interval, 5 mm; gantry rotation
time, 0.5 second; beam pitch, 1.75; 100350 mA
depending on the patients body habitus; 140 kVp.
Patients ingested 450 mL of a 2% barium sulfate
suspension (Readi-Cat 2, E-Z-EM) 12 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 operators 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 420 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 Scientic) was determined by the attending
radiologist. Abscess drainage was performed with
CT or CT uoroscopic 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 3050 mm Hg of suction. The inpatient
nursing service ensured catheter patency by ush-
ing the catheter lumen with 1015 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 ndings of com-
plete resolution of the target uid collection.
Data Collection
Preprocedure CT findings and risk catego-
rizationThree board-certied 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 nal
Fig. 1Flowchart 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 (dened as a uid collection adjacent to
the appendix with attenuation of 020 HU), peri-
appendiceal phlegmon (dened 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 identied, readers also documented the size
(dened as the single largest transverse diameter)
and margins (either well-circumscribed or poorly
dened) of the uid collection.
In an attempt at stratication according to se-
verity of inammatory disease and size and com-
plexity of abscess, patients were assigned to one of
three risk categories on the basis of the CT nd-
ings. Based on a classication 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 dened 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 detailsDetails 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.
EffectivenessThe 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 dened per patient (i.e., clinical out-
come) and per procedure (i.e., technical outcome).
Clinical success was dened as patient recovery
after single or multiple procedures with or with-
out interval elective appendectomy. Clinical fail-
ure was dened 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 dened 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 uid was aspirated
A
C
Fig. 2Three-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 airuid 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 dened periappendiceal abscesses
extending to distant locations). Transverse CT image shows large, poorly-dened
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 classied in accordance with suggested
reporting criteria [14].
Predictive variablesCandidate predictive
variables selected included demographic charac-
teristics (age and sex), preprocedure CT ndings
(risk category and presence of extraluminal gas or
appendicolith and small-bowel obstruction), and
factors related to the rst 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 rst 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 signicance.
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 ndings,
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, 0.810.5 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 identication 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 uid collections at pre-
procedure CT, 5350 mL of uid was aspirat-
ed during the drainage procedure. Aspiration
revealed purulent uid 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. 318-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, inammatory changes in
adjacent fat tissue (category 2), and 1-cm extruded appendicolith (curved arrow).
B, CT uoroscopic 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 uid. 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, 8199%), 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 ndings 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 uid 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 patients 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
rst procedure was 88% (36 of 41 patients;
95% CI, 7898%). Although ve procedures
(10%) in ve 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 uid
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
ndings, 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, 0.010.67; p = 0.05) and extralumi-
nal appendicolith (odds ratio, 0.09; 90% CI,
0.090.83; 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, 1.545140.48; 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 2375 1573 1657 1875
Abscess size (cm)
Mean 2.5 4.5 5.3 4.1
SD 0.4 1.6 2.1 2.0
Range 0.83 3.57 410.5 0.810.5
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 0200 15350 070 0350
NoteValues 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. 426-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 inammatory changes in adjacent
fat tissue (category 2). Abscess would have been difcult 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 uoroscopic 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. 519-year-old woman with right lower quadrant pain and fever.
A, Transverse contrast-enhanced CT scan shows 5.8-cm poorly dened abscess
(black straight arrows) in right lower quadrant of abdomen with inammatory
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 uoroscopic 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, 0.010.99; 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
12 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)
NoteValues 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 uid 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 [58] and
conrm 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, stula formation, wound infec-
tion, prolonged ileus, and adhesions [4].
Another clinically important nding 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 rst 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 inammatory 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
dened periappendiceal abscess (category 3)
and extraluminal appendicolith were the two
most specic predictors of unfavorable clinical
outcome of percutaneous drainage. This nd-
ing, which remained signicant 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-
ties 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 signicantly 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
nding did not reach statistical signicance, 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 ndings 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 reect 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 ndings of large, poorly dened
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
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