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Abdominal emergency interventions

Ole Einar Heieren

• The concept of IR

• Emergency interventions

• Septic patient

• - Percutaneous drainage of collections of fluid

• - Percutaneous urinary interventions

• - Biliary interventions

• Complications

• Summary

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• Percutaneous minimally-invasive

• Real-time

• Images are used to direct interventional instruments throughout the body

• Diagnose and treat patients using the least invasive techniques

The concept of interventional radiology

• Offering curative therapy to some patients

• Capability to perform bedside procedures

• Reduction / elimination of the need for general anesthesia

• Possibility of delaying surgery in critically ill patients until it is feasible time

Advantages of IR

• Diagnosing

• Radiologic interventions techniques allow non-surgical treatment

• Detecting complications in follow-up studies

Radiology - imaging / interventions

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• Assist procedure planning and risk assessment

• Optimizing the preoperative status of the patient

• an intravenous line should be established before the procedure.

Pre-procedure

Guiding modality for IR is chosen on:– “what” and “where” to treat

– “target” (/organ) size

– personal preference of the interventional radiologist

– and appearance on the previous images in the different modalities

Fluoroscopy / CT / Ultrasound / MRI

-different advantages / limitasions

Anestesia ?

Pre-procedure

• In general the procedures are done in local anesthesia, but the patient may be monitored by an anesthesiologist under intravenous sedation.

• Standardization of technique for treatment

• Prophylactic antibiotics should be considered if procedural time exceeds 3 hours

• Procedure time

– Minimize risk / improve outcome

Procedure

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You can reach anywhere throughout the body with your needle

The value of clinical interventional radiology.

• Trocar: many drainage catheters come with the option of being deployed as a trocar by putting in an inner stylet

Seldinger vs. trocar

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• Dr. Sven-Ivar Seldinger (1921-1998), a Swedish radiologist from Mora, Dalarna County, who introduced the procedure in 1953.

Dr. Sven-Ivar Seldinger

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• Observation

• Suggest follow-up examinations- an abscessogram to evaluate the reduction in size of an abscess cavity / fistula formation

Post-procedure

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• CNS

• Vascular / bleeding

• Septic patient

- instituting IR in an emergency setting

Emergency interventions

• The Emergency Radiology provides constant and immediate consultation by interpreting all studies performed in the University Hospital Oslo, Ullevål.

• These studies range from minor injuries and illnesses to the most severe life-threatening afflictions, e.g., motor vehicle accidents, falls, gunshot wounds, etc.

• Some life-threatening conditions will need immediate abdominal emergency interventions.

Acute care imaging / IR

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• CNS

• Vascular / bleeding

• Septic patient

Acute non-vascular Abdominal IR

Dealing with the septic patient in the interventional radiology setting.

Interventionists must be prepared to institute therapy and manage the patient through the procedure

Septic patient

Percutaneous abscess drainage (PAD)

Percutaneous urinary interventions

Biliary interventions

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Bacterial peritonitis

Pancreatitis

Mediastinal abscesses after esophagectomy

Percutaneous abscess drainage (PAD)

• Infected tissue categorized by

– Location

– Viscosity

– Complexity

– Contents

– Etiology

– Surrounding structures

Percutaneous abscess drainage (PAD)

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• Abscesses on CT and US, strong signs:

– well-circumscribed fluid collection

– thickened membranes or septations

– peripheral contrast enhancement

– does not demonstrate central enhancement on imaging studies

– gas bubbles

– debris

Preprocedure evaluation

• Size (3 cm)

• Viscosity and complexity

• Complexe abscesses: – lytic agents– multiple catheters– maceration technique– larger diameter catheters

What can be treatet?

• An aggressive practical approach with relatively simple devices and techniques may yield a high success rate with few complications.

• Flush the catheters ?

• Drainage bag?

What can be treatet?

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• Follow up studies (abscessogram)

• Drainage time from 1 week to months– A fistula increases the duration of catheter use

– Adjust the volume and frequency of catheter flush

• Removal of catheter: – withdrawn when clinical, laboratory, and radiologic improvement is

observed

Post-interventional to PAD

d) left anterior pararenalSpace

a) transhepatic transgastric route -> lesser sac

b) transgastric route -> lesser sac c) gastrosplenic ligament .-> lesser sac

e) paravertebral accessf) right pararenal space to the

g) through the duodenum

Routs to the pancreatic bed

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The Salamander is set free

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….looking for the gallbladder mouse

Percutaneous urinary interventions

Pyonephrosis

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Cholangitis

Cholecystitis

Biliary interventions

Biliary interventions

• Percutaneous transhepatic cholangiography, PTC– image obstructions

– treatment (catheters / stents placement)

PTC : treatment of choice in benign anastomotic stricture after bilioenterostomy

• Cholecystostomy– Placement of a tube into the gallbladder

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“Rendevouz” = date

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Drainage of the gallbladder

Identify

Avoiding

Complications

• General or specific

• Early and delayed complications

• Minor / major complications

Complications

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• Pain

• Perforation

• Pneumothorax

• Infection

• Vascular(bleeding) and biliary injury

• Death

Radiological postinterventional complications

• Peritoneal bleeding can be treated with blood transfusions and / or transarterial embolization

• Infections are treated with administration of antibiotics (PAD?) and observation.

Rad. postinterventional complications cont.

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ECIO - European Conference on Interventional Oncology

CIRSE – Cardiovascular and Interventional Radiological Society of Europe

• Strategies for improving IR outcome:

– instituting IR in an emergency setting

– standardization of technique for treatment

– optimizing the pre-interventional status of the patient

– identify & avoiding complications

Summary

uxoler@ous-hf.no

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uxoler@ous-hf.no

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