2011 27 recommends that timing of intervention
to control the source of sepsis, that is, surgery or
equivalent (for example, radiological drainage)
should be carried out in a time frame consistent
with the severity of the clinical situation, so that,
where relevant, source control should be
undertaken immediately in patients with septic
shock, within six hours in patients with organ
dysfunction but without shock, and in less
severely ill patients with uncomplicated sepsis
within 18 hours. These targets were established
prior to the most recent definitions of sepsis and
it remains to be seen how they will be changed
given more recent emphasis on qSOFA and
NEWS2 scores as soon as possible.
Early detection
and timely
therapeutic
intervention
can improve
prognosis and
overall clinical
outcome in
septic patients
Radiological intervention
Traditionally, drainage of collections has been
achieved by surgical exploration. However,
radiological drainage of abdominal abscesses
using ultrasound was first described in 1974 28 and
CT in 1977. 29 While surgical intervention is still
required where drainage of an abscess alone
cannot achieve source control (for example in
free visceral perforation or where resection or
debridement are required), where radiological
drainage cannot be undertaken adequately or
safely (for example, where there are multiple
and /or interloop abscesses), in many cases
radiological drainage is possible and here it is the
standard of care. 29,30 Most authorities recommend
draining all collections larger than 3cm in
patients with systemic signs of infection. 29,31
A national study conducted in the USA has
reported that the number of percutaneous
drainage procedures for intra-abdominal sepsis
more than doubled between 2001 and 2013,
while the laparotomy rate fell by 21% over the
same period. 30 Similar studies in patients with
intra-abdominal abscesses due to Crohn’s
disease noted that 29% could be managed
by percutaneous drainage, whereas 32% still
required surgery. 32
Interventional techniques can also be used
to treat other foci of sepsis. A study comparing
clinical efficacy and adverse events of
percutaneous cholecystostomy (PC) and early
cholecystectomy (EC) in a large group of severely
ill patients with acalculous cholecystitis (AC) has
shown PC to be a safe and cost-effective bridging
treatment strategy, with perioperative outcomes
superior to those of early open cholecystectomy.
Compared with open or laparoscopic EC, PC was
superior in terms of morbidity, intensive-care unit
admissions, length of hospital stay, and cost. 33
Two studies have shown that PC is an effective
procedure in seriously ill patients with AC and
may be regarded as a definite treatment option
in the majority of patients. 34,35 Percutaneous
drainage of liver and splenic abscesses can also be
undertaken safely as first-line treatment prior to/
instead of surgical intervention. A meta-analysis
of five randomised, controlled trials comparing
catheter drainage and repeated needle aspiration
of liver abscesses has demonstrated catheter
drainage to be more effective, with higher
success and shorter time to achieve clinical
improvement. 36 Drainage of retroperitoneal
collections can be performed transgastrically
where required. Drainage of pelvic collections can
be challenging and in appropriate circumstances
a transgluteal approach and endoscopically
assisted ultrasound-guided drainage by
transrectal, transperineal or transvaginal access
is associated with a low risk of complications and
should be considered for deep pelvic abscesses. 37
European consensus guidelines recommend
catheters of 7 – 10F for the treatment of most
abscesses, regardless of abscess dimensions.
However, large catheters (>10F) may be required
for complex abscesses with thick contents. 37
There are still no established guidelines for
subsequent management of drains with regards
to flushing the abscess, interval imaging and
timing of removal. Regular, small-volume, gentle
flushes should be used in such abscess cavities.
Some centres advocate contrast-imaging prior to
drain removal, 38 while others recommend that
drains be removed 48 hours after output has
stopped, following repeat imaging. 39
Surgical treatment
Surgery will be required where radiological
source control is not possible and where
a patient needs a definitive procedure, for
example, resection or debridement of necrotic
tissue, management of complete anastomotic
dehiscence, proximal diversion of the
gastrointestinal tract etc. It may also be safer
in some circumstances to transfer an unstable
patient to an operating theatre than to the
radiology department to establish source
control.
Timing and adequacy of surgical source
control are vital. The third National Emergency
Laparotomy Audit (NELA) reported on the
outcome of approximately 4000 patients
requiring laparotomy for peritonitis and found
an average delay of eight hours to reach theatre
after admission to hospital. 24 If the diagnosis has
been ascertained, a tailored approach should be
undertaken with regards to the optimum
approach and technique. In dangerously unstable
patients, a truncated ‘source/damage-control
operation’ can be undertaken, in which abscesses
are drained, bowel resected with the stapled ends
left in situ and a planned re-laparotomy (RL)
subsequently undertaken. 40
Kim et al showed that 22% of patients
undergoing emergency surgery for intra-
abdominal catastrophes, of whom at least 65%
had sepsis, required a further unplanned
laparotomy. Risk factors for RL were identified
to be peripheral arterial disease, alcohol abuse,
body mass index >29, ischaemic bowel and an
Inadvertent enterotomy
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