Chest and pleural cavity
Image guidance reduces the complication rate compared to "blind" drainage. The procedure is most commonly required for pleural collections: simple effusions (simple effusions), hemothorax, empyema, and pneumothorax. Ultrasound is sufficient for uncomplicated fluid, whereas CT is required for multiloculated encapsulated collections.
Early evacuation of exudate is necessary to sterilize the cavity, promote lung re-expansion (lung re-expansion), and prevent progression. The natural course of undrained exudate ends in the formation of a fibrous pleural peel (fibrous pleural peel), where percutaneous drainage is no longer effective and surgical decortication is required.
Choice of catheter size:
- 6–8 F: for simple, free-flowing fluid.
- >8 F: for more viscous, complicated collections.
- 36–38 F: classical surgical drains, preferred for post-traumatic hemothorax (though small postoperative collections can also be drained with small-bore catheters).
Access is established in the most dependent (lowest) part of the collection. The puncture is made strictly along the upper edge of the rib (to avoid injuring the neurovascular bundle), avoiding proximity to the scapula. For simple transudates, standard thoracentesis may be performed, but no more than 1.5 L of fluid should be evacuated at one time to avoid complications. Post-procedure imaging (X-ray or CT) is mandatory to rule out pulmonary edema and pneumothorax.
Note: Lung abscesses are rarely drained (only upon deterioration despite antibiotics), and pericardial collections are drained in the presence of signs of cardiac tamponade.
Liver parenchyma and biliary tract
Liver abscesses occur when microorganisms enter from the portal vein or biliary tract. In 46–71% of cases, more than one abscess is present.
- Pyogenic abscesses require mandatory catheter drainage. Isolated forms are frequently caused by Klebsiella pneumoniae, and multiple forms by Escherichia coli.
- Amebic abscesses are drained only if there is a risk of rupture, if the size exceeds 6–8 cm, or if conservative therapy fails.
- Infected tumors are rarely drained; the decision is made with extreme caution.
The procedure is performed under ultrasound or CT guidance. The ideal trajectory should run through an area of normal liver tissue. Transgression (puncture) of the pleura is undesirable, but if it occurs, careful monitoring of the pleural fluid is required. Before removing the tube, contrast must be injected to rule out communication between the abscess and the biliary tract. For patients with acute cholecystitis and high surgical risks, percutaneous cholecystostomy is the optimal solution.
Pancreas and pancreatonecrosis
To standardize the management of pancreatic pathologies, the revised Atlanta criteria (revised Atlanta criteria) are applied. Safe anterior access to the pancreatic head is achieved through the gastrocolic ligament (lig. gastrocolicum), and to the tail through the anterior pararenal space. Puncture of the liver and stomach is permissible during navigation, but passing through the intestinal wall is strictly prohibited.
Acute pancreatitis can lead to the formation of pseudocysts, which are drained if complicated by infection or resistant symptoms (pain, obstruction).
Acute pancreatonecrosis with signs of abscess formation (presence of gas or a thick contrast-enhancing wall on CT) requires large-bore catheters (22–24 F) with continuous irrigation, as the contents are extremely viscous. Essentially, this is percutaneous necrosectomy. Such drainage serves as a "bridge to surgery," since open operations in the first 4 weeks are associated with high mortality.
Removal of the drain in pancreatonecrosis may take months. A mandatory step is transcatheter fistulography (fluoroscopic contrast injection). If communication with the pancreatic duct is detected, endoscopic duct stenting is indicated.
Briefly: answers to topical questions
What are the indications for percutaneous drainage of lung abscesses?
Image-guided percutaneous drainage of lung abscesses is indicated only in cases of persistent or worsening clinical course.
Lung abscesses are rare, typically occurring against the background of aspiration or immunodeficiency. Most of them resolve with antibiotic therapy.
What clinical and radiological criteria are used to decide on chest tube removal?
The decision to remove a chest tube is based on the patient's clinical and radiological improvement.
The main criteria for removal include:
- Cessation of air leak — no bubbling through the drain for more than 24 hours (in pneumothorax (pneumothorax), the tube is removed 24 hours after complete resolution).
- Reduction in exudate volume — fluid output of less than 200 mL/day.
- Radiological signs — complete lung expansion on radiography and no signs of retained hemothorax (haemothorax).
The cessation of air bubbling through the drainage tube serves as the primary indication for considering its removal.
The rule of thoracic access: "Walk over the roof, not under the cornice" — the puncture is always made above the upper edge of the rib, as the neurovascular bundle is hidden beneath the lower edge (in the costal groove).
Class and exam questions
When is immediate drainage required for a pleural effusion?
An absolute predictor of the need for chest tube insertion is a pleural effusion pH drop below 7.2.
Is it permissible to puncture organs when accessing the pancreas?
Yes, transgression of the liver and stomach is permitted if necessary. However, passing a catheter through the small or large intestine is strictly prohibited.
What to do if a pleural effusion is too viscous and fails to drain?
In such cases, the catheter is replaced with a larger diameter one under fluoroscopic guidance, or fibrinolytics (e.g., tissue plasminogen activator — tPA) are administered into the lumen.
What else to study on this topic
- Chest tube management: eliminating air leaks and bronchopleural fistulas
- Chemical pleurodesis techniques for recurrent effusions and pneumothoraces
- Specifics of image guidance in mediastinal collection drainage
- Transcatheter fistulography in pancreatonecrosis: technique
- Differential diagnosis of transudate and exudate prior to drainage
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