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Technological advances currently allow safe percutaneous puncture of certain intra-abdominal collections, provided the indications and technical precision are imperatively respected. Our aim is to draw attention to success factors and the limits of this procedure.
In a series of 4350 children with abdominal surgical diseases operated at the Department of Pediatric Surgery in Sofia for a period of 3 years (1987-1989) the authors have observed 4 cases of pleuropulmonary complications (0.09 per cent). In two of these children the primary abdominal operation was for liver echinococcus, in 1--rupture of the liver and subphrenic abscess and in 1--perforative appendicitis and purulent peritonitis. Symptoms of respiratory failure developed in addition to the abdominal symptoms. Leading in the complex treatment was sanation of the abdominal cavity from the purulent process and double pleural drainage. The severe pathologic changes in the organs of the two adjacent cavities were responsible for the high case fatality rate (25 per cent).
Intraabdominal abscesses are life threatening complications of inflammatory processes or major surgery. Ultrasonography, computed tomography and scintigraphy are the diagnostic methods of choice. Diagnostic percutaneous puncture can be followed by therapeutic percutaneous drainage (PD). The diagnosis "intraabdominal abscess", however, is not sufficient for a rational therapeutic strategy. Therapy of intraabdominal abscesses (IAA) depends upon etiology and localization of the process and the individual situation of the patient.
The authors studied 30 patients with bleeding from esophageal varices due to portal hypertension. They underwent the disconnection of portal and azygos veins and splenectomy. The immediate postoperative complications were: portal thrombosis in four patients (13.3%); subphrenic abscess in two (6.6%); pulmonary embolism in one (3.3%) and esophageal perforation in one (3.3%). The manifestations of portal thrombosis were ascites, and fever (without leukocytosis). One patient with portal thrombosis who had intractable ascite was submitted to peritoneovenous shunting.
Montpellier Cancer Institute strategy and experience in surgical treatment of multi-bilateral hepatic metastases from digestive tract cancers is presented based on retrospective case by case analysis of survival time of 38 patients. The mean age was 46.2 years and the primaries were colorectal (22 patients) and endocrine (16 patients). Liver surgery was synchronous to the resection of primary lesions in 8 patients and metachronous in 22 patients. Two-step liver surgery was performed in 8 patients. Overall thirty-days postoperative mortality was 7.8% and morbidity 15.7% (wound sepsis, subphrenic abscess, transitory jaundice, biliary fistula). The analysis of survival time evidenced that with reasonable risk-benefit ratio the aggressive surgical approach can be justified especially in patients with endocrine primaries.
From 1978 to 1987, thirty patients were secondarily referred to Saint-Antoine Hospital for the treatment of their hepatic trauma. Seventeen were referred because of a postoperative complication (group I) and thirteen after peri-hepatic packing (group II). In group I, transfer was decided because of hemorrhage (8 patients), sepsis (6 patients) and haemobilia (3 patients). The lesions observed in this group (hemoperitoneum, hepatic sequestrum, intrahepatic hematoma, choleperitoneum and subphrenic abscess) were often related to an incomplete assessment of hepatic damage due to an inadequate exploration and the absence of operative cholangiography. In group II, peri-hepatic packing was effective in eleven patients. The overall mortality was 16.6% (17.6% in group I and 15.4% in group II). Postoperative complications occurred in 50% of the patients (64.6% in group I and 30.7% in group II). Good exposure of the liver, operative cholangiography and, in selected cases, a direct approach to the lacerated liver with suture ligation of severed blood vessels and bile ducts are mandatory for the complete exploration and the treatment of severe hepatic trauma. Peri-hepatic packing and the transfer of the patient to a specialized center is a reliable method when the injury cannot be treated locally.
Thirteen patients with abdominal trauma who developed abdominal sepsis resistant to conventional methods of reexploration and drainage were managed by an open method. Eleven of these patients had multiorgan failure. The extent of anatomic and physiologic injury was defined by Abdominal Trauma Index and Acute Physiology and Chronic Health Evaluation (APACHE) scores, respectively. Ten of the 13 patients (76.9%) survived, a significantly improved survival as compared with that predicted by APACHE (50%). Complications attributable to the open technique (enteric fistula and a subphrenic abscess) occurred in two of the ten survivors. It is concluded that the open method of management of abdominal sepsis is effective and feasible. It should be considered in patients with necrotizing wound infections, multiorgan failure, and ongoing abdominal sepsis uncontrolled by conventional methods. Larger, controlled series employing such systems as the APACHE are needed for a better definition of patient selection for the open method.
A total or nearly total gastrectomy was performed in 30 patients with adenocarcinoma of the stomach. The continuity of the alimentary tract was restored by end-to-side esophagojejunostomy or gastrojejunostomy using a Roux-Y and all the cases had one layer extramucosa suture with 3-0 mononylon. The complications were: one case of left subphrenic abscess; one case of anastomotic leakage (esophagojejunum anastomosis); 2 cases of abdominal wound infection. Surgical mortality was 0%.
Hydatid disease is rare and sporadically seen in our region. With the use of modern diagnostic methods the diagnose of echinococcus cyst in the liver is easily and exactly made; most frequently we performed cystectomy paying attention not to disseminate the parasite fluid, and treating the cavum of the pericyst as described by PAPADIMITROU. Using the drainage of subphrenic space we prevent postoperative complications. When the subphrenic abscess appears the hospitalisation period is prolonged, the patient's life is threatened and the treatment is getting expensive.
Over a period of 20 years, surgery was carried out in 581 patients for 952 hydatid cysts of the liver. Patients included 372 females and 209 males, aged from 6 to 70 years, with a mean age of 34 years. 52% of patients were aged between 20 and 40 years. The cyst was single in 324 patients, double in 102, triple in 22 and multiple in 133. Treatment most often consisted of resection of the projecting dome of the cyst (78%), and more rarely pericystectomy (5.5%), hepatic resection (3.5%) or external drainage (4.2%) via a median incision in 412 cases and a subcostal incision in 126 cases. Capitonnage of the residual cavity was combined with resection of the projecting dome, 176 cases included a cystobiliary fistula with migration occurring in 30 cases. Morbidity was 20% and included, in particular, 45 cases of subphrenic abscess. 19 patients showed signs of recurrence and 16 underwent further surgery. Overall mortality was 2.06% i.e. 12 patients. In endemic countries, resection of the projecting dome remains a method which gives good results and has a low mortality and morbidity.
Gastric adenocarcinoma locally advanced or located at the cardia, or of large size or with local lymphadenopathies are of bad prognosis. To improve the surgical results we have tested the feasibility and tumoral efficacity of pre-operative (neoadjuvant) chemotherapy. Twenty patients have been included between 6/87 and 12/88. Median age was 63 years (36-74); all patients were in good general condition (OMS 0-1). The tumors were located at the cardia in 50%. The tumor median size was 10 cm (6-19), pathological lymph nodes were seem at CAT. Scan in 10/20. The neoadjuvant chemotherapy was continuous IV, 5 FU 1 g/m2/day for 5 days + CDDP 100 mg/m2, day 1. The cycles were repeated every 4 weeks. The median number of cycles prior surgery was 2 (1-4) and depended of tolerance and efficacy. We have observed (WHO criteria). 1 CR, 12 PR (Responsible rate: 65%). 6 MR or S. One patient was non evaluable because coronary insufficiency complicating the first cycle. The neoadjuvant chemotherapy toxicity was mainly hematological. The surgical procedure was curative in 15/20 patients; palliative 4 and non feasible for progression 1. Normal rate of post-operative complications was encountered: 2 subphrenic abscess, 1 pneumopathy, 1 stercoral peritonitis. At this date 3/20 patients died (17 patients are still alive, among them 14 are NED (the overall median survival is more than 10 months). This study demonstrated the feasibility and high response rate of neoadjuvant chemotherapy in patients with locally advanced gastric carcinomas. A randomized trial is warranted to demonstrate the survival benefit.
The authors reviewed the case files of 49 adult patients undergoing splenectomy for chronic idiopathic thrombocytopenic purpura at the Centre Henri Becquerel between 1970 and 1987. Although the postoperative course was straightforward in 83.7% of cases, one reoperation for subphrenic abscess was necessary and there was one postoperative death. Remission from thrombocytopenia was obtained in 87.5% of the patients, but only transiently in 8.5% of them. No preoperative predictive factors could be demonstrated. An early postoperative rise in the platelet count to more than 500 G/litre appears to ensure a good subsequent result. Secondary infectious complications are not exceptional and can be fatal (one death in our series); they require prophylaxis by anti-pneumococcal vaccination. The place of prophylactic antibiotic therapy has yet to be defined.
Seventy-two perforated gastroduodenal ulcers were treated by an original method aimed at avoiding emergency surgery, which consists of peritoneal dialysis associated, during 3 days, with gastric aspiration. Over a 3-year period this method was applied to all patients admitted with a perforated ulcer. The ulcer was revealed by the perforation in 25 p. 100 of the cases, and 90 p. 100 of the patients had pneumoperitoneum. Contrast radiography with Gastrografine (sodium and meglumine amidotrizoate) located the perforation. Fifteen patients had another disease which made the prognosis worse. The time elapsed between perforation and treatment was 15 hours on average. Peritoneal fluid infection was present in 30 p. 100 of the cases. The outcome was favourable in 69 patients (96 p. 100). One patient died of pulmonary embolism, another was operated upon on the 4 th post-perforation day for a bleeding ulcer and a third patient with giant gastric ulcer developed subphrenic abscess. This method seems to be indicated in patients at high surgical risk (elderly people or people with severe underlying disease), and in young patients with perforated acute ulcer. In chronic ulcers, peritoneal dialysis ties the patient over the first hours, thus enabling radical surgery to be electively performed. In perforations seen after 24 hours, it helps in supporting the patient prior to surgery. The method in contra-indicated in gastric ulcers.
Various diseases of the gastrointestinal tract at times are accompanied by an exudative pleural effusion. The exudative pleural effusions resulting from esophageal perforation, pancreatic disease, subphrenic abscess, intrahepatic abscess, splenic abscess, abdominal operations, and diaphragmatic hernia are discussed in this article.
A total of 109 patients with histologically proved hepatocellular carcinoma (HCC) have undergone hepatic resection during the 56-month period from October 1978 to May 1983. There were two sources of patients: those with symptomatic HCC (n = 47) and those with asymptomatic HCC (n = 62). A family tendency of HCC was noted in 11% of the patients studied. The percent of positive hepatitis B surface antigen (HBsAg) was 87%, and the serum alpha-fetoprotein was less than 20 ng/ml in 30% in the group with symptoms. The operative mortality rate was 3% and the hospital mortality rate was also 3%. The postoperative course was complicated with pleural effusion in 10%, bile leakage in 4%, subphrenic abscess in 4%, and upper gastrointestinal bleeding caused by gastritis in 1% of the patients. The actual survival rate for the 103 cases was 84% for 350 days and 28% for 1400 days. However, in the group with asymptomatic HCC with an average tumor size of 3.35 +/- 1.49 cm in diameter, the rate was 92% for 350 days and 44% for 1400 days. In the group with symptomatic HCC with an average tumor size of 10.6 +/- 5.1 cm in diameter, the rate was 76% for 350 days and 8% for 1400 days. The survival rate of the group with asymptomatic HCC was far better than that of the group with symptoms (p less than 0.05). In analysis of factors that might affect the patient's survival, only second or third operations (p less than 0.05), typical gross findings of tumor appearance (p less than 0.05), and an adequate margin were closely related (p less than 0.001). Neither the tumor size, the status of accompanying liver cirrhosis, the tumor location, nor the patient's sex and age affected the patient's survival (all p greater than 0.05).
Twenty nine patients of an intensive care unit (9 women and 20 men), aged 63.9 +/- 15.8 years, with a mean body weight of 62.5 +/- 11.8 kg were treated during 9.4 +/- 2.1 days by aztreonam (2 x 1 g/24 h) administered by short infusion (30 min) for a severe infection due to a Gram-negative bacilli. The primary (n = 25) or nosocomial (n = 4) infection sites were a peritonitis (14), a septicaemia (6), a cholecystitis (6), a pyelonephritis (5), a cholangitis (2), a subphrenic abscess (1) or a pneumonia (2). The isolated Gram-negative bacilli were all susceptible to aztreonam, their MIC being less than or equal to 0.5 micrograms/ml, except for a Pseudomonas aeruginosa (MIC = 4 micrograms/ml). Aztreonam was administered as a single therapy to 7 patients and in association with metronidazole (18) and/or penicillin G (14) to 22 patients; in fact, anaerobes were isolated in ten patients. The mean serum concentrations of aztreonam, as measured by HPLC, before and after the 7th administration respectively were 83.2 +/- 17.5 and 6.1 +/- 5.5 micrograms/ml for peak and through levels. The treatment of the 29 infections was a success in all the cases. No complication occurred due to the presence of Gram positive cocci (n = 4) in the first bacteriological sample, or due to the emergence (n = 12) of Gram positive cocci, except for one case of sepsis of the abdominal wall by Staphylococcus aureus. Aztreonam (2 x 1 g/24 h) may be a suitable alternative for the treatment of severe infections of intensive care units, mostly due to Gram-negative bacilli.
Carumonam is a new N-sulfo-beta-lactam antibiotic active against aerobic Gram-negative bacteria. An open study was carried out to evaluate the efficacy, safety and tolerance of carumonam with either 1 g t.i.d. (group A) or 2 g t.i.d. (group B) in bacterial septicaemia or severe sepsis. A total of 24 patients (14 men and 10 women) were included in the study, their ages ranged from 48-87 years (mean age 59). Eighteen patients were treated for bacteraemia, three for bronchopneumonia, two for urinary tract infection and one for a subphrenic abscess; seven were in group A and fourteen in group B; three were treated with a variable regimen. The pathogens isolated included E. coli [10], Klebsiella aerogenes [9], Enterobacter cloacae [3], Citrobacter freundii [2], Pseudomonas spp. [4], Providence stuartii [2], Serratia marcescens [1] and Haemophilus influenzae [1]. Clinical improvement occurred in all patients in both groups. One patient in group A and four patients in group B required further antibiotic therapy. The overall clinical cure rate was 84% and the bacteriological cure rate was 72%. Supra-infection occurred in three patients and adverse reactions attributable to carumonam were seen in two patients: diarrhoea (in one), and aggravation of renal failure in the other. Carumonam is well tolerated at both the dosage regimens; it is effective in the treatment of aerobic Gram-negative sepsis.
Over a period of 6.5 years, 29 patients with liver hemangiomas have been examined. In 8 patients, the most frequent symptom was pain; in 11, a tumor was found. The diagnosis was made by means of scintigraphy with 99mTc, followed by real-time sonography, computed tomography using a contrast medium, and selective arteriography. In 16 patients (15 women, 1 man), the tumor radius was more than 6 cm and in 9 of these, more than 10 cm. In 3 patients, a left lobectomy was carried out, and in 5 a right lobectomy; in an additional 5 patients, a extended right lobectomy (three segments excised) was done. In the rest, a medial lobectomy, a segmentectomy on the left side, or a segmentectomy on the right was performed. The only complications observed in the whole series were: pleural effusion (1 case), subphrenic abscess (1), and transitory biliary fistula (1). All hemangiomas with a radius of more than 10 cm should be removed operatively, as should smaller symptomatic hemangiomas and tumors that are not clearly benign.