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A 71-year-old man had a splenic abscess complicated by rupture into the left subphrenic space with formation of a splenobronchial fistula. One percutaneous catheter was placed into the splenic abscess and a second was placed in the subphrenic collection. The abscesses resolved and the bronchial fistula closed in 12 days.
During a ten year period, 69 patients underwent 100 operations for more than 147 intra-abdominal abscesses. The over-all mortality was 24.6 per cent and the redrainage rate, 30.4 per cent. Most often, abscesses were located in the subphrenic space and followed elective gastrointestinal surgical procedures. Most patients harbored two or more different organisms. Mortalities were low in patients less than 20 years of age having a single abscess, a short duration of fever prior to drainage and after operations on the colon and secondary operations on the appendix. Mortalities were high in patients more than 40 years of age having multiple abscesses; a prolonged duration of fever prior to drainage; multiple drainage procedures, and abscesses after gastroduodenal, hepatobiliary and pancreatic procedures. The mortality and redrainage rate were lower in patients given appropriate perioperative prophylactic antibiotics than inappropriate perioperative prophylactic antibiotics at the antecedent operations. The mortality and the redrainage rate were not related to duration of administration of appropriate prophylactic antibiotics or the number of different isolates. The choice of incision for drainage should be based upon clinical findings rather than a matter of personal preference. Prompt defervescence was a sign of successful drainage. In the present study, the prime importance of prompt drainage and the secondary role of antibiotics in the treatment of intra-abdominal abscess are confirmed.
Over a 36-month period, prognostic factors in childhood intra-abdominal abscesses were evaluated in fifty-five Nigerian children (38 boys [69.1%] and 17 girls [30.9%] aged 2 months-15 years (mean 8.9, SD 4.3 years). The mortality rate was 20%. The adverse prognostic factors were: a high fever, a positive blood culture, subphrenic location of abscesses, abscesses associated with a typhoid perforation, post-operative abscesses, presence of organ impairment, and multiple abscesses occurring together in the same patient. The age of the patient, duration of illness before hospitalization as well as the number and type of microorganisms cultured from the abscess did not have any influence on the prognosis in the children in this study.
Peritonitis can result from many causes. We report a case caused by a renal abscess which contaminated the abdominal cavity. A 30-year-old patient was referred with suspected ruptured ectopic pregnancy with signs of peritoneal flooding. The culdocentesis was positive and returned frank pus. Endoscopic exploration with an open laparoscope revealed that the infection did not originate from a gynecological infection but did not identify the exact origin. Laparotomy was performed and revealed a splenic abscess and a subphrenic peritoneal breach releasing a purulent liquid. Splenectomy and abdominal lavage with draining was performed. A post-operative pyelourogram showed a silent kidney with multiple coralliform lithiases. Interventional sonography allowed drainage of a retroperitoneal collection. The post-operative period was uneventful. Left nephrectomy was later performed. Only rare cases of ruptured pyonephrosis leading to peritonitis have been reported, usually with poor prognosis.
The differential diagnosis of radiographic homogeneous opacities in the lower thorax and upper abdomen is very often a dilemma for radiologists. Recently we have encountered the following 8 cases in which the correct radiologic diagnoses (confirmed pathologically) were made only by computed tomography: pyogenic liver abscesses (2 cases), subphrenic hematoma, pancreatitis with pseudocyst, adrenal cortical carcinoma, ovarian carcinoma with liver metastasis, lower lobe pulmonary infarction, and metastatic breast cancer in the peri-esophageal region. The CT findings displayed not only the anatomic location and extent of these lesions but also the unique characteristics of many of the pathologic processes that produce these otherwise nonspecific radiographic opacities. It is our purpose here to demonstrate the CT findings in such patients and to advocate CT study as a very effective diagnostic modality in those patients who present with radiographic homogeneous opacities in the lower thorax and upper abdomen.
A retrospective review of 88 male patients older than 60 years of age with billiary tract disease showed a mortality of 6.8%. More than 40% of the patients (39 of 88) had acute cholecystitis. Medical therapy failed for almost all of the patients (38 of 39) with acute inflammatory disease and they then required an operation during their initial hospitalization. In this acute disease group, 21% had empyema of the gallbladder, 18% had gangrenous cholecystitis or free perforation of the gallbladder, and 15% had subphrenic or liver abscesses. Escherichia coli and Klebsiella were obtained from 78% of the bile cultures, and obligate anaerobes were present in 25% of them. A delay in diagnosis and operation occurred in 33% of the patients with acute disease. Factors responsible for this delay included a deceptively benign clinical presentation and the requirement for prolonged resuscitation. Since response to conservative measures is unlikely in the elderly patient with acute cholecystitis, optimal management consists of resuscitation and prompt operation for control of infection.
A series of 1068 operations for peptic ulcer has been analyzed for evidence of mortality or morbidity related to duodenal dissection or closure. There were 85 patients with catheter duodenostomy and 43 additional patients with acute pancreatitis or duodenal leak. The mortality rate was 17.2% for the entire group of 128 patients. Complications included acute pancreatitis, subphrenic or subhepatic abscess, duodenal blowout, and stomal delay. Forty-two secondary operations were required. Another series of 61 patients was treated by truncal vagotomy and a new technique of antrectomy with intramural dissection and gastroduodenostomy. The mortality rate in this series was 1.6%. Complications included stomal delay, thromboembolism, and gastric leak following gastrostomy tube removal. No secondary operations were required.
BACKGROUND: The study shows operative results with complications occurring in first 30 days after total gastrectomy for stomach cancer. METHODS: A retrospective analysis was performed using medical documentation and histological findings for 76 patients after total gastrectomy was done between 1990 and 1997. Mortality and postoperative complications were analyzed. Complications were sorted as specific and nonspecific. All operations were performed either for intestinal gastric cancer located in proximal stomach or for diffuse stomach cancer. All anastomoses were hand sewn. RESULTS: There were 43 male and 33 female patients. Postoperative mortality was 14.4%. The most frequent complications were dehiscence of the oesophago-jejunal anastomosis in 15.8% of operated patients, postoperative temperature without apparent infection in 5.2%, thrombophlebitis in 5.2%, pneumothorax in 3.9%, hepatic necrosis in one patient (1.3%), and perforation of jejunal loop with nasogastric tube in another (1.3%) ended fatally. The average postoperative intra-hospital treatment lasted 12.3 days. Dehiscence of the oesophago-enteric anastomosis, resulted in generalized peritonitis in 66.6%. Six patients succumbed as a consequence, while two survived with subphrenic and interenteric abscesses. Pneumothorax in combination with total gastrectomy was always fatal. CONCLUSIONS: Routine use of stapling surgery, subspecialization in surgery, and better early intensive care monitoring and treatment could reduce the mortality rate.
Treatment of 681 cases of liver trauma during the past ten years at the San Francisco General Hospital was reviewed. The mortality was 14.7 per cent and the morbidity rate 18.9 per cent. The complications relating specifically to liver injury were bleeding subphrenic or subhepatic abscesses, intrahepatic abscess, biliary fistula, and liver failure. These complications and the recommended management of the liver injury are discussed.
Thoracobiliary fistulas are a commonly reported complication of subphrenic or liver abscesses and biliary tract obstruction. However, they are a rare and unusual complication of traumatic thoracoabdominal wounds. Due to their rarity, the experience of any one surgeon is minimal, and there is a paucity of information available in the literature regarding their treatment. We describe a case of a traumatic thoracobiliary fistula, review the existing literature, and discuss the proper management of this potentially lethal sequela of trauma.
Two patients with Caroli's disease are reported who did not have renal abnormalities or hepatic fibrosis. Extra hepatic complications of Caroli's disease in these two patients were best evaluated by computed tomography (CT). Although ultrasound evaluates the ductal abnormalities of Caroli's disease well, it does not delineate subphrenic or subhepatic abscesses, pancreatitis, pancreatic phlegmon, or pseudocysts as well CT.
BACKGROUND/AIMS: The purpose of this study was to describe the echographic features of Ascaris lumbricoides invasion of the alimentary tract, biliary system, liver and pancreas. METHODOLOGY: We studied 38 patients with roundworm heavy infection whose diagnosis were primarily supported by ultrasonographic examination. RESULTS: Thirty-seven patients were admitted with the following clinical complications: bowel obstruction, intra and extrahepatic dilatation, acute cholecystitis, intrahepatic abscess, acute appendicitis, subphrenic collection and acute pancreatitis. Ultrasound scanning was able to recognize in 30 cases the echogenic, nonshadowing images of the worms as single or multiple strips; in 8 cases, coiled structures and amorphous material were detected. The "inner tube" sign was considered as the most specific one. In two cases the roundworms were displayed within the stomach, a curious finding, up to now never reported in medical literature. CONCLUSIONS: Real-time sonography represents an efficient, reliable and non-invasive diagnostic approach for hepatobiliary, enteric and pancreatic ascariasis.
Between January 1988 and April 1991, a total of 79 ultrasound-directed percutaneous punctures and (or) drainage of abscesses were performed on 31 patients (15 men, 16 women; mean age 63 [31-85] years). There were 14 hepatic, 4 splenic, 4 abdominal wall and 3 pancreatic abscesses, and one each subphrenic, presacral, retrocaecal, ischiorectal, pulmonary and in the psoas. After ultrasound localization of the abscess a fine-needle puncture was performed, after which the abscess cavity was emptied as much as possible or, in abscesses larger than 5 cm in diameter, drained through a pig-tail catheter (6-8, 4 F). Several punctures were needed in 16 patients, while in 15 a percutaneous drainage over 2-8 days was necessary. Treatment was successful after 4-17 days in 25 patients. One patient died in septic shock. Operative intervention after diagnostic puncture was undertaken in 5 patients. There were no complications related to the method. In 11 patients the further course was determined by an underlying malignant disease. No recurrence has been noted (4-36 months after treatment) in 14 patients with a benign underlying disease. Percutaneous puncture and drainage of pyogenic abscesses is a technically simple method which achieves good results.
The appearance of perihepatic fluid collections on sectional imaging is discussed. The coronary ligamentous attachments of the right lobe of the liver to the diaphragm delineate a bare area that separates the right subphrenic and posterior subhepatic spaces. These attachments explain the configuration of right perihepatic fluid collections on sectional images and allow differentiation of subphrenic, posterior subhepatic, and pleural fluid with ultrasound and computed tomography. More medially, the caudate lobe of the liver invaginates the superior recess of the lesser sac, so that fluid collections within this recess may mimic intrahepatic masses on sectional images. This is illustrated with anatomic sections, computed tomographic scans, and ultrasound images.
Despite recent advances in the diagnosis and management of intra-abdominal abscesses, these infections still cause substantial morbidity and mortality. Low pH, large bacterial inocula, poor perfusion, the presence of hemoglobin, and large amounts of fibrin (which impedes antibiotic penetration) make the abscess a cloistered environment that is penetrated poorly by many antimicrobial therapies. Therefore, management of these infections requires prompt recognition, early localization, and effective drainage, as well as appropriate antimicrobial use. Although various imaging techniques, such as ultrasonography, gallium scans, and indium-labeled white-blood-cell scans, can be used for the diagnosis and localization of intra-abdominal abscesses, computer-assisted tomography is the most useful study. Once the diagnosis is made and the abscess is localized, treatment should begin promptly. Percutaneous or open surgical drainage should be used. Broad-spectrum antibiotics should be given until culture and sensitivity data are obtained. Once these data are obtained, a therapy with appropriate coverage that is likely to work in the abscess environment should be chosen. Percutaneous drainage is inappropriate for abscesses in the posterior subphrenic space or in the porta hepatis, for those among loops of small bowel, for suspected echinococcal cysts, and for abscesses containing necrotic or neoplastic tissues. Finally, surgeons need to be cognizant of risk factors, such as advanced age, obesity, complex abscesses, and high Acute Physiology and Chronic Health Evaluation (APACHE) II or APACHE III scores, which correlate with poor outcomes for these patients.
An otherwise healthy young male sustained a non-displaced fracture of the pelvis in a blunt trauma from a motor vehicle accident. A fever developed on his second post injury day which led to discovery of an intrahepatic abscess by CAT scan. After blunt trauma to the abdomen, one must consider not only a retroperitoneal hematoma but also, subphrenic, subdiaphragmatic and intrahepatic abscess as its complication.
The authors report their experience with 19 percutaneous drainages of abdominal abscesses in 19 patients. Six collections were in the subphrenic spaces, 6 in the liver, 1 in the infracolic space, 2 in the psoas muscle, 3 within the abdominal wall, and 1 in the pararenal space. Their etiology was abdominal surgery in 10 patients, biliary obstruction in 1, and trauma in 2; in the extant patients a hematogenous infection was supposed. The procedures were performed under combined US and fluoroscopic guidance, following Seldinger technique in all but two cases. Van Sonnenberg double-lumen sump catheter was successfully employed in all cases. After a review of the technique the authors discuss the advantages of US-fluoroscopic over CT guidance. The latter is preferred if the collection is not well demonstrated by US and in the cases where a posterior approach is needed. The economic advantages of US-fluoroscopic over CT guidance are also stressed.
The aim of this study was to examine the feasibility of a hybrid interventional MR system, which combines a closed bore magnet with a C-arm fluoroscopy unit for percutaneous drainage of abdominal fluid collections. During the past 2 years, we have performed four drainage procedures in four patients (mean age 47 years). Three patients had abscesses (psoas muscle, kidney, subphrenic location) and the fourth patient had a recurrent splenic cyst. All procedures were performed on an interventional MR system consisting of a 1.5-T ACS-NT scanner combined with a specially shielded C-arm. The drainages were guided by T1-weighted fast gradient-echo images, T2-weighted single-shot turbo spin-echo images or both. A standard 18 G (1.2 mm) nonferromagnetic stainless steel needle with a Teflon sheath was used for the punctures following which a 0.89 mm nitinol guidewire was inserted into the fluid collection. Thereafter, the patient was positioned in the immediate adjacent fluoroscopy unit and a drainage catheter was placed under fluoroscopic control. All drainage catheters were successfully placed into the fluid collections, as proven by fluid aspiration and resolution of the collection. The mean time needed for the entire drainage procedure (MR and fluoroscopy) was 110 min. No procedure-related complications occurred. It is feasible to perform drainage procedures on a closed-bore MR scanner. The multiplanar imaging capabilities of MR are particularly helpful for fluid collections in the subphrenic location.