Stephen Richard Preece MD, Presenter: Nothing to Disclose

Clare M. Haystead MD, Abstract Co-Author: Nothing to Disclose

Mustafa Rifaat Bashir MD, Abstract Co-Author: Research grant, Bracco Group

Tracy Anne Jaffe MD, Abstract Co-Author: Research Consultant, Osiris Therapeutics, Inc

Rendon C. Nelson MD, Abstract Co-Author: Consultant, General Electric Company Research support, Bracco Group Research support, Becton, Dickinson and Company Speakers Bureau, Siemens AG Royalties, Lippincott, Williams & Wilkins

This study was conducted to test the hypothesis that an intercostal approach to imaging-guided percutaneous subdiaphragmatic abscess drainage is equally as safe as a subcostal approach. The intercostal technique has been avoided by many clinicians, possibly based on out-dated evidence in the literature.

IRB approval and a waiver of informed consent was obtained for this retrospective study. A cohort of 202 consecutive patients with one or more subdiaphragmatic abscesses referred for imaging-guided percutaneous drainage was identified. Demographic characteristics and clinical outcomes were compared between patients who underwent an intercostal versus a subcostal approach for drainage catheter placement.

Percutaneous drainage was performed for 339 abscesses in 202 patients in 313 separate sessions (160 via an intercostal approach, 146 by a subcostal approach, and 7 by a combined approach). The total number of pleural complications in the intercostal group (44/160, 27.5%) was significantly higher than the subcostal group (14/146, 9.6%); p < 0.001. This included a significantly higher pneumothorax rate in the intercostal group (8/160 versus 0/146; p < 0.01), and a higher incidence of new or increased pleural effusions (33/160, 20.6% versus 13/146, 8.9%; p <0.005). The incidence of empyema was low and similar comparing the two groups (3/160 intercostal, 1.9% versus 1/146, 0.7% subcostal; p = 0.62). A subgroup analysis of the patients in the intercostal group found the overall rate of pleural complication to be independent of catheter size, direction of percutaneous entry, and the intercostal level traversed. Of the increased complications in patients who underwent an intercostal approach, few were clinically significant. Of the 8 pneumothoraces, only two required thoracostomy tubes; and of the new or increased pleural effusions, 8/33 (24.2%) underwent thoracentesis (versus 4/13 in the subcostal group, 30.8%), with only one considered infected.

An intercostal approach for imaging-guided percutaneous abscess drainage carries a significantly higher risk of pleural complication. The majority of these complications, however, are mild and do not require further intervention.

A subcostal approach is recommended for subdiaphragmatic abscess drainage; however, given the mild nature of intercostal approach complications, this should still be considered in selected patients.

Preece, S, Haystead, C, Bashir, M, Jaffe, T, Nelson, R, Safety of an Intercostal Approach for Imaging-guided Percutaneous Drainage of Subdiaphragmatic Abscesses.  Radiological Society of North America 2011 Scientific Assembly and Annual Meeting, November 26 - December 2, 2011 ,Chicago IL. http://archive.rsna.org/2011/11034261.html