British Journal of Radiology 75 (2002),470-473 © 2002 The British Institute of Radiology
Mediastinal abscess successfully treated by percutaneous drainage using a unified CT and fluoroscopy system
T Tanaka, MD
Y Inaba, MD
Y Arai, MD
K Matsueda, MD
T Aramaki, MD
and
S Dendo, MD
Department of Diagnostic Radiology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-ku, Nagoya 464-8681, Japan
Correspondence: Yoshitaka Inaba, MD
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Abstract
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We report two patients with mediastinal abscess developing after surgery for oesophageal cancer who were treated by percutaneous drainage using a unified CT and angiography system, which allows both CT and fluoroscopy to be conducted with the patient on the same bed. Fine needle puncture is performed under CT guidance and this needle is used as a tandem for insertion of the drainage needle under fluoroscopic guidance, making safe puncture possible whilst confirming the position of the needle tip. Moreover, contrast medium can be injected from the drainage tube, allowing the extent of the abscess cavity to be determined by fluoroscopy and CT, thereby making accurate drainage possible.
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Introduction
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When performing percutaneous drainage for mediastinal abscess, it is vital that the positions of the adjacent lung and large vessels are known to establish whether an approach under CT guidance is useful [1]. However, since the direction of the puncture needle and catheter manipulations cannot be appreciated in real-time with CT alone, most techniques are forced to rely on blind manipulations, which are not only difficult but also raise safety issues.
In recent years, unified CT and angiography systems have made it possible to perform both CT and fluoroscopy with the patient on the same bed. Because fluoroscopy can be added to widely available CT systems, such unified systems can be used for post-operative abscess drainage, a situation in which their usefulness has already been reported [2, 3]. In this paper we describe our experience of two patients with mediastinal abscess developing after surgery for oesophageal cancer who were treated by percutaneous drainage performed under both CT and fluoroscopy using this type of unified CT/angiography system.
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Case 1
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An 80-year-old man underwent thoracico-oesophagectomy and cervico-oesophagogastrostomy via the retrosternal route for stage IV oesophageal cancer. Persistent fever of 38 °C developed from the 4th post-operative day. On blood examinations, white blood cell count (WBC) and C-reactive protein (CRP) were markedly elevated to 12 150 µl-1 and 9.4 mg dl-1, respectively. Chest CT performed on the 10th post-operative day revealed an abscess on the dorsal side of the tracheal bifurcation (Figure 1a
), for which percutaneous drainage was performed the following day. Initially, a puncture route was planned on the basis of the chest CT obtained the previous day, approaching the abscess from the dorsal side via the right paravertebra. After CT was performed with the patient in the prone position, a puncture route was decided and the patient's skin was marked with a puncture point. A puncture was made under local anesthesia with a 23 G fine needle and its direction confirmed by CT. Using the fine needle as a tandem, a 17 G drainage needle was inserted under fluoroscopic guidance (Figure 1b). By sliding the single bed between the CT gantry and the fluoroscopic imager, CT and fluoroscopic monitoring were available as necessary. After confirming with CT that the drainage needle tip had reached the cavity (Figure 1c), the presence of reverse flow of abscess fluid from the needle on aspiration was confirmed. A 0.035'' J-shaped guidewire was then inserted and a 12 F drainage tube was placed under fluoroscopic guidance. Immediately after placement, contrast medium was injected from the tube. Filling of the entire cavity with contrast medium was confirmed by CT (Figure 1d). The inflammation subsided the following day. Antibiotics (gentamicin or piperacillin) were administered for 20 days and the abscess cavity was shown to have completely disappeared on contrast enhanced CT performed 35 days later, thus the drainage tube was removed. The patient was discharged on the 45th day after the drainage procedure.
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Figure 1. Case 1. 80-year-old man with mediastinal abscess after surgery for oesophageal cancer. (a) CT obtained 10 days after surgery shows the abscess cavity on the dorsal side of the tracheal bifurcation. (b) Radiograph shows the position of the 17 G drainage needle inserted under fluoroscopic guidance in tandem with the 23 G fine guiding needle. (c) CT shows the appropriate course of the drainage needle. (d) CT after injection of contrast medium from the drainage tube shows the abscess cavity.
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Case 2
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A 47-year-old man underwent thoracico-oesophagectomy and cervico-oesophagogastrostomy via the retrosternal route for stage IV oesophageal cancer. Fever of 39 °C persisted from the 2nd post-operative day. On blood examinations on the 6th post-operative day, WBC and CRP were markedly elevated to 19 200 µl-1 and 29.5 mg dl-1, respectively. Chest CT performed on the 7th post-operative day revealed an abscess on the right of the trachea, for which abscess drainage was performed the following day using the same technique as in Case 1. In this case, a route from the right anterior chest was selected (Figure 2). The inflammation subsided the following day. The same types of antibiotics (piperacillin or imipenem) were administered for 6 days and the abscess cavity was shown to have almost completely disappeared on contrast enhanced CT performed 11 days later, thus the drainage tube was removed. The patient was discharged on the 26th day after the drainage procedure.
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Figure 2. Case 2. 47-year-old man with mediastinal abscess after surgery for oesophageal cancer. CT shows the drainage tube placed percutaneously.
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Discussion
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Mediastinal abscess is a serious condition associated with a high mortality rate of approximately 25% [4]. Causes include oesophageal and cardiac/aortic disorders in the post-operative state in many cases, as well as perforation due to a foreign body in the oesophagus, endoscopic trauma and spread of cervical infections. In the case of oesophageal cancer surgery, inadequate wound closure is seen in many cases after surgery, and surgical materials left within the operative field are thought to be another possible cause [5]. Treatment of this condition requires administration of antibiotics effective against anaerobic bacteria as well as mediastinal drainage [6]. With regard to the drainage method, early surgical mediastinotomy has been reported to be desirable, but it is not feasible in many cases owing to the presence of factors such as advanced age, disseminated intravascular coagulation, immunodeficiency and malnutrition. Moreover, particularly in the early post-operative period, the patient's general state is usually poor, with the risk of re-operation high, and so in a large proportion of cases percutaneous drainage is indicated [1].
Percutaneous drainage in which puncture drainage of the abscess is performed under conventional CT guidance has been reported [7–9]. CT is excellent in defining the positional relationship between the abscess and its adjacent organs and is also useful in determining a puncture route. However, because the puncture and catheter manipulations are performed in a blind fashion, there may be an increased chance of major complications in the mediastinum, particularly in areas adjacent to lung and large blood vessels. Using fluoroscopy in addition to CT without transfer of a patient may reduce the number of blind manipulations, avoiding much of this risk.
In the present study, mediastinal abscess drainage was performed using a unified CT/angiography system. Initially, CT was used to define the positional relationship of the abscess with adjacent lung and large blood vessels, and the safest as well as the shortest drainage route was established. In Case 1, because the abscess cavity was located in the posterior mediastinum dorsal to the tracheal bifurcation, a route from the dorsal side via the right paravertebra was selected. In Case 2, however, the abscess cavity was located to the right of the trachea, thus a route from the anterior chest was selected, since a puncture route that reached the abscess cavity from the right side of the sternum without passing through the lung could be achieved. Next, a puncture was made with a fine needle and, after confirming by CT that this route was suitable, a 17 G drainage needle was inserted along the fine needle. Particularly in cases such as Case 1, in which the puncture angle was slanted, use of fluoroscopy makes it possible to confirm the angle at which the puncture is made, greatly enhancing the safety of the procedure compared with blind puncture. In addition, subsequent insertion of the guidewire into the abscess cavity in an arc-like manner can be confirmed by fluoroscopy. Placement of the drainage tube along the guidewire, also under fluoroscopic guidance, is possible with confidence that it has been inserted into the intended site, thus making accurate drainage tube placement and drainage of the entire abscess cavity possible. Moreover, immediately after placement of the drainage tube, contrast medium was injected from the drainage tube and the extent of drainage was confirmed by CT, making it possible to judge the usefulness of the inserted drainage tube. We previously reported that the abovementioned technique under CT and fluoroscopic guidance using a unified CT/angiography system was also useful for percutaneous drainage of abscesses developing in other regions such as the abdomen and pelvis [2].
We conclude that this type of unified CT/angiography system, which makes possible the use of both CT and fluoroscopy on the same bed, is extremely useful in performing mediastinal abscess drainage safely and accurately.
Received for publication July 30, 2001.
Revision received October 30, 2001.
Accepted for publication November 27, 2001.
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Abstract
Introduction
