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A fatal case of cervical cellulitis is described in which mediastinal and subphrenic abscesses formed. Subphrenic abscess formation is a previously unrecorded complication of oro-pharyngeal infection. The anatomical pathways involved in the spread of infection from the neck to the abdomen and the difficulties in obtaining an airway in such a case are discussed.
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One hundred consecutive patients requiring elective cholecystectomy in one surgeon's practice were booked as outpatients between April 1994, and July 1995. Two patients had massive adhesions and 18 had acute disease. Outpatient surgery was successful for 94 patients, who spent an average of less than 6 h in hospital. Six patients required postoperative admission, four because of conversion and two for other causes. There were three readmissions, unrelated to outpatient status: one to treat a wound infection, one to drain a subphrenic abscess, and one to repair an umbilical hernia. Complications were one subphrenic abscess, one case of significant atelectasis, and, at the umbilical incision seven wound infections, one hematoma and one postoperative hernia. Advanced age and increased comorbidity correlated significantly with the need for hospital admission, but were not contraindications, either alone or in combination, to outpatient surgery. Patient satisfaction was high.
Biliary-bronchial fistula is an extremely unusual complication of thoracoabdominal trauma or suppurative hepatobiliary disease. We treated a patient with a biliary-bronchial fistula that developed after right hepatectomy for an infected traumatic intrahepatic hematoma. The diagnosis of biliary-bronchial fistula was confirmed by percutaneous transhepatic cholangiography. Surgical therapy included a primary transabdominal choledochostomy, with the insertion of a T-tube, sphincteroplasty, and open marsupialization of the chronic subphrenic abscess.
A 14-year old boy presented with chest and abdominal pain and fever for one week. He had been treated with several antibiotics at home and in a peripheral hospital for respiratory infection. Physical examination showed features of right lobar pneumonia and peritonitis. Chest radiograph showed consolidation in the right lower lung field and abdominal ultrasonography showed a subphrenic collection. At exploratory laparotomy, a right subphrenic abscess and general peritonitis without an intra-abdominal focus were found. The abscess was drained and broad-spectrum antibiotics given. Death, however, occurred from overwhelming infection. Subphrenic abscess complicating pneumonia is unusual but can be the cause of poor response to treatment. The diagnosis should be excluded in a child with pneumonia and persisting abdominal symptoms. Prompt treatment is necessary to avoid morbidity and mortality.
Late complications of laparoscopic cholecystectomy are less addressed. Spillage of stone during laparoscopic cholecystectomy is a recognized complication. However, late sequelae of spillage of stones are less clear. We report a case of late and recurrent subphrenic abscess following laparoscopic cholecystectomy. This was a 65-year-old gentleman who underwent laparoscopic cholecystectomy in 1991. He presented 3 years and even 10 years after the operation with subphrenic abscess. Interesting CT scan findings are described. Surgical open drainage is recommended as opposed to percutaneous drainage. Emphasis is given to take precautions to avoid spillage of stones. We feel that this is the first case of a complication of laparoscopic cholecystectomy presenting so late and as a recurrent problem.
Gastrobronchial fistula is a rare complication of antireflux surgery, whereas esophagobronchial fistula as a complication of Nissen fundoplication has, to the best of our knowledge, not been reported previously. We report on a case of esophagobronchial fistula in a patient with left subphrenic abscess following redo Nissen fundoplication. Chest radiographs suggested an unresponsive pneumonia of the left lower lobe. Computed tomography (CT) of the abdomen showed partial consolidation of the left lower lobe and contrast filling of the left bronchial tree from a left subphrenic abscess. CT diagnosis of fistula originating from the region of fundoplication was confirmed by Gastrografin follow-through.
Liver resection for a neoplasm was performed in 100 patients between 1979 and 1987. There were 43 hepatocellular carcinomas (70% of them arising in patients with cirrhosis), 28 metastases from colorectal cancers, 20 benign tumors, and 9 miscellaneous tumors. Forty-nine patients had a major liver resection, 36 a segmentectomy, and 15 a nonanatomic liver resection. Great care was taken to avoid intraoperative and postoperative bleeding, including late ligation of the hepatic vein, the use of Kelly fracture and resorbable clips for hemostasis of transection planes in 74 patients, and temporary clamping of the portal pedicle in 22. Drainage of the abdomen was avoided in 21 patients to prevent ascitic leakage to decrease the postoperative hospital stay. Operative mortality was 1%. There were eight major complications, including one bile leak, one subphrenic abscess, and three subphrenic hematomas. The use of resorbable clips significantly reduced operative time and transfusion requirements. In patients with cirrhosis, temporary clamping of the hepatic pedicle significantly decreased blood loss. Avoiding drainage significantly decreased the postoperative hospital stay.
Eighty-eight patients with bleeding esophageal varices due to portal hypertension underwent splenectomy and devascularization of the upper half of the stomach and the abdominal esophagus. A Hegar dilator no. 17 was introduced into the esophagus through a gastrotomy. A ring of separated stitches was applied at cardia level, the needle being inserted as far as the metallic surface so as to include the entire wall of the esophagus. Complete interruption of all gastroesophageal vascular communication was thus obtained. After suture of the gastrotomy, a Nissen or Lind's fundoplication was performed. In 62 (70.45%) patients, the immediate postoperative course was uneventful, 21 had non-lethal complications, 13 had abdominal evisceration, six pulmonary complications, four subphrenic abscesses, five patients died, two in hepatic coma, two after reoperation for subphrenic abscess and one after massive hemorrhage due to an acute gastric ulcer. Forty-three patients (48.8%) developed transient ascites which disappeared before they were discharged from the hospital. In thirteen patients (15.6%), the hemorrhage recurred. Of the 32 patients operated one to two years ago, only one rebled. Of the 35 patients operated three to five years ago, nine rebled and three, of the 16 patients operated from five to seven years ago, rebled. With radiological and endoscopic investigations, reduced varices were seen above the suture line, in many cases, passively filled up with blood returning from the azygos vein. Reflux esophagitis was observed in 17 patients who had had a Lortat-Jacob procedure to reduce the His angle; of these, eight rebled later. No gastroesophageal reflux was seen after Nissen or Lind's fundoplication. No fistulae, dysphagia or stenosis was observed.
BACKGROUND: The incidence of complications following gastric bypass surgery has decreased markedly over the last 30 years; nevertheless, significant morbidity and mortality is still associated with this procedure. Much of the improved risk of this technique can be attributed to the numerous modifications that have taken place in its evolution. METHODS: We compared our series of 640 primary cases of vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RGB), a form of gastric bypass, with gastric bypass series reported in the literature from 1966 to 1996. Incidences considered were those of subphrenic abscess, gastrointestinal leaks, obstruction of the excluded segment of gastrointestinal tract, splenectomy and death. RESULTS: The overall trend during the last 30 years has been a reduction in the rate of major complications. In our series, we had one major complication, a subphrenic abscess. This compares favorably with the incidence of major complications reported in the literature. CONCLUSIONS: The gastric bypass is a significantly safer operation today than three decades ago. We believe that the relatively low complication rate of VBG-RGB results from: (1) the anatomic location of the gastric pouch; (2) the type of stapling device used in its construction; (3) a pouch outlet restricted by a prosthetic band rather than a narrow anastomosis; and (4) the construction of a retrocolic, retrogastric Roux-en-Y gastrojejunal anastomosis.
In order to study the frequency and complications related to pancreatic fistula following distal pancreatectomy we have reviewed 19 patients operated on between January 1st 1981 and February 28 1986. There was no mortality but the incidence of pancreatic fistula was 52%. 40% of these cases developed a subphrenic abscess (21% of the total number of cases). These fistulas closed after an average post-operative period of 42 days. Reoperation for an infected collection was required in 4 cases. The incidence of pancreatic fistula was not related to the initial pancreatic pathology. Splenectomy did not influence the incidence of subphrenic abscess. Different techniques of closure of the distal pancreas after resection have not changed the incidence of this complication. The use of somatostatin appears to favourably influence the course of the fistula. These conclusions tend to confirm the results of other reported series.
We reviewed retrospectively the septic postsplenectomy complications after splenic rupture from abdominal trauma in 53 patients treated in the last five years (1984-1988). We recorded a higher incidence of complications (pneumonia, subphrenic abscess) in these patients than in those who underwent clean surgery during the same period, but we did not demonstrate the same difference in other infectious processes (infection of the surgical wound). Infections had a higher incidence in patients with splenic rupture with associated lesions (54.10%) than in those with only a splenic lesion (37.50%) (SD p less than 0.05). The predominant agents usually isolated were aerobic Gram-positive. We remark the importance of open drainage systems (Penrose type) in the genesis of subphrenic abscesses.
Twenty-one patients undergoing distal pancreatectomy from January 1980 through April 1987 were studied retrospectively. Group I (n = 10) had distal pancreatectomy with splenectomy, and Group II (n = 11) had distal pancreatectomy with splenic preservation. The groups were comparable in mean age and extent of pancreatic resection. Operative time in Group I patients who did not require additional major procedures was 3.74 +/- 1.01 hours, compared with 2.86 +/- 1.68 hours for similar Group II patients. The overall complication rate in Group I was 40 per cent, including two pancreatic fistulas, one subphrenic abscess, and one gastric fistula. In Group II the overall complication rate was 36.4 per cent, with one pancreatic fistula, one subphrenic abscess, and one colonic fistula. Splenic infarction occurred in only one patient (Group II), in whom both splenic vessels were ligated. No patient developed insulin-dependent diabetes. There were no deaths. The mean hospitalization time was 18.8 days in Group I, and 17.5 days in Group II. Splenectomy should not be considered a routine part of distal pancreatic resection. Splenic preservation can be achieved in selected cases with no increase in complication rate, operative time, or length of postoperative hospitalization.
A 23-year-old girl affected by Papillon-Lefèvre syndrome developed, during Etretinate therapy (1 mg/kg/day), two liver abscesses caused by pyogenic bacteria and a subphrenic abscess. The immunological effects of retinoids may precipitate severe infections in patients with Papillon-Lefèvre syndrome, who probably have a basic, even though not always evident, defect of PMN chemotaxis.
A case of emphysematous pyelonephritis with perinephric gas is presented. The patient was an elderly female diabetic and in addition had a subphrenic abscess as a complication of EPPG. Diabetes was not under control and E. coli was the sole pathogen. As the patient did not respond to conservative treatment, nephrectomy and drainage of subphrenic abscess were done and the patient improved rapidly.
Splenectomies have been performed on 58 patients with chronic myelogenous leukemia (CML) during the last 16 years. For the 27 patients operated upon during the first 12 years, the operative mortality was 26%. Four patients also had to be re-explored for bleeding and three required drainage of subphrenic abscesses. There has been no operative mortality in the 31 patients operated using a standardized procedure during the last four years but two had to be re-explored for bleeding and one required drainage of a subphrenic abscess. The operative risks for leukemic patients are infection, perhaps related to granulocyte abnormalities and hemorrhage in patients with thrombocytopenia or qualitative platelet abnormalities. When the splenectomy in patients with CML is timed with the patient's chemotherapy cycle, the use of local antibiotics and platelet concentrates should permit a safe operation. Survival rates were not comprised even when the patients had their splenectomy during CML-blast crisis.
Two hundred and twenty-two patients presented with clinical suspicion of an abdominal or pelvic abscess. Abscesses tend to locate in the perihepatic spaces or the pelvis, and these areas can easily be examined by ultrasound, using the liver or the urinary bladder as acoustic windows. Thirty-eight of 42 abdominal abscesses, and 32 of 33 pelvic abscesses were correctly diagnosed and located by ultrasound, giving a sensitivity of 93.3%. Of the 145 patients without abscesses, 143 were correctly excluded, giving a specificity of 98.6%. Thirty of these patients also underwent gallium 67 examination. This detected all 7 true negatives and all 10 abscesses, 1 of which was missed by ultrasound. Of the remaining 13 patients with positive gallium results, 10 had nonspecific uptake in diffuse inflammatory conditions, and 3 were false positives with uptake in bowel or in a surgical wound. In those patients with nonspecific gallium uptake, ultrasound was valuable in documenting the absence of an abscess cavity. Conversely, gallium detected a left subphrenic abscess missed by ultrasound. For reasons of economy, speed, and high sensitivity, we believe that ultrasound should be the initial screening procedure for patients with clinical suspicion of abdominal or pelvic abscess. Gallium should be reserved for patients with equivocal ultrasound results of those with septic foci not revealed by ultrasound.
The case of recurrent subphrenic abscess with the jejunal fistula after stomach resection in 41-years old male is presented. In microbiological examination E. coli antibiotic-resisted was discovered. The bacteriophages were prepared and administered to the patient. The operation was performed without any antibiotics. During the whole stay at hospital the patient had got bacteriophages. He left the hospital in 33rd day of stay without any abscesses.