[Subphrenic abscess. Apropos of 51 cases observed in a resuscitation unit].
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Late trans-diaphragmatic migration of a postoperative abdominal foreign body followed a left hepatectomy for injury. Operative treatment, by means of the low posterior thoracic approach consisted of partial resection of the right inferior lobe with immediate closure of the diaphragm and subphrenic drainage. The natural history of the course taken by this abdominal foreign body is used as a basis for discussing diagnostic and therapeutic factors, particularly the surgical route of approach.
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(Gullino's) three-way tube consists of a large 30-35 cm long suction tube, with a diameter of 10 x 14 mm, closed at the proximal end close to which 6-8 holes have been made for suction along a 5 cm stretch. Two small tubes of equal length and with a diameter of 4-6 mm are glued or bound to the tube: one represents an air intake with a sealed opening above the suction holes; the other, used for washing, opens freely at the level of the closed proximal end of the large section tube. After a short review of the drama and disappointments in lung surgery concerning the treatment of postoperative septic complications, the authors briefly describe the advantages of the use of two-way suction drainage tubes: using air suction (Saratoga's and Shirley's model), and above all water suction, with irrigation-washing (Luizy's and Vankemmel's models). Compared to the two-way tubes, the paper then emphasises the advantages of the three-way model: using the flow of the lavage solution for the top, it is possible to obtain an improved, continuous and rapid washing and sterilisation of the pleural cavity, while suction from below serves to avoid stasis and in the event of bronchial fistula it is therefore easy to prevent broncho-pulmonary inundation. The three-way tube was used in two cases of post-pneumonectomy pyothorax, one of which was complicated by a bronchial fistula, and in a case of sub-phrenic abscess. In the treatment of pyothorax, the three-way tube must be divided into two parts: the large suction tube and the small air-intake tube, the two-way tube, and the small washing tube. The two-way tube must be positioned on the posterior axillary line in contact or nearly with the diaphragm, the small washing tube in the 1st anterior intercostal space and the patient must change decubitus with a certain rolling rhythm. Simple pyothorax may be resolved in 48 hours; bronchial fistula in 25 days and sub-phrenic abscess in 9. These are undoubtedly exceptional results, but require further confirmation.
The authors exam 8 subfrenic abscesses cases observed in the last 5 years in Fatebenefratelli Hospital of Milano - Emergency Surgical Department. After considering etiologic, clinical and therapeutic aspects of their casuistry, they remark the importance of the basal illness, particularly in secondary subfrenic abscesses which are the most part in their series and in the literature ones. In this series of cases they always used trans-abdominal laparatomy which never gave technical problems, so they underline it may be preferable in comparison with other surgical methods.
Subdiaphragmatic abscess has not yet been reported as a manifestation of tuberculosis. We report an IgA deficient patient with recurrent episodes of unusual extrapulmonary manifestations of tuberculosis including subdiaphragmatic abscesses and metacarpophalangeal osteomyelitis that was improved each time with antituberculosis drugs. There was not any resistance to the drugs used against mycobacterium despite repeated courses of antituberculosis regimens. In such recurrent cases, one should rule out any immunodeficiency states.
The interpretation of a combined liver/lung scan can be difficult in patients with pleural or pulmonary disease. A procedure is suggested to circumvent these difficulties by injecting 99mTc-sulfur colloid into the pleural cavity. A scan of the pleural cavity can then replace the lung scan in the conventional liver/lung scan. Two examples of liver/pleural cavity scans are shown.
We report the case of an 18-year-old boy who developed an intrathoracic abscess with rupture of the diaphragm following a laparoscopic appendectomy (LA) for a perforated appendicitis. LA is an established procedure in the treatment of appendicitis. It is a safe and efficacious technique, but several complications can occur with this procedure, and surgeons should be aware of the potential dangers. Herein, we present a previously unreported thoracic complication following an LA.
A 62-year-old lady presented with fever and abdominal pain. History revealed cholecystectomy two years ago due to cholecystolithiasis, complicated by perforation of the common bile duct, leading to hepaticojejunostomy, jejunocholedochostomy, endoscopic retrograde insertion of two plastic stents and percutaneous drainage of bilioma. The patient was lost to follow-up until she presented two years later in the emergency room. ERC was performed. Both stents were occluded. After extraction dirty bile popped out. Injection of contrast medium showed stones in the remaining common bile duct and dilatation of the intrahepatic bile ducts and the interposed jejunum. After stone extraction a subphrenic intrahepatic fluid collection became visible when injecting contrast medium in the intrahepatic bile ducts. Pus was aspirated. The abscess was drained with a nasobiliary tube. Antibiotics were given. Temperature and CRP normalized. The nasobiliary tube was removed when the biliary fluid was clear. Recovery was uneventful with complete resolution of symptoms.