Percutaneous Aspiration, Drainage, and Biopsy in Children

By Peter Liu, Alan Daneman, David A. Stringer, and Sigmund H. Ein Toronto, Ontario

�9 Between 1983 and 1987, 44 infants and children had 50 percutaneous aspiration, drainage, and/or biopsy pro- cedures under sedation and local anesthesia. Ultrasound occasionally supplemented by fluoroscopy was most com- monly used as guidance. Results of all 17 aspirations without drainage helped in management. Eighteen of 25 aspirations with drainage were successful. The major clinical improvement was related to the initial decompres- sion. Six of the eight biopsies were diagnostic, There were no complications or mortality. Our results show that percu- taneous techniques can be performed safely and effec- tively in infants and children. �9 1989 by W.B. Saunders Company.

INDEX WORDS: Interventional radiology; percutaneous aspiration, drainage, biopsy.

I NTERVENTIONAL radiology is now a widely accepted part of adult radiology. In recent years,

there has also been a steady growth and development of interventional techniques in pediatric radiology) -6 We report our experience with percutaneous interven- tional techniques in 44 children, and believe that these techniques can be performed safely and effectively in children.

MATERIALS AND METHODS

Between 1983 and 1987 (inclusive) we performed 17 aspirations (without drainage) in 14 patients (seven boys, seven girls), aged 1.5 to 17.5 years (mean 11.5 years) (Table 1). Percutaneous aspiration with drainage was performed 25 times in 22 patients (11 boys, 11 girls), aged 1.5 to 17 years (mean, 10.6 years) (Table 2). Percuta- neous biopsies were performed eight times in eight patients (five boys, three girls), aged 10 months to 17 years (mean, 9.6 years).

The patients and parents were visited before to explain the procedure and to secure an informed consent. Appropriate history, including drug, allergy, and bleeding histories were obtained. Bleed- ing parameters including PT, PTT, platelets, and hemoglobin were verified. The patients were fasted for at least four hours before the procedure. If they were to undergo aspiration and drainage, an intravenous (IV) line was established. All infants and children over 3 months of age were sedated intramuscularly in the Radiology Department 1/2 hour before the procedure. Local anesthesia was used at all puncture sites; supplemental IV sedation was sometimes administered during the procedure. One child required a general anesthetic. A pediatric nurse from the Radiology Department was in constant attendance in all cases to help monitor the vital signs, and for assistance.

Ultrasound was the image modality most commonly used, and was supplemented by fluoroscopy in one third of the cases. CT was used in six patients. Most interventional cases were performed in a remote control fluoroscopic suite with an overhead table tube. For percuta- neous aspiration, a no. 22 gauge spinal needle was used. For percutaneous drainage, a second puncture was then performed with an 18 gauge needle, and an appropriate size pigtail catheter (8.3 and 10 French) introduced via the Seldinger technique. A prepackaged nephrostomy kit (Cook, Bloomington, IN) was used for all cases. As

much of the fluid collection as possible was evacuated immediately after placement of the catheter. The pigtail catheter was usually connected to a Hemovac suction apparatus and the catheter irri- gated at least twice daily with normal saline. The timing of catheter adjustment and removal was made with the clinicians; most were removed within four days. The percutaneous biopsy needle selection was made in conjunction with the clinicians and the pathologists. The needles used included no. 22 gauge Chiba, no 22 spinal, no. 18 Tru-cut, and no. 19 Menghini Sure-cut.

RESULTS

Posi t ive cu l t u r e s were ob t a ined in 17 p e r c u t a n e o u s

asp i ra t ions w i t h o u t d r a i n a g e f r o m five d i f fe ren t loca-

t ions ( lung, l iver , spleen, paro t id , and subphren i c ) . T h e

resul t s of al l p e r c u t a n e o u s asp i ra t ions he lped in t he

c l in ica l dec is ion and m a n a g e m e n t o f t he ch i ld ren .

S u r g e r y was avo ided in 18 o f 22 pa t ien ts w h o h a d

p e r c u t a n e o u s asp i ra t ion wi th d ra inage . F o u r pa t i en t s ,

a l t h o u g h success fu l ly d ra ined , e v e n t u a l l y r e q u i r e d sur-

g ica l d r a i n a g e because o f pers i s ten t fever ( l iver , th ree ;

panc reas , one).7 S ix o f t he e igh t p e r c u t a n e o u s biopsies

were d iagnos t ic , i nc lud ing two l iver infec t ions , p resa -

c ra l i n f l a m m a t o r y mass , h e p a t o b l a s t o m a , a d e n o c a r c i -

n o m a involv ing the r igh t c a r d i o p h r e n i c node, and

r e c u r r e n t W i l m s ' t u m o r ; t he re were two t e c h n i c a l

fa i lures . T h e r e were no compl i ca t i ons or mor t a l i t y .

DISCUSSION

The radiologist should be actively involved in assess- ing the indications for percutaneous aspiration, drain- age, and biopsy with the referring physicians and surgeons. The principles of access route planning are similar to those in adults. They include avoidance of intervening bowel loops and vessels, avoidance of con- tamination of sterile spaces (such as pleural or perito- neal cavity) and collections, and if possible, using an extraperitoneal approach, the shortest path, and dependent drainage. The ideal fluid collection to drain would be unilocular and discrete, in contact with the abdominal wall and where an extraperitoneal access route is available. Almost any fluid collection can be drained, but major contraindications include the lack

From the Division of General Surgery and the Department of Radiology, Hospital for Sick Children, Toronto.

Date accepted: August 12, 1988. Address reprint requests to Peter Liu, MD, Department of

Radiology, Hospital for Sick Children, 555 University Ave, Toron- to, Ontario, M5G IX8 Canada.

�9 1989 by W.B. Saunders Company. 0022-3468/89/2409-0004503.00/0

Journal of Pediatric Surgery, Vo124, No 9 (September), 1989: pp 865-866 865

866 LIU ET AL

Table 1. Locations of Percutaneous Aspirations Without Drainage

Abdominal 7 Liver 4 Spleen 2 Parotid 1 Pleural 1 Lung 1 Subphrenic 1

Total 17

of an access route, frank peritonitis, uncontrolled coag- ulopathy, and Ecchinococcal disease. Minor contrain- dications include multiple or multilocular abscess, fungal abscess, necrotic infected tumor, and tiny col- lection. In our series, the peritoneal and subphrenic collections were mostly postoperative or posttraumatic in origin.

Choosing the appropriate sedation can be difficult, but is obviously essential. Fortunately our sedation protocol has worked well, and has also been the seda- tion used for cardiac catheterization in our hospital for over 20 years. CM3 consists of Meperidine 25 m g / m L , chlorpromazine 6.25 m g / m L , and promethazine 6.25 m g / m L ; the dose used in 0.1 mL/kg , to a maximum dose of 2 mL. CM3 is not given to infants <3 months of age, because of bradycardiac effect.

The "last image" hold feature of the fluoroscopic equipment (Siemens Siregraph; Siemens Medical Sys- tems, Erlangen, Federal Republic of Germany) 2 kept fluoroscopic time to less than a minute when needed. Real-t ime ultrasound was easier and faster than CT; the latter was reserved for small lesions, lesions that could not be visualized by ultrasound, or when the access route was difficult.

Table 2. Locations of Percutaneous Aspirations With Drainage

Abdominal 12 Subphrenie 6 Pancreas 4 Retroperitoneum 3

Total 25

Depending on clinical circumstances and in consul- tation with the clinicians and pathologist, small or large bore needles may be used for percutaneous biopsy. Some considerations in the needle selection include lesion size, access route, bleeding parameters, known primary malignancy, and the preference of the cytopathologist, s'9 In our hospital, the pathologists prefer larger samples because pediatric tumors tend to be sarcomas, which require larger tissue samples for a more specific diagnosis.

The major clinical improvement with percutaneous drainage was related to the initial decompression. Successful drainage decreased fever, pain, leukocyto- sis, volume of drainage, and size of the collection. Potential complications include sepsis, hemorrhage, bowel perforation, pneumothorax, empyema, and sinus tract and fistula; there were no complications in our series. Four of our 22 percutaneous aspiration with drainage patients required surgical drainage (three, liver; one, pancreas). Hematomas and pseudocysts were more difficult to treat as in other series. 1,7

Our results concur with other published series 16 that percutaneous techniques can be performed safely and effectively in infants and children. They also suggest an increasingly important role for percutaneous drain- age in the future, with avoidance of the risks of general anaesthesia and surgery, better patient tolerance and cost savings to the health care system.

REFERENCES

1. Stanley P, Atkinson JB, Reid BS, et al: Percutaneous drainage of abdominal fluid collections in children. A JR 142:813-816, 1984

2. Diament M J, Boechat MI, Kangarloo H: Interventional radi- ology in infants and children: Clinical and technical aspects. Radiol- ogy 154:359-361, 1985

3. Towbin RB, Strife JL: Percutaneous aspiration, drainage and biopsies in children. Radiology 157:81-85, 1985

4. Van Sonnenberg E, Wittich GR, Edward DK, et al: Percuta- neous diagnostic and therapeutic interventional radiologic proce- dures in children: Experience in 100 patients. Radiology 162:601- 605, 1987

5. Diament M J, Stanley P, Kangarloo H, et al: Percutaneous

aspiration and catheter drainage of abscesses. Pediatrics 108:204- 208, 1986

6. Baker DE, Silver TM, Coran AG, et al: Postappendectomy fluid collections in children: Incidence, nature, and evolution evalu- ated using US. Radiology 161:341-344, 1986

7. Torres WE, Evert MB, Baumgartner BR, et al: Percutaneous aspiration and drainage of pancreatic pseduocysts. A JR 147:1007- 1009, 1986

8. Schaller RT, Schaller JF, Buschmann C, et al: The usefulness of percutaneous fine-needle asPiration biopsy in infants and chil- dren. J Pediatr Surg 18:398-405, 1983

9. Sabbah R, Ghandour M, Ali A, et al: Tru-cut needle biopsy of abdominal tumors in children. Cancer 47:2533-2535, 1981