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PubMed2007

Indwelling trans-anastomotic rectal tubes in colorectal surgery: a survey of usage in UK and Ireland.

BACKGROUND: The use of rectal tubes in colorectal surgery appears to be a matter of individual choice, with little documented evidence to support their use. This study assesses the current practice of rectal tubes amongst consultant members of the Association of Coloproctology of Great Britain & Ireland (ACPGBI). METHODS: A piloted questionnaire was sent to practising ACPGBI consultant members listed in the 2003-04 directory. Statistical analysis was performed using SPSS software and Fishers exact test. RESULTS: Three hundred and thirty-nine replies were received from 579 posted questionnaires (response rate = 58.5%). Rectal tubes were used by 116 (35%) of responding surgeons. Rectal tubes were more commonly used by surgeons with less than 10 years practice as a consultant (P < 0.005). The main indications for tube placement were following ileo-anal or colonic pouch surgery (73%), after any anterior resection (36%) (rectal tubes were reserved for only low anterior resections by 16% of surgeons) and in the rectal stump after total or subtotal colectomy for acute colitis (11%). Twenty-three percent of these practising surgeons would use a rectal tube as an alternative to a diverting stoma, predominantly in selected patients following ileo-anal pouch surgery. A Foley catheter was the commonest type of tube used (70%) and this was usually placed above the anastomosis (80%). Rectal tubes were left in situ for a median of 5 days (range = 1-13 days). Three surgeons (2.6%) reported serious complications including tube perforation of the bowel or anastomosis. Several different mechanisms were suggested for the purpose and functioning of the rectal tube, the commonest being to decompress the rectum and/or pouch. CONCLUSION: Rectal tube placement is simple and safe and is used by a third of colorectal surgeons in UK and Ireland. Given their simplicity, the efficacy of rectal tubes in reducing local anastomotic complications requires further evaluation within the confines of a randomised controlled trial.

Catheterization↗
PubMed1997

Complications of laparoscopic colorectal surgery. Analysis and comparison of early vs. latter experience.

PURPOSE: The aim of this study was to test if the techniques learned during our early learning experience have proved to be effective in reducing the complications specifically related to the laparoscopic technique of colorectal surgery. METHODS: From October 1991 until July 1996, 195 laparoscopic operations were performed on the colon and the rectum. These data were divided into "early" and "latter" groups. The conversion reasons and early and late postoperative complications were analyzed and compared. RESULTS: Incidence of conversions required because of iatrogenic injuries showed a decline from 7.3 percent in the early group to 1.4 percent in the latter group. Sixty-six postoperative complications were observed in 59 (30.3 percent) patients. Complications specifically related to the technique of laparoscopic surgery occurred in nine (4.6 percent) patients. These were postoperative bleeding in three patients, port site hernias in five patients, and left ureteric stricture in one patient. Eight (6.5 percent) of these complications occurred in the early group, whereas one (1.4 percent) occurred in the latter group. Analyzing the conversions caused by intraoperative iatrogenic injuries and the specific postoperative complications together reveals that the incidence of 13.8 percent (17/123) in the early group has been reduced significantly to 2.8 percent (2/72) in the latter group. CONCLUSIONS: On the basis of our experience, we have identified techniques, which are discussed in detail, to make laparoscopic colorectal surgery safe. Strict adherence to these techniques has significantly reduced the incidence of complications, specifically those related to the laparoscopic technique.

Adult↗
PubMedDate not supplied

[FastTrack approach to major colorectal surgery].

Intensive rehabilitation programs after major abdominal, thoracic and vascular surgery have been published over the last few years, showing early recovery, fewer complications and a quicker discharge. The aim of the study was to evaluate the feasibility and efficacy of a multimodal intensive rehabilitation program (FastTrack) after major colorectal surgery, according to the experience of Dr. H. Kehlet of Hvidovre University Hospital, Copenhagen. The study design was of the prospective, randomized, controlled type. Forty patients undergoing elective colonic surgery were randomly selected and assigned to two groups well matched for age, weight, ASA and type of resection. The FastTrack group underwent a multimodal rehabilitation program with epidural analgesia, short laparotomy, early feeding and mobilisation. The control group had the usual postoperative treatment with a pain control program. The FastTrack group exhibited a shorter need for assisted ventilation, a lower sedation level and lower opioid consumption over the first 24 hours. We also observed a statistically significant earlier onset of peristalsis (0.5 vs 2.7 days), gastrointestinal function (defecation) (2.8 vs 5.8 days), regular feeding (3.1 vs 7.2 days) and autonomous ambulation (3.3 vs 6.9). The multimodal rehabilitation approach to colon surgery permits an earlier postoperative recovery, better postoperative performance and quicker functional autonomy. These results may have important implications for the management of patients after major colorectal surgery.

Aged↗
PubMed2001

Trimethoprim-sulphamethoxazole and metronidazole as prophylaxis in colorectal surgery: a study of bioavailability after an oral single dose.

OBJECTIVE: To evaluate oral single dose prophylaxis in colorectal surgery. DESIGN: Prospective study. SETTING: University hospital, Sweden. SUBJECTS: 24 patients (13 women; 11 men; mean age 57 years, range 27-81) listed for elective colorectal operations. INTERVENTION: At 0630 on the day of the operation all patients were given an oral dose of trimethoprim-sulphamethoxazole (TMP 160 mg and SMZ 800 mg) and metronidazole (2 g). The serum concentrations of TMP and SMZ were analysed in venous samples taken at the start and end of each operation. RESULTS: The earliest operation started at 0830 and the last finished at 1700. The median (range) serum concentrations of TMP were 1.4 (0.7-2.6) mg/L (start) and 1.3 (1.0-2.8) mg/L (end), and of SMZ 35 (15-65) mg/L (start) and 33 mg (13-70) mg/L (end). The individual values were above or equal to the minimal inhibitory concentration (TMP 0.8 mg/L; SMZ 15.2 mg/L) for relevant gram-negative species. CONCLUSION: Oral TMP/SMZ in the morning gives satisfactory serum concentrations independently of when the operation is done during the day. The regimen is simple and has the potential for being an effective alternative to intravenous prophylaxis.

Administration, Oral↗
PubMed2005

Laparoscopic versus open colorectal surgery: cost-benefit analysis in a single-center randomized trial.

SUMMARY BACKGROUND DATA: Studies comparing the costs of colorectal resection by laparoscopic (LPS) and open approaches are small sized or not randomized. The main purpose of this study is to compare the hospital costs of LPS and open colorectal surgery in a large series of randomized patients. METHODS: A total of 517 patients with colorectal disease were randomly assigned to LPS (n = 258) or open (n = 259) resection. The following costs were calculated: surgical instruments, operative room (OR) occupation, routine care, postoperative morbidity, and length of hospital stay (LOS). Follow-up for postoperative morbidity was carried out for 30 days after hospital discharge. RESULTS: Operative time was 37 minutes longer in the LPS group. Overall morbidity rate was 18.2% (47 of 258) in the LPS versus 34.7% (90 of 259) in the open group (P = 0.0005). The mean LOS was 9.9 (2.6) days in the LPS group and 12.4 (3.9) days in the open group (P < 0.0001). The additional OR charge in the LPS group was 1171 per patient randomized (864 due to surgical instruments and 307 due to longer time). The saving in the LPS group was 1046 per patient randomized (401 due to shorter LOS and 645 due to the lower cost of postoperative complications). The net balance resulted in 125 extra cost per patient allocated to the LPS group. CONCLUSIONS: The present cost-benefit analysis showed a slight additional cost in the LPS group. The better postoperative short-term outcome in patients receiving LPS had a key role to nearly balance the operative room charges due to laparoscopy.

Aged↗
PubMed1980

Single and multiple dose cotrimoxazole and metronidazole in colorectal surgery.

Cotrimoxazole and metronidazole were given prophylactically to patients undergoing colorectal surgery as a single preoperative dose or in multiple doses for 5 days. A total of 60 operations randomly divided into two groups showed that the rate of wound infection was low in both groups and there was no statistical difference between them. There were no cases of anastomotic dehiscence in those patients where the anastomosis was carried out from within the abdomen, but 7 out of 9 patients with transphincteric colo-anastomoses developed a suture line dehiscence. A greater degree of post-catheterization urinary tract infection was seen in the single dose group (which lacks statistical significance). There were no toxic effects.

Adult↗
PubMed2004

Endoanal and endorectal ultrasound: applications in colorectal surgery.

Endoanal and endorectal ultrasound have an important role in colorectal surgery. They can be applied in the management of faecal incontinence, rectal tumours and inflammatory perianal conditions. In faecal incontinence, anal ultrasound will confirm the presence or absence of sphincter defects. This will direct any operative intervention such as direct sphincter repair. Ultrasound in rectal cancer allows staging of the tumour by assessing the depth of invasion through the bowel wall and involvement of mesenteric nodes. Such staging might influence the choice of operation and determine which patients might benefit from preoperative chemotherapy and radiotherapy. Ultrasound has a particular role in recurrent and complex anal fistula and perianal sepsis. Preoperative and perioperative planning with accurate delineation of fistula tracts, extensions and sphincter involvement might help prevent recurrence and impaired continence from sphincter damage after surgery. Correct interpretation of ultrasound images requires training and experience so that the results can be properly correlated with the clinical situation.

Endosonography↗
PubMed1989

Imipenem concentrations in colorectal surgery and impact on the colonic microflora.

Twenty patients undergoing colorectal surgery were given, as prophylaxis, imipenem-cilastatin intravenously. Ten of them received a dose of 0.5/0.5 g of imipenem-cilastatin at induction of anesthesia, followed by subsequent doses of 0.5/0.5 g every 6 h for 48 h. The other 10 patients were given 1.0/1.0 g imipenem-cilastatin in the same way for 48 h. Samples from serum, intestinal mucosa, and feces were taken for analysis of imipenem concentrations during the day of surgery. The mean concentrations in serum at 1 h after the first imipenem dose were 15.9 +/- 1.7 micrograms/ml for the 0.5-g dose and 68.2 +/- 8.2 micrograms/ml for the 1.0-g dose. The mean half-lives were 1.5 and 1.4 h, respectively, and the mean areas under the serum concentration-time curve were 41.2 +/- 6.0 and 128.3 +/- 13.5 mg.h/liter, respectively. The imipenem concentrations in the intestinal mucosa varied between less than 0.1 and 3.6 mg/kg for the 0.5-g dose and 3.2 and 13.4 mg/kg for the 1.0-g dose. The concentrations in the fecal samples varied between less than 0.1 and 5.0 mg/kg for the 0.5-g dose and 0.7 and 11.3 mg/kg for the 1.0-g dose. Fecal samples were also collected during the investigation period for cultivation of aerobic and anaerobic bacteria. The aerobic bacteria--staphylococci, streptococci, enterococci, and enteroaerobic enterococci, and enterobacteria--were and anaerobic bacteria. The aerobic bacteria--staphylococci, streptococci, enterococci, and enterobacteria--were suppressed significantly during the imipenem prophylaxis period. Among the anaerobic bacteria, cocci, bifidobacteria, eubacteria, lactobacilli, clostridia, fusobacteria, and bacteroides decreased markedly during the same period. The microfloras were normalized after 2 weeks. There were no differences between the patients receiving 0.5-g doses of imipenem and those receiving 1.0-g of imipenem. No postoperative infections occurred.

Adult↗
PubMed1985

Peroperative systemic prophylaxis in colorectal surgery.

In an effort to reduce infection rates in elective colorectal surgery to acceptable levels without oral non-absorbable antimicrobials, using only a short course of systemic antimicrobials, 50 patients were studied in a multicentre trial. Each patient received metronidazole for anti-anaerobic coverage. The anti-aerobic coverage consisted of netilmicin, cefuroxime or placebo, administered in a double-blind manner. Five out of 36 evaluable patients had an infection at the operation site. Two patients had peritonitis (one metronidazole-netilmicin and one metronidazole-placebo) and three had a wound abscess in the abdominal wall (all metronidazole-placebo). It is concluded that a short course of peroperative systemic prophylaxis with metronidazole and netilmicin or cefuroxime--without the use of oral non-absorbable antimicrobials--gave acceptable results in the centres studied.

Cefuroxime↗
PubMed1987

Single-dose chemoprophylaxis in elective colorectal surgery. A comparison between doxycycline plus metronidazole and doxycycline.

In a prospective, randomized double-blind study either 400 mg of doxycycline + 1500 mg of metronidazole (D + M) or 400 mg of doxycycline (D) alone were given intravenously as a single preoperative dose to patients admitted for elective colorectal surgery. A comparison of the rate of postoperative septic complications was made. After excluding drop-out patients, 261 patients remained for evaluation. In 135 patients with D + M treatment there were four postoperative septic complications (3.0%). In 126 patients with D treatment 20 septic complications related to the surgical procedure occurred (15.9%). The difference is highly significant (p less than 0.005). Most postoperative infections were superficial wound infections (14 of 24 patients), and the mean hospital stay in the two treatment groups was equal. Bacteriologic studies showed a highly significant reduction in anaerobes in cultures from perioperative intra-abdominal fluid in the D + M treatment group. The study has thus showed that the addition of metronidazole, an efficient agent against anaerobic bacteria, to an antimicrobial agent against aerobic bacteria significantly reduces postoperative septic complications in elective colorectal surgery.

Adolescent↗
PubMed2003

Short-term pre-operative smoking cessation intervention does not affect postoperative complications in colorectal surgery: a randomized clinical trial.

BACKGROUND: Smokers have a higher risk of complicated tissue and wound healing after surgery than nonsmokers. We tested the hypothesis that short-term pre-operative cessation of smoking in colorectal surgery decreases the incidence of postoperative tissue and wound complications. METHODS: From February 1998 to March 2001, 60 patients, who smoked daily, undergoing colorectal resection were randomly assigned 2-3 weeks before scheduled surgery to either abstinence from smoking, counselling and nicotine replacement therapy or maintenance of daily smoking habits. Postoperative tissue and wound complications necessitating surgical or medical treatment were evaluated at discharge and 30 days after surgery by blinded outcome assessment. RESULTS: In the pre-operative period of 15 days (8-24) (median, interquartile range (IQR)), 89% of the patients in the intervention group vs. 13% in the control group abstained from smoking or reduced by more than half (P < 0.05). In the postoperative period of 11 days (10-13), the corresponding figures were 92% and 50%, respectively (P < 0.05). Postoperative tissue and wound complications occurred in 33% (9 of 27) of the patients in the intervention group compared to 27% (8 of 30) in the control group (NS). Likewise, no difference in overall postoperative complication rate was found between the groups. CONCLUSION: Short-term cessation of smoking does not reduce the risk of complicated tissue and wound healing or other complications in colorectal surgery.

Adult↗
PubMed2000

Randomized trial of oral sodium phosphate compared with oral sodium picosulphate (Picolax) for elective colorectal surgery and colonoscopy.

BACKGROUND: Sodium picosulphate (Picolax) is considered by most British surgeons as standard preparation for colonoscopy and elective surgery. Oral sodium phosphate may be better tolerated and more efficient as bowel preparation. METHODS: A randomized trial was performed to compare oral sodium phosphate (n = 76) with Picolax (n = 77) as bowel preparation for elective colorectal surgery. A parallel study randomized colonoscopy patients to sodium phosphate (n = 51) or Picolax (n = 52). Patient acceptability was measured for seven symptoms with a linear analogue score. Quality of preparation was graded by the surgeon and faecal residue was measured in resection specimens. During colonoscopy, bowel preparation has graded 0-24 using an endoscopic score. RESULTS: Abdominal pain, nausea, vomiting, embarrassment, fear and fatigue did not differ significantly between the groups. Surgeons grade of quality was judged poor or awful in 5 of 76 in the sodium phosphate group (9%) compared with 13 of 73 in the Picolax group (18%, p = 0.084). Mean faecal residue in the resection specimen was 0.1 g/cm after sodium phosphate compared with 0.45 g/cm after Picolax (p < 0.01). The endoscopic score was significantly lower using sodium phosphate (2.0 +/- 2.2) than picolax (3.1 +/- 2.9; p < 0.05). CONCLUSIONS: These results suggest that oral sodium phosphate is well tolerated and superior to Picolax in elective colorectal surgery and colonoscopy.

Administration, Oral↗
PubMed1999

Laparoscopic colorectal surgery: A five-year experience.

OBJECTIVE: The aim of this study was to assess the feasibility and outcome of 300 laparoscopic colorectal procedures performed within 5 years for both benign and malignant disorders. The specific purpose was to identify the impact of the learning curve on reducing morbidity and on improving the outcome of laparoscopic colorectal surgery. PATIENTS AND METHODS: All cases were divided into 3 groups: the first 100, the second 100 and the third 100 procedures were analyzed. Statistical analysis was performed by Student's t test and chi2 test. RESULTS: The laparoscopic procedure had to be converted to open surgery in 22 cases (mean conversion rate 7.3%). Thus, a total of 278 procedures could be performed laparoscopically. The mean major complication rate was 8.6%, minor complications occurred in 9.7%. The overall morbidity rate was 18.3%. In 44 cases, laparoscopic resections were performed for the cure of colorectal malignancy. The mean lymph node harvest was 12.8 nodes, no port-site recurrence was documented at a mean follow-up of 22 months. Analyzing our 5-year experience, the incidence of conversion showed a decline from 8.0% (1st and 2nd 100) to 6.0% in the last 100 procedures (p > 0.05). The major complication rate was significantly decreased from 15 to 6.0% (1st vs. 2nd 100) and was 5.0% in the 3rd group. The minor complication rate, overall morbidity rate and laparotomy rate have also been reduced (p > 0.05). The duration of surgery was shortened from 251.4 to 213.5 min (1st vs. 2nd 100, p < 0.05) and was 196.9 min in the last 100 procedures. Postoperative hospital stay was decreased from 16.3 to 14.3 days (1st 100 vs. 2nd 100, p > 0.05) and could be shortened to 11.2 days (2nd vs. 3rd 100, p < 0.05). CONCLUSION: With increasing experience, laparoscopic colorectal surgery can be performed with reduced morbidity and improved outcome. To evaluate the role of laparoscopic colorectal procedures, particularly for the cure of malignancy, prospective randomized trials are necessary.

Adolescent↗
PubMed2005

Prospective, randomised study on antibiotic prophylaxis in colorectal surgery. Is it really necessary to use oral antibiotics?

BACKGROUND AND AIMS: The use of prophylactic antibiotics in addition to mechanical cleansing is the current standard of care prior to colonic surgery. The question of whether the antibiotics should be administered intravenously or orally, or by both routes, remains controversial. Our aim was to compare three methods of prophylactic antibiotic administration in elective colorectal surgery. METHODS: Three hundred consecutive elective colorectal resections were studied. All patients had preoperative mechanical colon cleansing with oral sodium phosphate and intravenous antibiotic prophylaxis with cefoxitin (one dose before skin incision and two postoperative doses). Patients were randomised to one of the following three groups: group A: three doses of oral antibiotic (neomycin and metronidazole) at the time of mechanical colon cleansing; group B: one dose of oral antibiotic; group C: no oral antibiotics. All patients were followed during their hospital stay and at 7, 14 and 30 days post-surgery. RESULTS: Vomiting occurred in 31%, 11% and 9% of the studied patients (groups A, B and C, respectively) (p<0.001). Nausea was present in 44%, 18% and 13% of patients (p<0.001). Abdominal pain was recorded in 13%, 10% and 4% of patients (p: 0.077). Wound infection was present in 7%, 8% and 6% and suture dehiscence occurred in 2%, 2% and 3% of the patients in the three groups (no differences among them). Neither were differences found among the three groups in terms of urinary infections, pneumonia, postoperative ileus or intra-abdominal abscess. CONCLUSION: The addition of three doses of oral antibiotics to intravenous antibiotic prophylaxis is associated with lower patient tolerance in terms of increased nausea, vomiting and abdominal pain, and has shown no advantages in the prevention of postoperative septic complications. Therefore, we recommend that oral antibiotics should not be used prior to colorectal surgery.

Administration, Oral↗
PubMed2006

Predicting postoperative mortality in patients undergoing colorectal surgery.

Well-known and suitable instruments for surgical audit are the POSSUM and P-POSSUM scoring systems. But these scores have not been well validated across the countries. The objective of the present study was to assess the predictive value of scores for colorectal surgery in France. Patients operated on for colorectal malignant or diverticular diseases, whether electively or on emergency basis, within a 4-month period were included in a prospective multicenter study conducted by the French Association for Surgery (Association Française de Chirurgie, AFC). The main outcome measure was postoperative in-hospital mortality. Independent factors leading to death were assessed by multivariate logistic regression analysis (AFC-index). The ratio of expected versus observed deaths was calculated, and the predictive value of the POSSUM and P-POSSUM scores were analyzed by the receiver operating characteristic (ROC) curve. A total of 1426 patients were included. The in-hospital death rate was 3.4%. Four independent preoperative factors (AFC-index) have been found: emergency surgery, loss of more than 10% of weight, neurological disease history, and age > 70 years. POSSUM had a poor predictive value; it overestimated postoperative death in all cases. P-POSSUM had a good predictive value, except for elective surgery, where it overestimated postoperative death twofold. The predictive value of the AFC-index was also good. It had the same sensitivity and specificity as the P-POSSUM. POSSUM has not been validated in France in the field of colorectal surgery. P-POSSUM was as predictive as the AFC-index which is a simpler instrument based on four clinical parameters (without any mathematical formulas).

Aged↗
PubMed1998

Double-blind comparison of single-dose alatrofloxacin and cefotetan as prophylaxis of infection following elective colorectal surgery. Trovafloxacin Surgical Group.

BACKGROUND: Alatrofloxacin, the prodrug of trovafloxacin, is a novel fluoroquinolone antimicrobial agent with a broad spectrum, including activity against gram-positive and gram-negative aerobes and anaerobes. Its pharmacokinetic properties (long half-life, excellent tissue distribution, and good safety profile) suggest a role in surgical prophylaxis. This prospective, multicenter, double-blind trial compared alatrofloxacin with cefotetan, an approved drug for surgical prophylaxis, in reducing postoperative infections. METHODS: The efficacy and safety of a single 200-mg intravenous dose of alatrofloxacin were compared to a single 2-g intravenous dose of cefotetan in 492 patients undergoing elective colorectal surgery. The efficacy of alatrofloxacin as a prophylaxis for wound, intra-abdominal, or remote-site postoperative infectious complications was compared with cefotetan in 317 clinically evaluable patients; 161 received alatrofloxacin and 156 received cefotetan. The patients were monitored for infections and safety for 30 days postoperatively. RESULTS: No statistically significant between-treatment difference was detected in successful clinical response rates at the end of the study (72% for each group). The incidence of primary wound infections at the time of hospital discharge was also similar: 21% in patients treated with alatrofloxacin and 18% in those treated with cefotetan. Safety, established by the incidence of adverse events, did not differ statistically between the groups. CONCLUSIONS: A single intravenous dose of alatrofloxacin given within 4 hours prior to surgery was as effective as an intravenous dose of cefotetan in the prevention of postoperative infectious complications in patients undergoing elective colorectal surgery. The safety profiles of the two medications were similar.

Adolescent↗
PubMed2002

Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery.

Intra-abdominal abscesses are a frequent source of morbidity and mortality following both elective and emergent surgery of the alimentary tract. CT-guided percutaneous drainage of intra-abdominal abscess is an alternative to immediate surgical intervention. We studied the clinical characteristics and outcomes of patients undergoing percutaneous drainage of intra-abdominal abscesses arising after elective colorectal procedures. We retrospectively identified 40 patients with postoperative intraabdominal abscess following elective colorectal surgery who underwent CT-guided percutaneous drainage with a Von Sonnenberg sump drain between 1990 and 1998. The most common presenting symptoms were pyrexia in 39 (97%), abdominal tenderness in 32 (80%), guarding in 1 (2.5%) and abdominal mass in 3 (7.5%); no patient had generalized peritonitis. The most common index procedure was proctocolectomy with ileoanal anastomosis and ileal Jpouch in 12 (30%) patients. Drainage was performed using an anterior approach in 32 (80%) and a transgluteal window in 8 (20%) patients. Thirty-five (87.5%) patients had a single collection, while 2 (5.0%) patients had 2 collections and 3 (7.5%) patients had 3 collections. Thirteen (32.5%) patients had perioperative steroids, 30 (75%) had preoperative antibiotics, and 40 (100%) had postoperative antibiotics. Follow-up at a mean of 35.8 days revealed complete resolution of abscess in 26 (65%) patients; 14 (35%) patients had residual or recurrent abscess successfully treated by repeat drainage in 8 patients and requiring laparotomy in 6. Percutaneous CT-guided abscess drainage is an effective method for treating intra-abdominal abscess following elective colorectal surgery. The primary success was 65% after the first and 85% after a second drainage. In conclusion, this technique should be considered as the treatment of choice in patients with localized intra-abdominal abscess without signs of generalized peritonitis.

Abdominal Abscess↗