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This article has tried to provide some perspective on the results of surgical and percutaneous drainage of intra-abdominal abscesses and the impact of CT localization on the successful management of this problem. It is most likely that the recent decrease in mortality for intra-abdominal abscesses over the past decade is due to a variety of factors, including better antibiotics, more aggressive critical care, and earlier diagnosis and treatment of the intraabdominal problem. These factors combined to reduce the incidence of pre-drainage organ failure and the degree of physiologic derangement of these patients at the time of their abscess drainage. Percutaneous drainage and surgical drainage techniques should not be considered competitive but rather complementary. If an abscess is accessible by percutaneous techniques, it is reasonable to consider a nonoperative approach to the problem. It is also clear that patients should respond promptly to whatever technique is employed to drain their intra-abdominal abscess. An improvement should be seen clinically within 24 to 48 hours following drainage. Should improvement not be forthcoming, the patient must be aggressively re-evaluated with repeat CT and decisions made by the responsible surgeon in consultation with the radiologist as to the next appropriate course of action. As our review of the Wayne State University experience suggested, patients are never too sick for an appropriate operation. Although it appears that most abscesses can be successfully treated by percutaneous drainage, pancreatic abscesses with pancreatic necrosis should generally be treated by surgical debridement, usually accompanied by repeated explorations. In addition, splenectomy has not yet been replaced by percutaneous drainage of splenic abscesses.

The APACHE II Score was used to stratify retrospectively severity of illness in 91 patients postoperatively undergoing drainage of intra-abdominal abscesses. The method of initial abscess drainage (percutaneous or operative) was selected by the attending physician. The two groups of patients, those whose initial drainage was performed percutaneously versus operatively were similar with respect to age, sex, abscess location and, most importantly, severity of illness as assessed by the APACHE II score calculated on the day of their abscess drainage. Over-all, the mortality rate was 29 per cent (26 of 91 patients). Only 1.7 per cent of the patients with an APACHE II score of less than 15 died compared with 78 per cent when APACHE II was equal to or more than 15 (p less than 0.0001). Only 8 per cent of patients with APACHE II equal to or more than 15 undergoing percutaneous drainage survived compared with 30 per cent of patients who underwent surgical drainage procedures. While chi-square analysis demonstrated independence between outcome and drainage technique, outcome was dependent upon severity of illness (p less than 0.0005). Paradoxically, despite the attractiveness of a percutaneous technique for abscess drainage in the most ill patients, in this series, a better, although not statistically improved, chance for survival was noted with surgical treatment. We recommend that an objective severity scoring system be used whenever assessing results of treatment of intraabdominal infection and that surgical treatment not be avoided because the patient is considered to be too ill.