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Splenic abscesses are infrequent and usually associated to sepsis and immunodepression. The diagnosis is commonly made in the necropsy. We report two cases of multiple splenic abscesses in type II diabetic patients that were diagnosed by ultrasound. Both patients were successfully managed with surgery (drainage of left subphrenic space in one and splenectomy in the other) and antimicrobial agents.
Pancreatic abscess has been characterized by a high rate of reoperation for persistent sepsis and by a high mortality. Nine patients with pancreatic abscess have undergone synchronous anterior celiotomy and posterior drainage following resection of the 12th rib. Pancreatic abscess was secondary to acute pancreatitis in seven of the cases. In two cases, the combined procedure was a secondary operation to treat abscess that developed following surgery for pancreatic trauma. All of these nine patients survived. One patient required reoperation for drainage of a left retrocolic abscess. A synchronous approach permits adequate exploration of the abdomen, provides the exposure necessary to remove necrotic tissue, and allows dependent drainage of the left subphrenic space without fear of splenic, pancreatic, or vascular injury.
We describe a rare case of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing pyogenic liver abscess in a 59-year-old man. The patient was diagnosed as having a hollow viscus perforation based on a sudden onset of acute abdominal pain along with radiological evidence of bilateral subphrenic feee air (pneumoperitoneum), and underwent an emergency laparotomy. Contrary to expectations, the surgery revealed no perforations of the hollow viscus, but instead a ruptured liver abscess at the dome of the right hepatic lobe was identified associated with suppurative peritonitis. To the best of our knowledge, such a case of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing liver abscess is extremely rare.
The failure of medical therapy for amebic liver abscess may be followed by its perforation, a complication associated with high mortality. We assessed the role of percutaneous catheter drainage in management of the sequelae of ruptured amebic abscesses in 13 critically ill patients; 22 intrahepatic lesions, three of which were multiloculated, were drained. Catheters were also placed in 17 extrahepatic collections: pleural space (n = 5), subphrenic (n = 7), perihepatic/subhepatic (n = 3), greater sac of peritoneum (n = 2). No attempt at percutaneous drainage failed. Prompt resolution of clinical features following drainage was a uniform feature. Successful resolution of the abscesses occurred within 20 days in 11 patients. In the remaining two, catheters needed to be retained in situ for 35 and 50 days. The mean hospital stay was 15 days (range 10-20 days). 100% patient survival was achieved, without a single morbid episode. Our results suggest that patients with ruptured amebic abscesses can be effectively and safely managed by percutaneous catheter drainage irrespective of the extent of extrahepatic contamination.
BACKGROUND: We assessed computed tomographic (CT) features of postoperative complications and recurrent tumors in gastric cancer patients who underwent radical surgery. METHODS: We performed a retrospective study of 397 patients who had undergone radical surgery for the treatment of gastric carcinoma and underwent postoperative CT in our institution over a 2-year period. Patients were assigned to one of two groups: group A consisted of 47 patients who underwent CT for complications in the early postoperative period, and group B consisted of 355 patients who underwent CT for evidence of tumor recurrence during the follow-up period. We classified recurrent tumors into four categories: local recurrence, lymph node metastasis, peritoneal seeding, and remote metastasis. RESULTS: In group A, localized fluid collections or abscesses in the surgical bed were found in 38 patients (81%) and usually involved the left subphrenic area (74%) or the superior recess of the lesser sac (47%). In group B, recurrent tumors were found in 196 patients (55%). Among these, lymph node metastasis was the most common pattern (52%), followed by peritoneal seeding (44%), local recurrence (40%), and remote metastasis (37%). CONCLUSION: CT after radical surgery for the treatment of gastric carcinoma frequently shows postoperative complications or tumor recurrence. Familiarity with the common postoperative complications and patterns of the tumor recurrence is a prerequisite to accurate interpretation of CT findings in these patients.
In this study of 503 consecutive cases of amebic liver abscess documented during a 21-year period, 110 (22%) were complicated by perforation. Perforation sites included pleuropulmonary structures (79 cases, 72%) subphrenic space (15 cases, 14%); and peritoneal cavity (11 cases, 10%). The less common sites were the thoracic and abdominal wall, pericardial sac, bile duct, kidney, mediastinum, colon, and right flank. Trophozoites were recovered in 29% of cases. For the rest of the cases, diagnosis was based on the clinical manifestations and the dramatic response to a therapeutic trial of amebicides. Open surgical drainage was done in 10 of 11 patients who had peritoneal perforation; 6 of them were cured and 5 died. Of 97 patients with perforation sites other than the peritoneal cavity, 64 were treated with metronidazole in addition to needle aspiration and/or percutaneous catheter drainage, and all achieved complete remission without relapse during subsequent follow-up. Of the 36 cases treated with metronidazole alone, 22 (61%) were cured. The mortality rate in the group with perforated abscess was 17% (19/110), compared with 5% (25/503) in the whole series. The results suggested that (1) amebic liver abscess can be difficult to diagnose, especially when the pathogen is not isolated; and (2) metronidazole combined with needle aspiration and/or percutaneous catheter drainage is the treatment of choice for amebic liver abscess with perforation.
Meconium pseudocyst results from a loculated inflammation occurring in response to spillage of meconium into the peritoneal cavity after a bowel perforation. Certain cystic lesions, such as abscesses and dermoid and epidermoid cysts, are known to show reduced water diffusion on DWI. MRI has recently become a valuable adjunct to ultrasonography for fetal gastrointestinal anomalies. Complementary to ultrasonography, prenatal MRI can help further characterize the lesion and can clearly demonstrate the anatomical relationship between the lesion and adjacent organs. We report a case of meconium pseudocyst that was prenatally imaged with ultrasonography and MRI, postnatally complicated by pneumoperitoneum, and proved by postnatal surgery and histopathology. We emphasize the MRI of the pseudocyst, particularly T1-weighted and diffusion-weighted imaging.
CT- and ultrasound-guided catheters were used to locate and drain empyemas in 17 patients, most of whom had failed to improve with conventional chest-tube drainage due to a poorly positioned tube. Fifteen patients (88.2%) were treated successfully, averting surgery or further drainage, and bacteremia in 1 patient was the only complication. Previously unrecognized communications with the bronchi, esophagus, and subphrenic space were demonstrated, and intracavitary tumor biopsy and instillation of a sclerosing agent were performed in several patients. Compared to the tubes used to drain abdominal abscesses, empyema catheters need less irrigation; dionosil is often the preferred contrast agent, the catheter can be withdrawn in one step, and a residual fibrotic or tumor cavity may persist after pus has been evacuated.
Intra-abdominal abscess, resulting either from primary intraperitoneal disease or as a complication of surgery, remains a serious problem with high patient mortality if not treated early and adequately. The initial attempt at diagnosis rests on strong clinical evidence supported by nonspecific laboratory findings. The most helpful advance over conventional x-ray studies has been the advent of noninvasive imaging techniques such as ultrasonography or computed tomography. Radioisotopic scanning with gallium or indium makes possible a generalized survey of the peritoneal cavity, but only after a delay from the time of injection. Ultrasonography is somewhat limited in utility, particularly in the left subphrenic space, and CT scanning remains the technique with highest resolution. These noninvasive imaging techniques also have the potential for directed percutaneous catheter drainage.
This paper describes the clinical, ultrasonographic, radiographic and postmortem findings in 12 cows with thrombosis of the caudal vena cava. The principal clinical signs were chronic bronchopneumonia and fever in 11 cows; one cow had epistaxis and one cow bled from the mouth; eight cows had anaemia and leucocytosis, and the clotting time for the glutaraldehyde test was markedly decreased in all the cows; in nine of the cows the activity of gamma-glutamyltransferase was high, suggesting chronic hepatic congestion. The most important ultrasonographic finding was congestion of the caudal vena cava attributable to thrombosis of the vein. In all the cows the caudal vena cava was round to oval on cross-section, rather than the normal triangular shape. The hepatic, splenic and portal veins were dilated in five, three and one cow, respectively. The results of radiography and endoscopy supported a diagnosis of bronchopneumonia, but there were radiographic changes in the diaphragmatic lung lobes that supported a diagnosis of vena caval disease in only four cows. Postmortem there was a thrombosis of the caudal vena cava in all the cows, and the thrombi were located in the thoracic, subphrenic and abdominal part of the caudal vena cava at the level of the liver in four, one and seven cows, respectively. In three cows, the thrombus was situated where a hepatic abscess had broken into the caudal vena cava, and in one cow it was at the site of a diaphragmatic abscess. In another cow, there was a fistula between the major bronchus of the right diaphragmatic lung lobe and the caudal vena cava where the thrombus was situated. Three cows had liver abscesses that had not broken into the caudal vena cava. There was severe bronchopneumonia in 11 of the cows, some of which also had multiple pulmonary abscesses.
An analysis of 3,260 admissions to St. Francis General Hospital during a 20-year period for acute and chronic cholecystitis and two traumatic gallbladder perforations revealed 115 cases for an incidence of 3.5 percent. The most common gallbladder perforation in this series was localized perforation with abscess formation in 72 patients (63 percent). Other perforations were fistulization to another hollow viscus, or to the skin, 32 (27.5 percent), and free perforation, 11 (9.5 percent) into the peritoneal cavity.Nineteen or 46 percent of 41 postoperative complications were related to bacterial infections. In spite of a complication rate of 32 percent, the mortality was zero.Of 115 cases categorized as perforated gallbladder, 63 percent were localized with abscess formation, and 9.5 and 27.5 percent, respectively, were classified as free and as fistulization. Mortality was zero; however, morbidity was 32 percent. The significant complications were related to infection, ie, wound, urologic, subphrenic, and pulmonary and leg vein. Early operation is indicated for acute cholecystitis after rapid preoperative perforation.
BACKGROUND: Laparoscopic adjustable silicone gastric banding (LASGB) is the bariatric operation of choice in our institution for most morbidly obese patients. The advantage of LASGB is a minimally invasive procedure, with low systemic and operative complication rates. However this procedure is not free from significant postoperative problems that may arise at a later stage. PATIENTS AND METHODS: 950 patients underwent LASGB between November 1996 and May 2000, with a median follow-up of 21 months. 3 patients (0.31%), developed band erosion 6 to 8 months following the original procedure. Laparoscopic band removal was attempted in all 3 patients. The charts of all patients were reviewed for the postoperative course of the original operation as well as the removal of the band. RESULTS: 2 patients presented with abscess formation at the port site, and 1 patient suffered from a gastric fistula at the port site 6 months following surgery. In all patients the immediate postoperative course was not smooth; 2 patients developed a subphrenic collection drained percutaneously, and one patient had fever, treated empirically with intravenous antibiotics. In all 3 patients, no leak was demonstrated by CT and barium meal. The diagnosis of band erosion was confirmed by gastroscopy, which demonstrated part of the band eroding through the gastric wall. All patients were operated laparoscopically. The band was removed and the gastric wall was sutured. The postoperative course was uneventful and patients left the hospital within 3 days. CONCLUSION: LapBand erosion following LASGB is very rare and may occur months following the operation. The postoperative course suggests that the erosion is the consequence of a minute stomach wall injury during the primary operation. Diagnosis is essential and the treatment of choice is laparoscopic band removal with suturing of the stomach wall. It is possible that a minute injury to the gastric wall during the initial procedure is the underlying cause of this complication.
The peritoneum of the great abdominal cavity and its recesses are a blind radiographical area which can however be easily outlined by US when it contains fluid. The anatomical study of these usually virtual cavities represents the purpose of this paper. The natural contrast of the peritoneal fluid as amplified by the mechanical effect produced by an adequate amount of fluid, allows a clear visualization of the anatomy of various peritoneal structures in either upper (subphrenic, subhepatic, lesser sac, etc.) or lower (pelvic) areas. The sovramesocolic and the infracolic compartments are in communication through the two external paracolic gutters which are the main passageways for the fluids between upper and lower compartments. In fact, peritoneal fluids are in constant movement due to different factors, such as gravity, statics, which causes the peritoneal fluids to flow into the lowest part of the peritoneal cavity, and hydrostatic pressure. Pressure differences are thought to convey fluids from various sites of the abdomen into different areas. In the lower abdomen, pressure is 3 times as much as in the upper abdomen, which causes the fluids to move into the subhepatic and subphrenic regions. The redistribution of fluids can be influenced by particular anatomical causes. The phrenicocolic ligament, eg, is a barrier to the advancing of fluids along the left paracolic gutter, which makes the right paracolic gutter the main passageway for the fluids. This pattern explains why abscesses are more frequent in the right than in the upper left abdominal regions. Another example is the tiny Winslow opening, which does not allow inflammatory material to pass into the lesser sac in case of inflammatory processes of the great peritoneal cavity and vice versa. Moreover, pointing out fluid collections and abscesses is important, since an early diagnosis and a topographic map are essential in order to plan treatment.
Fourteen patients with scimitar syndrome, aged from 4 days to 20 years, underwent surgical treatment between September 1980 and August 1988. Patients were separated into two groups. Group A comprised four neonates with heart failure and severe pulmonary hypertension; part of the right lung was supplied by large aberrant systemic subphrenic arteries (ASSAs) in each. Group B included ten patients (nine children and one adult) with mild to moderate symptoms, normal pulmonary artery pressures; only two had ASSAs. In group A, one neonate with multiple ventricular septal defects underwent pulmonary artery banding but later required a lobectomy because of a lung abscess. The other three neonates underwent ligation of ASSAs; two improved rapidly, and one died of sepsis. In group B, all patients survived intracardiac repair and remain asymptomatic during a follow-up of 24 to 108 (mean 54.9) months. In summary, prognosis after intracardiac repair is excellent in patients without pulmonary hypertension. Neonates with heart failure usually improve after ligation of ASSAs, and pulmonary resection is only indicated in patients with intractable pulmonary sequestrations.
Laparoscopic cholecystectomy entails the risk of gallbladder rupture and consequent loss of stones within the abdominal cavity, which is not an uncommon complication. The development of intraperitoneal abscesses due to the spilled gallstones is one of its major complications. When gallbladder was injured during laparoscopic cholecystectomy, gallbladder was dissected on the medial and lateral side, or from the fundus of the gallbladder in the original position to reduce the spillage of stones. After putting the removed gallbladder into the endoscopic bags, hepatorenal fossa and right subphrenic space was thoroughly examined using retractor and oblique view scope. We performed these procedures in 30 consecutive patients with gallbladder ruptured during operation. Dropped stones were noted in 5 patients and were retrieved successfully. Reduction of stone spillage and the retrieval of spilled stones were essential. It is advisable to retrieve as many gallstones as possible after gallbladder perforation during laparoscopic cholecystectomy.
Fifty patients undergoing splenectomy for complications of hematologic malignancy were reviewed to define indications and results. Primary diseases included lymphoma (n = 14), chronic lymphatic leukemia (n = 13), hairy-cell leukemia (n = 12), myeloid metaplasia (n = 6), and other similar disorders (n = 5). Indications for splenectomy in these patients included cytopenia (n = 37), diagnostic laparotomy (n = 8), "small stomach" syndrome (n = 3), and abdominal pain (n = 2). Splenectomy was performed by the midline approach in 32 patients. In 40 patients, the splenic artery was ligated prior to mobilization of the spleen. The spleens averaged 1650 g; in eight patients accessory spleens were removed. Additional surgical procedures included liver biopsy (n = 30), lymph node biopsy (n = 15), and cholecystectomy (n = 3). Intraoperative blood loss averaged 750 ml. In 14 patients, drainage of the left subphrenic space was used. Splenectomy was effective in 36 of 50 patients. In seven patients, splenectomy was ineffective in correction of cytopenia. Seven mortalities were from bleeding (n = 2), pulmonary embolus (n = 2), postoperative sepsis (n = 2), and progression of primary disease (n = 1). Additional complications included reoperation for bleeding (n = 3), septic complications including pneumonia (n = 14), wound infection (n = 4), and intra-abdominal abscess (n = 2). Splenectomy for the patients with hematologic malignancy is generally effective. Meticulous hemostasis, timely administration of intraoperative platelets, surgical asepsis, and aggressive pulmonary care are essential to reduce morbidity and mortality.
Percutaneous drainage of infected intraabdominal hematomas has often been contraindicated due to its greater number of complications. The results of percutaneous drainage of infected localized hematomas in five cases are described, two in the lesser sac and three in the right subphrenic space. The catheter size ranged from 8.4 to 24 French. Mean maintenance time of the drainage was 37 days. Drainage tube obstruction occurred in three patients, in two of whom the drainage tube had to be changed for one with a broader gauge. Hematomas were completely resolved in all the cases. We describe our experience with one patient in whom we used intracavitary urokinase who showed successful results. Percutaneous drainage is not contraindicated in the management of infected hematomas, although the drainage tube must be closely controlled; drainage time may be longer than in other types of abscesses.
OBJECTIVE: To evaluate the effect of anatomic hepatectomy performed under vascular exclusion in management of hepatolithiasis. METHODS: From May 2002 to March 2005, fifty-three patients with unilateral hepatolithiasis underwent anatomic hepatectomy with exposure and control of inferior vena cava and main trunk of hepatic veins. The hepatic lobes involved by hepatolithiasis were left lateral lobe (S(2), S(3)) in 12 patients, left lobe (S(2), S(3), S(4)) in 26 patients, right posterior lobe (S(6), S(7)) in 8 patients and right lobe (S(5), S(6), S(7), S(8)) in 7 patients. Atrophy of involved hepatic lobes was found in 38 patients. Fourteen patients had experienced more than one operation on biliary tract. Nine patients showed the symptoms of acute cholangitis preoperatively and 4 patients complicated with liver abscess. RESULTS: Vascular exclusion was successfully performed on all patients to control the blood inflow and outflow of liver. The anatomically resected hepatic lobes were left lateral lobe (S(2), S(3)) in 12 patients, left lobe (S(2), S(3), S(4)) in 26 patients, right posterior lobe (S(6), S(7)) in 8 patients and right lobe (S(5), S(6), S(7), S(8)) in 7 patients. Except hepatectomy, the additional procedures performed on the patients were choledocholithotomy in 39 cases, choledocho-jejunostomy in 5 cases. The majority of complications were bile leakage in 3 cases, subphrenic infection in 2 cases, hydrothorax in 5 cases and wound infection in 5 cases. CONCLUSIONS: Anatomic hepatectomy under vascular exclusion is effective treatment to eradicate intrahepatic stone foci in case of unilateral hepatolithiasis, and help to reduce intraoperative blood loss and decrease postoperative complications.