Is there a good controlled trial with large number of patients?
The number of aspiration needed and timing to achieve complete resolution
Is it working for small as well as for large abscess?
Meddling provides a number of studies that establish the efficacy of needle aspiration of breast abscesses. However, this technique is used in specific patient and abscess-related conditions. E.g., the patient should not be toxic from the abscess and should in general be well. The abscess should be unilocular, without any overlying necrotic skin changes. It is recommended the procedure is performed ultra-sound guided, and the patient is followed up to ensure there is no re-formation of the abscess. The procedure can be repeated, but if there is any doubt or if the patient becomes septic, then incision and drainage must be performed, Most of us will use a small incision in a dependent area, though for cosmetic reasons some prefer to use a periareolar curved incision. Like in other including ischiorectal abscesses, the modern practice is to avoid large cruciate incisions. A Foley's catheter may be left or a corrugated drain, but only with a couple of corrugations.
I will be influenced by the size of the abscess. A small abscess is more likely to respond to aspiration and appropriate antibiotic treatment.
We tried in about 10 patients and then abandoned needle aspiration in favor of drainage. However small abscesses in our opinion can be treated with aspirations if patients desire so.
The principles of managing any abscess are the same - treat the patient, not the disease; drain, if indicated; cause the minimum necessary morbidity to achieve complete drainage and look for and manage re-accumulation. The role of antibiotics in treating established abscesses cannot be condoned, hence the issue most of us have with the study by Erilmaz et al. Aspiration is not a novel technique - it is applying common sense to a common problem. It is not a matter of incision versus aspiration; like all surgery it is a matter of choosing the right procedure for a given patient in a given set of circumstances and be willing to alter
needle aspiration can be done only if it is a small abscess otherwise it is always better to open the abscess because of the fact that abscess always heal better when the whole of abscess cavity is cleaned properly. If not cleaned properly there are chances of developing sinus.
In fact, that is the point of the question. Rather than just relying on ancient wisdom, which, of course still holds, one needs to take more specific details into account to ensure there is proper drainage of any abscess. The easiest is to lay an abscess open. Though this affords the highest chance of pus drainage and reduces re-accumulation, it is not a cosmetically acceptable procedure in a large number of cases. Hence, instead of a dogmatic approach, evidence shows that if conditions are suitable, aspiration can be equally therapeutic. Local conditions eg depth of the abscess, clear definition and more liquified nature of the pus, overlying skin condition, absence of a thick wall and deputation are all important in choosing the mode of drainage. This is precisely why I would suggest that for those wishing to attempt aspiration would be well-advised to use ultrasound findings and ultrasound guidance while gaining expertise in the technique. The principles of localised sepsis remain the same I.e., if incision is necessary, then it must be adequate; that is, without any overhang, unless a VAC-type dressing is to be used. If it is amenable to per cutaneous drainage, then ensure that drainage has indeed been achieved at the end of the aspiration, rather than labelling an inadequate drainage a re-accumulation.
I have done a number of ultrasound guided aspirations (14). Two of such cases were loculated. The success rate was high as no case was eventually referred for incision and drainage, although about 4 cases had a further repeated aspirations. All abscesses were less than 5cm. It should be attempted in suitable cases or the option offered to the patient.
I am wondering for either procedures, which is of most consideration to the mother‘s ability to continue nursing? Studies have shown that mastitis is not a contraindication to breastfeeding and that it is still infact recommended for mother to continue nursing. which of the two procedures will not interfere with the moms ability to nurse and continue to produce milk? That is one of the primarly concerns lactating mother have. Incisions may severe milk ducts which is less likely in needle aspirations. What approach would you recommend having this in mind?