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The authors have found that subdiaphragmatic abscesses developed in 67 (0.62%) out of 10,757 patients operated on organs of the abdominal cavity. A detailed analysis of incidence, causes and localization of subdiaphragmatic abscesses after different operations is given. Questions of clinical and roentgenological diagnostics and results of the treatment of these complications are discussed.
A case is presented of a 14-year-old boy with massive gastric bleeding 8 months after a splenectomy. A linear gastric ulcer was found associated with perforation leading to an abscess in the former splenic site. The vulnerability of proximal greater curvature to perforation after splenectomy, and the possibility of extrinsic erosion causing gastric or duodenal ulceration are emphasized.
Patients who endured complications due to a presumed or genuine medical error often request an extrajudicial medicolegal opinion. Frequently, the problems appear to originate from an insufficient (preoperative) information of the patient. These expert opinions are an instructive source of learning about possibly avoidable errors. Publishing such cases, in a completely anonymized form, should hopefully contribute to the prevention of the recurrence of certain mistakes. We present and comment on two postoperative events: (1) incisional hernias after abdominal hysterectomy and (2) a sub-diaphragmatic abscess after laparoscopic removal of a dermoid ovarian cyst with intraabdominal spillage of its content.
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We present a case of a Richter's hernia through a traumatic, diaphragmatic defect presenting with the appearance of an abscess on computed tomography. We underscore the importance of this hernia variant, the need for its recognition, and stress caution in percutaneous aspiration of a lesion where a hernia might exist.
Salmonella typhi is known to produce acalculous cholecystitis and related gall bladder perforation. Following is a documentation of a patient of sub-phrenic abscess and gall bladder perforation which was possibly a result of Salmonella paratyphi A.
Combined liver-lung scanning has proven to be an extremely rapid and useful tool in the diagnosis and localisation of sub-phrenic abscess and differentiation of basal defects of the right lung. There is little discomfort to the patient who may be experiencing considerable chest pain. The patient spends less than 20 minutes in the nuclear medicine department. The results are quickly obtained, no complex mathematical analyses are needed, and the images are easily interpreted.
One hundred and sixty-seven patients subjected to splenectomy on haematological indications were studied. They were grouped into five diagnostic categories: auto-immune disorders (52 patients), Hodgkin's disease (32) lymphoproliferative malignancies (60), myeloproliferative malignancies (18) and miscellaneous (5). The total number of complications and deaths were 42 (25 per cent) and nine (5 per cent), respectively. Infections were the most common complication, occurring in 30 cases and accounting for 59 per cent of all sequelae. Patients with auto-immune disorders had a high frequency of subphrenic left-sided abscesses (5/52). Splenectomy for Hodgkin's disease was associated with a very low frequency of complications. In the 60 patients with lymphoproliferative malignancies left-sided pneumonia was common (9/60). Complications occurred in 56 per cent of the patients with myeloproliferative disorders, the associated mortality rate being 28 per cent. It is concluded that elective splenectomy in haematological diseases seems to be a safe procedure in most patients with the exception of individuals with myeloproliferative malignancies. The high operative risk in this group makes the benefit questionable. In patients with auto-immune disorders the high frequency of subphrenic abscesses indicates that prophylactic antibiotic treatment should be considered.
Nine cases of percutaneous drainage of intraabdominal fluid collections in eight patients are reported. Ultrasonography and conventional radiography was utilized to make the diagnosis and to plan and perform puncture and drainage. In one case of subhepatic abscess only punction and aspiration was performed. In all other cases draining catheters were left between 3 and 21 days. Except in one case which later proved to be a cystic adenopapillary carcinoma of the kidney the results were good.
At the clinic of pediatric surgery of the Sverdlovsk Medical Institute 30 children aged from 3 to 14 years were treated for subdiaphragmatic abscesses in 1979-1989. In 27 of them the abscesses occurred in 6 days to 6 months after an emergency operation. The largest group (19 children) was formed of patients who underwent operation for destructive appendicitis and peritonitis. The subdiaphragmatic abscess was found on the left side in 16 (53.3%) and on the right side in 14 (46.6%) cases. In 11 (36.6%) patients in was combined with abscesses of other localization. X-ray and ultrasonic studies and, occasionally, computed tomography were used along with clinico-laboratory methods in establishing the diagnosis of subdiaphragmatic abscesses. Operations were performed on 29 patients. One patient was treated by puncture followed by drainage of the abscess after Seldinger. The choice of the approach was determined by the localization of the abscess. The intraperitoneal approach was used in 11 cases (36.6%), Klermon's extraperitoneal approach in 16 (53.3%), Melnikov's extrapleural approach in 2, and the posterior retropleural approach in one case. Complex intensive therapy was applied in the postoperative period. Among the 30 patients one died from sepsis and developed polyorganic insufficiency.
We report here the results of a series of 360 patients operated on for hydatic cyst of the liver, all of them have undergone a conservative procedure which is the resection of the bulging dome. Diagnosis has not raised any problems in an endemic country. We stay conservative although we are aware of the fact root of morbidity (Sub phrenic abscess 4.1% cholerragy 5.5%). The resection of the bulging dome has a feeble mortality (1.3%) which is the advantage of this method in regard of the radical ones, involving operative risks which can compromise vital prognosis.
The main cause (60.8%) of subdiaphragmatic abscesses in a series of 62 patients (of which 46 were males), was found to be hepatobiliary in nature. Radiology proved to be helpful in correct diagnosis (61%), as did ultrasonography (60%). Right sided subdiaphragmatic abscesses were (55/62) 88.7% of the total. Mean abscess volume was 500 ml while culturing efforts were in vain in 32% of the abscess cases (able to be cultured). The incidence of morbidity was (12/62) 19.4% and mortality (3/62) 4.8% in this series, where the treatment was solely through surgical drainage. Though closed drainage using ultrasonic guidance has been popular in the past decade, it has its drawbacks. Open surgical drainage therefore, as a well established mode of treatment, is recommended.
The gallbladder is perforated and stones are spilled more frequently during laparoscopic cholecystectomy than during open cholecystectomy. Recent reports have implicated spilled gallstones as a source of infrequent but serious complications of laparoscopic of laparoscopic cholecystectomy. They can cause serious morbidity, and in most cases the patient will require open surgery for management of these complications. The authors report the case of a patient who was ill for 14 months after laparoscopic cholecystectomy when spilled stones formed a nidus for intra-abdominal abscess and colocutaneous fistula. Every effort must be made to prevent gallbladder perforation. When it does occur, all stones should be retrieved. Attempts at repairing gallbladder perforations are often unsatisfactory. A simple solution to this potential problem is to retrieve all stones immediately, place them in an intraperitoneal specimen bag, and "park" the bag on the liver. As soon as the gallbladder is dissected off the liver it should be placed in the specimen bag with the stones and removed through the umbilical port opening.
Complications (stenosis, intestinal obstruction, abscess or fistula formation, inflammation, etc.) of colonic diverticulitis are seen in 35% of patients affected. Multiple operative procedures involve less risk than surgery performed in a single session. The mortality in emergency surgery is reported to be up to 40%, while subsequent resection of the diseased colon involves the usual mortality of surgery on the colon, i.e. 1.5-9%. The vital factor in this illness is the earliest possible surgical treatment of the diseased diverticulum, so that the extremely problematical complications can be avoided.
The authors had 21 patients with various types of transdiaphragmatic bronchopleural fistulas which development as secondary complications of a subdiaphragmatic abscess as a consequence of late diagnosis, ineffective drainage, and use of transpleural approaches to the abscesses. Clinical and radiological diagnosis including contrast fistulo- and pleurography, bronchography and bronchoscopy, and contrast endoscopic examination of the stomach and other organs made it possible to determine the character and localization of the transdiaphragmatic fistula and the condition of the sprained organs. The therapeutic tactics were determined by the form and causes of the transdiaphragmatic bronchopleural fistulas. Nineteen patients recovered, 2 died. The success of treatment depended on the time when operative drainage was begun and on its rational application on bronchological cleansing, and on other components of complex treatment.
The analysis of diagnostic abilities of ultrasound and miniinvasive treatment under ultrasound examination control in 39 patients with subdiaphragmatic local fluid accumulations in abdominal cavity has been carried out. The revealed by US examination manifestations of the abscess formation in 15 patients, local noninfected accumulation of fluid in 20 patients, haematomas (hemolized)--in 4 are described. Indications for the treatment by punctures and drainage of local subdiaphragmatic fluid accumulations under US control depending on the size, form and character of liquid accumulation are given. 11 patients were cured by a single puncture, 1--by multiple punctures, 27--by drainage under US-control. The use of miniinvasive technologies resulted in no complications and mortality in this group of patients. Laboratory examination of the material taken by punctures and drainage under US-control demonstrated in 20 patients infected material and in 14--uninfected one, in 5 patients hematoma was detected. Standard operations performed from 1946 in the surgical clinic resulted in lethality of 19%.
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