What is the management of retroperitoneal fluid collections?

From the Guidelines

Management of retroperitoneal fluid collections requires a tailored approach based on the collection's etiology, size, and patient symptoms, with percutaneous drainage guided by ultrasound or CT being the first-line intervention for symptomatic or enlarging collections, as recommended by the most recent guidelines 1.

Key Considerations

• Initial management often involves observation for small, asymptomatic collections that may resolve spontaneously.
• For symptomatic or enlarging collections, percutaneous drainage guided by ultrasound or CT is the first-line intervention, using catheters sized 8-14 French that remain in place until drainage output decreases to less than 10-20 mL per day.
• Antibiotics are necessary for infected collections, with empiric coverage including piperacillin-tazobactam 3.375g IV every 6 hours or meropenem 1g IV every 8 hours, later tailored to culture results, as suggested by 1.

Surgical Intervention

• Surgical intervention becomes necessary for collections that fail to resolve with drainage, have significant loculations, contain necrotic tissue, or when there's an underlying condition requiring surgical repair.
• The choice of surgical approach, including laparoscopy, depends on the patient's condition, the collection's characteristics, and the surgeon's expertise, with laparoscopy being a viable option for many emergency conditions, as noted in 1.

Postprocedural Care

• Postprocedural care includes monitoring for complications such as bleeding, infection, or organ injury.
• The management approach is guided by understanding the retroperitoneum's complex anatomy and the potential for fluid collections to cause significant morbidity through compression of vital structures, infection spread, or metabolic derangements when left untreated, as highlighted in 1.

From the Research

Causes of Retroperitoneal Fluid Collections

• Retroperitoneal infection is usually caused by secondary complications such as inflammation, damage, or perforation of adjacent organs in the retroperitoneal space 2
• Pathogenic bacteria invade the retroperitoneal space through retroperitoneal and interstitial organs, peripheral tissue, and the blood 2
• Infections mostly arise from severe acute pancreatitis, acute colonic diverticulitis, inflammatory bowel disease, kidney abscess, and biliary tract injury 2
• Retroperitoneal collections can also be caused by haematomas, abscesses, and other conditions 3

Diagnosis of Retroperitoneal Fluid Collections

• Computed tomography (CT) is a primary diagnostic tool for retroperitoneal infection 2
• Ultrasound is also a valuable diagnostic study for retroperitoneal fluid collections 4
• Magnetic resonance imaging (MRI) can be used in some cases 3
• Helical CT plays an important role in diagnosis of retroperitoneal emergencies, providing useful informations on the type, site, extent and management of the fluid collections 5

Management of Retroperitoneal Fluid Collections

• Strategies that control the source of infection, rational use of antibiotic agents, and nutritional interventions are the primary approaches to treat the infections 2
• Percutaneous drainage is a common treatment option for retroperitoneal abscesses, with high cure, temporization, or palliation rates 6
• Percutaneous drainage allows effective management, even in the presence of a secondary abscess 3
• Surgical intervention may be necessary in some cases, but there are no uniform standards on the timing of surgical intervention and treatment options 2