PULTENEY STREET SURVEY - WINTER 2010
Dr. Stephen Gerzof '64
After finishing my residency in radiology, I set up the Boston VA Hospital's ultrasound laboratory. This was in 1974, and ultrasound technology was primitive. There were no textbooks on the subject, so I had to learn a lot of those skills on my own.
One day, I happened upon a surgeon trying to reinsert a drainage tube into a patient. The surgeon had performed an operation to drain an abscess under the patient's diaphragm ten days earlier, and, feeling better, the patient had pulled out the drainage tube himself. The surgeon knew that if he couldn't reinsert the tube and establish free drainage, he'd have to operate again to re-drain the abscess. Watching this unfold, I realized that we could use angiographic techniques to reinsert a drainage tube without surgery. I injected the drainage track with contrast to visualize it and then, under fluoroscopy, negotiated a guide wire through the existing track to gain access to the abscess. Then, I inserted a drainage catheter over the guide wire into the abscess and achieved complete drainage.
Two years later, I saw a patient with a rapidly-expanding cyst on his kidney. I thought the cyst must be infected, so I did a sonogram to show the exact site and depth of the cyst. With the above case in mind, but without a pre-existent drainage track, I used the ultrasound to plan a safe route for needle aspiration. The aspirated fluid was pus and the patient should require surgery, unless I could introduce a drainage catheter. Again, I did so under ultrasound guidance for a second success, without surgery.
In the mid 1970’s, a 2/2 success rate without surgery was so improbable that I thought there must be much wider application and began reading extensively on abscesses in the medical literature. Traditional surgical thought indicated that percutaneous catheter drainage was simply was not possible. However, with newly developed CT to detect the abscess, angiographic techniques to safely place catheters based on the CT anatomy, and IV antibiotics, I could see no reason why this method wouldn't continue to work. Over the next year, I treated 12 more patients who had been considered too high risk for surgery, all successfully.
The responses were truly remarkable. Commonly, patients who were seriously ill improved dramatically within minutes of decompressing the abscess. I had several patients who were moribund due to sepsis and who, just five minutes after drainage, were awake and communicative. I found myself in the awkward position of propounding something no one else had ever heard of (or, at the time, would believe) so I became very messianic, speaking at Radiology meetings around the country.
In 1979 my article on “Percutaneous Abscess Drainage” (PAD) was published as a lead article in the American Journal of Roentgenology. However, there seemed to be no change in its acceptance nationally, possibly since few surgeons followed the Radiology literature. The very concept remained foreign.
So, in 1981, I sent a comprehensive 5-year review of my experience to The New England Journal of Medicine where it was published as the lead article. I included the data to show that PAD actually had a lower complication and recurrence rate and a higher success rate than operative drainage all without need for general anesthesia. Now, however, PAD was viewed as another application of CT. For the next two years, I was out of the hospital almost as often as I was in, traveling all over the world as a visiting professor lecturing on the subject. Today, the procedure is common practice. In fact, most students in medical school see only the percutaneous method for draining abscesses.
What I did was to combine three separate technologies—CT and ultrasound (for anatomy and guidance), techniques from angiography, and antibiotics to control infection—to solve a problem that had been plaguing doctors for years. In retrospect, it's so obvious that its development seems nearly inevitable. I was in the right place at the right time with the right preparation: an independence of thought and observation exemplified in the classrooms, lecture halls and labs surrounding the Quad at Hobart.
The Minds Behind the Advancements
more coming soon