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PubMed1983

Surgical treatment of bronchobiliary fistulas.

We have reviewed our experience with thoracobiliary fistulas due to biliary tract disease. Early diagnosis and treatment of subphrenic abscesses and bile duct obstruction will decrease the incidence of these fistulas. Once established, relief of biliary obstruction, subphrenic drainage, excision of the fistulous tract and appropriate supportive measures will decrease the morbidity rate and mortality of this rare but distressing condition. In our series, all of the patients ultimately had relief of the symptoms. There was no mortality.

Adult↗
PubMed1987

Volvulus of the stomach: an African series and a review.

A radiological diagnosis of gastric volvulus (GV) was made in 11 of 576 consecutive upper gastrointestinal series at the University of Benin Teaching Hospital, Nigeria, over a two-year period. The clinical symptoms were thoracico-abdominal in three and abdominal in eight; these cases were evaluated as acute in three, acute upon chronic in two, and chronic in six. There was a significant delay in the diagnosis in all cases (except a neonate in the series), and no case was diagnosed on clinical grounds alone.THE PREDISPOSING FACTORS (EXCEPT THE CLINICAL MISDIAGNOSIS OF THE NEONATE) IN SIX OF THE SEVEN CASES THAT CAME TO SURGERY WERE: diaphragmatic hernia and perigastritis (left lung abscess, thoracic empyema), arteriomesenteric compression of the duodenum in pregnancy (peptic ulcer), splenomegaly (hepatosplenomegaly, ascites, esophageal varices), previous gastrojejunostomy (stomal ulcer, left subphrenic abscess) and two cases of intestinal malrotation with mesenteric abnormalities (small bowel obstruction in one and duodenal atresia in the other). In one idiopathic case, gastric outlet obstruction was clinically suspected prior to surgery. Thus, the putative rarity of GV in black Africans is not supported by this experience.Gastric volvulus is a clinico-radiologic entity that may present with a confusing thoracico-abdominal symptom complex. A greater awareness of the radiologic features is quintessential to an expeditious and usually successful surgical management that will avoid potentially serious complications. Negative surgical findings do not exclude GV as the underlying cause of acute abdomens necessitating emergency laparotomies.

Adolescent↗
PubMed1992

[Pericardectomy and acute infectious pericarditis].

Between 1980 and 1990 12 patients (5 male, 7 female) were operated on for acute infectious pericarditis at a mean age of 42 years. The infections were 6 bacterial (purulent 4, abscess 2), 4 tuberculous, 1 viral and 1 Candida. Pericarditis resulted from contiguous spread of infection from bilateral pneumonia in 3 patients, from subphrenic abscess in 2 and followed bacteremia in 1. Clinical signs were: tamponade/shock in 9, elevated jugular venous pressure in 11, edema in 6, hepatomegaly in 6, ascites in 1, and pericardial friction rub in 3. A preoperative pericardiocentesis in 9 patients allowed only 4 positive microbiological diagnoses and was an insufficient drainage in all cases. The preoperative mean NYHA class was 3.3. The pericardectomy was total in 9 patients and partial in 3. Total mortality was 1/12 patients (8%) with one late death due to recurrent tuberculous pericarditis. No patient with purulent pericarditis died. Another recurrence occurred 6 months after acute viral pericarditis. Atrial fibrillation in one patient was the only postoperative complication. After a mean follow-up period of 48.5 months no cardiac constriction had occurred in 11 surviving patients Actuarial survival after pericardectomy is 100% after 1 month and remains 91% after 5 years. The mean NYHA class has significantly improved to 1.2 (p less than 0.05) at the end of the follow-up. We conclude that pericardectomy combined with a specific antimicrobial therapy is a safe treatment for acute infectious and especially purulent pericarditis with low mortality and excellent longterm results. Early pericardectomy allows rapid decompression of the heart, removal of intrapericardial adhesions and infected tissue and prevents late constriction.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1992

A perforated appendix: should we drain?

The effectiveness of intraperitoneal drain was studied on patients undergoing appendicectomy for perforated appendicitis. Randomly 40 patients were allocated with drainage by corrugated rubber drains and 46 patients were without drainage. There were 5 deaths in the series, out of which 4 (10%) were in the drainage group and one (2.2%) in the group without drainage. The incidences of major wound sepsis, paralytic ileus, intraperitoneal abscess and urinary infection were observed in 55%, 42.5%, 12.5% and 15% respectively in drainage group and 50%, 28.3%, 21.7% and 15.2% respectively in non-drainage group. Occurrence of subphrenic abscess (7.5%), burst abdomen (5%) and faecal fistula (5%) were confined to drainage group only.

Adult↗
PubMed1984

[Percutaneous drainage of intra-abdominal fluid collections using computed tomography].

Percutaneous catheter drainage guided by computed tomography has been used to treat 45 intraabdominal collections in 32 patients. The 45 drainages involved 15 pancreatic cysts of chronic pancreatitis, 15 spontaneous abscesses and 15 postoperative abscesses. The collections were treated either by one puncture only or by drainage, with a success rate of 87.5%. Morbidity was 2.2% (one right empyema after puncture of a postoperative right subphrenic abscess). Mortality was nil. Three inadequate drainages due to enteric communication required secondary surgery. It is concluded that, if the indications are correct, percutaneous drainage guided by CT is as good as surgery and involves lower morbidity and mortality.

Abdomen↗
PubMedDate not supplied

Endoscopic treatment of biliary tract fistulas.

Endoscopic therapy was attempted in 24 patients with spontaneous or postoperative persistent biliary fistulas. Endoscopic retrograde cholangiography demonstrated the site of the fistula in 22 cases. Sphincterotomy or biliary stent placement resulted in rapid resolution of the fistula in 16 of 24 patients. Failures were attributed to exclusion of the injured intrahepatic bile duct in two cases, insufficient dilation of a bile duct stricture in one, the large size of the bile duct defect in two, and associated lesions in three (cirrhosis, arterial trauma, subhepatic abscess). Endoscopic management of biliary fistulae requires: (1) visualization of the location of the fistula by retrograde cholangiography especially in case of an intrahepatic lesion, (2) prior percutaneous drainage of associated subhepatic or subphrenic abscesses, and (3) appropriate relief of distal biliary obstruction in order to reduce the intraductal biliary pressure. The outcome is uncertain when endoprostheses are used to bridge large bile duct defects.

Adult↗
PubMed1979

[Spenic abscesses].

Abscess of the spleen is an uncommon entity that seems even less common as it still represents a diagnostic problem. The most common cause of splenic abscess is metastatic hematogenous seeding of the diseased spleen especially of the infarcted areas or traumatic hematomas. It can result also from the direct spread of infection from surrounding structures. Many patients with splenic abscess have a rapidly progressive generalized sepsis and even the combination of well-timed surgery and antibiotic therapy is not always curative. Local symptoms may be mild and overlooked and there may be only general symptoms of suppuration present. X-rays investigations often yield valuable information about the location of the abscess. By far the most promising technique is splenic scanning with the use of radioisotopes. Our case of splenic abscess following appendicitis has been described. The course and the diagnosis has been established using liver-spleen scanning. The patient was treated with Obracin and Dalacin and the diseased spleen has been removed. After drainage of the left subphrenic abscess the recovery was uneventful.

Abscess↗
PubMed1997

Right hepatectomy for pyogenic liver abscesses with true multiloculation.

We report the case of 61-year-old woman with cryptogenic liver abscesses who had been profoundly ill with severe upper abdominal pain, impaired consciousness, prostration, continuous high fever secondary to sepsis, and thrombocytopenia (platelets, 1-5 x 10(4)/mm3) since admission. Ultrasonograms and computed tomograms revealed two separate multiloculated lesions in the right lobe of the liver, consistent with the liver abscesses. Immediately after diagnosis, percutaneous abscess drainage was performed under ultrasonographic guidance; however, only a small amount of pus was drained, prompting continuous irrigation of the abscess cavity. Four days later, transcatheter hepatic arterial infusion of antibiotics was attempted. However, the abscesses had enlarged and her general condition had worsened. On hospital day 8, she underwent right hepatectomy because the multiloculated lesions were refractory to drainage. The operation was successful in terms of hepatectomy, although she continued to suffer from sepsis, secondary right subphrenic abscess formation, and prolonged thrombocytopenia with associated coagulation disorders for two months. Examination of multiple cross sections of the resected specimen disclosed that the lesions consisted of aggregations of multiple small locules. There was no communication between the locules and there were true septations, rather than multiloculated lesions with pseudoseptations. The patient has been well for 2 years without recurrent abscess of the liver or any infectious disease.

Drainage↗
PubMed1985

Liver abscess complicating Crohn's disease presenting as thoracic empyema. Case report and review of the literature.

A 28-year-old man with a history of Crohn's disease presented with right pleuritic pain and dyspnea. Chest radiography showed a right pleural effusion. Thoracocentesis yielded purulent fluid that subsequently grew Enterobacter aerogenes. Computed axial tomography of the abdomen revealed right subphrenic abscess and right hepatic lobe abscess. Antibiotic therapy and surgical drainage resulted in complete recovery. A review of the English literature produced 18 cases of liver abscess complicating Crohn's disease. Details of 14 of these cases are summarized.

Adult↗
PubMed1989

[Abscess of the spleen: diagnosis and treatment. Apropos of 12 cases].

Twelve cases of splenic abscess, seen at our hospital between January 1980 and June 1987, were reviewed retrospectively. The most common causes of splenic abscesses were subacute endocarditis and intra abdominal sepsis. Diagnosis was suspected on clinical grounds and was always confirmed by sonography and/or computerized tomography. Two patients were drained unsuccessfully under CT scan guidance and underwent splenectomy. The other patients were operated primarily. One patient developed a subphrenic abscess postoperatively. One patient died from intractable cardiac failure due to subacute endocarditis. The authors stress the role of CT scan in the diagnosis of splenic abscess and recommend early splenectomy in cases of failure of percutaneous drainage.

Abscess↗
PubMed2000

Diagnostic and therapeutic fistuloscopy: an adjuvant management in postoperative fistulas and abscesses after upper gastrointestinal surgery.

BACKGROUND AND STUDY AIMS: Postoperative fistulas and abscesses pose difficult management problems. We report our experience in the use of fistuloscopy in postoperative fistulas and abscesses after upper gastrointestinal surgery. PATIENTS AND METHODS: From June 1993 to January 1997, nine patients (seven men, two women; mean age 65) with postoperative fistulas and abscesses were treated with therapeutic fistuloscopy. Diagnostic fistuloscopy was carried out using a 5-mm choledochoscope under fluoroscopic guidance. Therapeutic procedures included mechanical debridement, irrigation, and sealing of fistula with fibrin sealant and gelatin sponge. RESULTS: The patients were suffering from duodenal stump fistula (three cases), gastrojejunostomy dehiscence after gastrectomy (three cases), gastropleurocutaneous fistula (two cases), and subphrenic abscesses (two cases). Fistuloscopy was performed 4-19 days (mean 12 days) after the diagnosis of the fistula. The median number of sessions required was 2 (range 1-4). The average daily fistula output prior to fistuloscopy was 154 ml (range 30-560 ml), and all fistulas healed in an average of 18.7 days (range 2-46 days) after index fistuloscopy. No procedure-related complications occurred. The mean hospital stay was 61 days. During a mean follow-up period of 12 months, no recurrent abscesses or fistulas developed. CONCLUSIONS: Fistuloscopy provides a new means of managing patients with postoperative fistula and abscess formation.

Abscess↗
PubMed1980

Anaerobic pleural and pulmonary infections.

Radiographic findings are reviewed for 69 patients with bacteriologically proven anaerobic infections in the thorax. On the initial films, the disease was confined to the lung parenchyma in 50%, and to the pleura in 30% of patients. The other 20% had combined pleural and parenchymal disease. Over 50% of cases had lung necrosis on the initial films, and many patients who began with a noncavitary pneumonia developed necrosis during hospitalization despite antimicrobial therapy. Once necrosis developed, resolution was slow with an average closure of 65 days for lung abscesses. Parenthymal disease was usually confined to one anatomic site. This site was almost always in a basal or posterior part of the lungs. Pleural effusions tended to progress very rapidly and always proved to be empyemas. Many empyemas occurred without recognizable pneumonic disease. A few were nosocomial, occurring as a complication of surgery, penetrating chest wounds, or subphrenic abscesses. Many patients developed empyemas as a complication of parenchymal disease, frequently while on antimicrobial therapy. Almost all empyemas required surgical drainage with either a rib resection or decortication.

Adolescent↗
PubMed1994

Salmonellal splenic abscess in the antibiotic era: a Latin American perspective.

Ten cases of salmonellal splenic abscesses recently documented in various Latin American countries are discussed. All patients were adults; the mean age was 32.6 years, and there was a predominance of males (seven). Predisposing conditions were identified in four cases. All 10 cases were documented by diagnostic imaging techniques; in one case, exploratory diagnostic laparotomy was also performed. Splenectomy was performed on eight patients, while two other patients responded to long courses of intravenous antimicrobial therapy alone. One patient died as the result of perioperative splenic rupture, and two patients underwent second laparotomies because of left subphrenic abscesses. Except for one human immunodeficiency virus-infected individual, all patients were immunocompetent and had large solitary lesions. Salmonella typhi was the predominant organism isolated and was recovered in six of the 10 cases.

Abscess↗
PubMed2002

Technical standardization of laparoscopic splenectomy: experience with 105 cases.

BACKGROUND: Some reports have suggested that laparoscopic splenectomy (LS) can be successfully performed in adults. However, several aspects of this procedure remain as yet undefined; therefore, several attempts have been made to modify the standard technique to try to optimize the procedure. Herein we analyze our experience with 105 laparoscopic splenectomies. METHODS: From 1993 to 2000, 105 patients underwent LS at our hospital. Twelve of these patients also underwent a concomitant cholecystectomy. There were 66 women and 39 men whose ages ranged between 4 and 78 years (median, 27.7). All patients underwent an elective laparoscopic splenectomy. Seventy five patients had thrombocytopenia (ITP), 14 had hereditary spherocytosis, eight were affected by b-thalassemia, two had splenic cysts, two had lymphoma, (two had myeloid chronic leukemia, one patient presented with a splenic abscess and one had incurred an iatrogenic spleen lesion during adrenalectomy. The first patients in this series were positioned in dorsal decubitus; however, as the team's experience increased, the right lateral decubitus became the position of choice because it provides better exposure of the splenic hilum. This procedure requires the use of only four trocars. RESULTS: Mean operating time was 95 min (range, 35-320). Hospital stay ranged from 2 to 21 days (median, 4.5). There was only one conversion to open surgery. One patient died in the postoperative period due to the evolution of a preexisting malignant disease. We recorded nine complications-four subphrenic abscesses, two cases of pleuritis, two episodes of postoperative bleeding, and one intestinal infarction 16 days after surgery. Only two patients needed redo surgery. CONCLUSIONS: We believe that the laparoscopic approach is a valid alternative to open splenectomy, but mastery of some of the technical details of this procedure could greatly help avoid its complications. On the basis of our experience, it seems that the lateral approach should be considered the position of choice because it provides exposure and easier dissection of the splenic hilar structures. We also found that a 30 degrees scope and an ultrasonic dissector allowed for perfect vision and optimal hemostasis during the procedure. At the end of procedure, the spleen should be fragmented and then extracted using an extraction bag.

Adolescent↗
PubMed1993

Hepatic resection for hepatolithiasis.

OBJECTIVE: To analyze the results of hepatic resection for hepatolithiasis. DESIGN: A retrospective study of case records of patients with hepatolithiasis undergoing hepatic resection. These patients had been followed up for 3 to 38 months. They were referred to Queen Mary Hospital, a tertiary referral center in Hong Kong. PATIENTS: Of 172 patients with hepatolithiasis seen between January 1984 and December 1981, 63 patients underwent hepatic resection because the affected liver segments were destroyed by repeated infection (n = 51), multiple cholangitic liver abscesses were found in the affected liver segments (n = 9), or concomitant intrahepatic cholangiocarcinoma was diagnosed (n = 3). INTERVENTION: Left lateral segmentectomy was performed in 42 patients, left hepatic lobectomy in 15 patients, right hepatic lobectomy in one patient, and segmentectomy in five patients. MAIN OUTCOME MEASURES: Postoperative morbidity and mortality analysis. RESULTS: Contrary to hepatic resection in a normal liver, dissection to isolate inflow and outflow vasculature was difficult in 52% of cases owing to severe inflammatory fibrosis at the liver hilum, at the umbilical fissure, or at the junction of hepatic vein with inferior vena cava. The operative morbidity rate was 32% and the mortality rate was 2%. The majority of complications were wound infection, subphrenic abscesses, or biliary fistulas, which could be due to the presence of infected bile (85%) and liver abscesses (25%) in this disease. Statistical analysis of the preoperative hematological and biochemical variables and the amount of intraoperative blood loss could not identify any factor with significance in correlating with the development of postoperative complications. Stones recurred in 16% after a median follow-up of 47 months. CONCLUSION: Hepatic resection is a satisfactory treatment for hepatolithiasis. The postoperative septic complication rate is high and is an intrinsic problem related to liver resection in a septic condition.

Adult↗
PubMedDate not supplied

Subphrenic and pleural abscess due to spilled gallstones.

BACKGROUND: A 70-year-old male approximately 3 years after laparoscopic cholecystectomy presented to his primary care physician with a 4-month history of generalized malaise. METHODS: A workup included magnetic resonance imaging that revealed a perihepatic abscess. The patient underwent ultrasound-guided drainage, with the removal of 1400 mL of purulent fluid and placement of 2 drains. Computed tomographic scanning showed resolution, and he was discharged home on oral antibiotics. At 2-month follow-up, the patient was asymptomatic, denying any constitutional symptoms. However, abdominal computed tomographic scanning revealed recurrence of the abscess, which measured approximately 18 x 9 x 7.5 cm, with mass effect on the liver. The patient was placed on intravenous antibiotics and scheduled for operative drainage. The abdomen was entered with a right subcostal incision, and 900 mL of purulent fluid was drained. We also noted abscess erosion through the inferolateral aspect of the right diaphragm into the pleural space. The pleural abscess was loculated and isolated from the lung parenchyma. Palpation within the abscess cavity revealed 9 large gallstones. Following copious irrigation and debridement of necrotic tissue, 3 drains were placed and the incision was closed. RESULTS: The patient had an uneventful recovery and was discharged home on postoperative day number 6. Follow-up imaging at 3 months demonstrated resolution of the collection. CONCLUSION: Spillage of gallstones is a complication of laparoscopic cholecystectomy, occurring in 6% to 16% of all cases. Retained stones rarely result in a problem, but when complications arise, aggressive surgical intervention is usually necessary.

Abscess↗