Safety of an intercostal approach for imaging-guided percutaneous drainage of subdiaphragmatic abscesses

The objective of our study was to test the hypothesis that an intercostal approach to imaging-guided percutaneous subdiaphragmatic abscess drainage is as safe as a subcostal approach.

A cohort of 258 consecutive patients with one or more subdiaphragmatic abscesses referred for imaging-guided (CT or ultrasound) percutaneous drainage was identified. Demographic characteristics and clinical outcomes were compared between patients who underwent drainage catheter placement via an intercostal approach versus those who underwent drainage catheter placement via a subcostal approach.

Percutaneous drainage was performed for 441 abscesses in 258 patients in 409 separate procedures (214 via an intercostal approach, 186 by a subcostal approach, and nine by a combined approach). The total number of pleural complications was significantly higher in the intercostal group (56/214 [26.2%]) than the subcostal group (15/186 [8.1%]; p < 0.001). These complications included a significantly higher pneumothorax rate in the intercostal group than the subcostal group (15/214 [7.0%] vs 0/186 [0%], respectively; p < 0.01) and a higher incidence of new or increased pleural effusions (38/214 [17.8%] vs 14/186 [7.5%]; p < 0.01). The incidence of empyema was low and similar between the two groups (intercostal vs subcostal, 3/214 [1.4%] vs 1/186 [0.5%]; p = 0.63). A few of the complications in the patients who underwent an intercostal-approach drainage were clinically significant. Four of the 15 pneumothoraces required thoracostomy tubes and eight of 38 (21.1%) pleural effusions required thoracentesis, none of which was considered infected.

An intercostal approach for imaging-guided percutaneous drainage is associated with a higher risk of pleural complications; however, most of these complications are minor and should not preclude use of the intercostal approach.