Rare case of perforated appendicitis presenting as persistent perineal discharge following laparoscopic abdominoperinal excision of rectum (APER).

Abdominoperineal excision of rectum (APER) is one of the widely used surgical procedures to treat low rectal cancer, benign conditions like Crohn's proctitis with anal involvement and as a salvage procedure for anal cancer. Perineal wound infection is a well-recognised complication following such major surgery. Occurrence of appendicitis in a few weeks' time following such a major surgery is uncommon. However, here we present a rare case report of perforated appendicitis presenting as persistent perineal discharge in an elderly man, following laparoscopic APER for a low rectal tumour. To our knowledge, this is the first time such a rare clinical presentation of appendicitis is reported in the history of medical literature. Through this case report, we aim to highlight the importance of considering such an uncommon presentation in patients with perineal discharge, following APER.

Infected Abdominal Aortic Aneurysm After Transrectal Ultrasound-Guided Biopsy of the Prostate: A Report of Two Cases.

Primary infected abdominal aortic aneurysm (AAA) is an uncommon presentation which can be associated with significant morbidity and mortality. In this report, we present 2 cases of infected AAAs less than 10 days after a transrectal ultrasound-guided (TRUS) prostate biopsy. A 63-year-old male presenting with sepsis and back pain 9 days after TRUS biopsy was found to have a 27-mm ectatic abdominal aorta which expanded to 59 mm in the course of a week, despite antibiotic therapy. He underwent successful surgical excision of the infected aortic aneurysm and reconstruction using a vein. A 55-year-old male presented similarly, 7 days after prostate biopsy with a 60-mm aortic aneurysm. His aneurysm ruptured 2 days before planned intervention-he did not survive an emergency repair. In both cases, aortic tissue biopsies confirmed growth of Escherichia coli. Preexistence of an aortic aneurysm was not known in either case as neither patient had imaging of the abdominal aorta. We postulate the pathophysiology was due to hematogenous spread.

Tunneled Pleural Catheters for Patients With Chronic Pleural Infection and Nonexpandable Lung.

Chronic pleural infection is characterized by thickened pleura and nonexpandable lung often requiring definitive surgical intervention, such as decortication and/or pleural obliteration procedures. Such procedures are associated with significant morbidity and require proper patient selection for a successful outcome. We report a cohort of 11 patients with pleural space infection and a nonexpandable lung treated with tunneled pleural catheters (TPCs). Following placement, hospital discharge and TPC removal occurred after a median of 5 and 36 days, respectively. Three patients presented with residual loculated effusion that resolved with instillation of intrapleural fibrinolytic therapy. One patient eventually required open window thoracostomy for ongoing pleural infection due to poor medical compliance with TPC care and drainage instructions. TPCs represent an alternative option for drainage of an infected pleural space in nonsurgical candidates with a nonexpandable lung. Their use, as a compliment to traditional treatment, may facilitate prompt hospital discharge and ambulatory management in patients with limited life expectancy.

Spinal Intradural Escherichia coli Abscess Masquerading as a Neoplasm in a Pediatric Patient with History of Neonatal E. coli Meningitis: A Case Report and Literature Review.

BACKGROUND: Central nervous system abscesses frequently can be seen in the immunocompromised population and most commonly consist of intracranial collections in the adult patient. Spinal intradural abscesses are less commonly encountered, and there are even fewer numbers in the pediatric population with a concordant absence of documentation in the published literature. CASE DESCRIPTION: In this case report, we describe the presentation of a 2-year-old boy with a history of perinatal Escherichia coli meningitis at 2.5 months of age who was found to have an intradural spinal lesion, initially concerning for neoplasm, but later confirmed as an E. coli abscess following biopsy. He was managed with surgical aspiration of the abscess and a long course of intravenous antibiotics. The patient was treated with antibiotics with repeat imaging studies that revealed residual abscess that required re-aspiration at a later date. CONCLUSIONS: Here we present an unusual disease process with an unusual disease pathogenesis in a pediatric patient currently residing in a developed country.

Pyogenic Spondylodiscitis of the Thoracic Spine: Outcome of 1-Stage Posterior Versus 2-Stage Posterior and Anterior Spinal Reconstruction in Adults.

OBJECTIVE: The aim of this study was to compare the clinical, radiologic, and functional outcomes of a 1-stage posterior treatment versus a 2-stage posterior-anterior treatment in patients with pyogenic thoracic spondylodiscitis. METHODS: A 1-stage posterior debridement, stabilization, and fusion with titanium-coated polyetheretherketone (PEEK) or mesh cage through a dorsolateral approach was performed in group A. A 2-stage procedure with initial posterior stabilization and debridement and second-stage fusion with a PEEK cage or mesh cage was performed with an anterior approach in group B. Clinical outcomes included Oswestry Low Back Pain Disability Questionnaire and visual analog scale score. Radiologic outcomes included fusion rate and kyphotic angle correction. Secondary variables included pathogens, complications, blood loss, and operative time. RESULTS: One-level spondylodiscitis was treated surgically in the thoracic spine of 47 patients: 25 patients in group A and 22 patients in group B. The most frequent segment was T12-L1 (27%). There was a significantly longer operative time and greater blood loss (P > 0.001) in group B. At last follow-up, sagittal profile reconstruction was significantly better (P > 0.05) in group B. Both groups showed similar radiologic results with fusion in 92% of cases. Improved clinical outcomes, pain, and quality of life were achieved in both groups with no significant differences between the 2 groups. CONCLUSIONS: Better reconstruction of the sagittal profile was achieved in the posterior-anterior-treated group, but this did not affect the clinical outcome. No significant differences were found in the clinical and functional outcomes between the 2 groups. Posterior-anterior combined treatment should be considered in cases of large anterior defects if a posterior reconstruction is inadequate.

Clinical predictors of escalating care in hepatic and renal cyst infection in autosomal dominant polycystic kidney and liver disease.

BACKGROUND: Cyst infection may occur in autosomal dominant polycystic kidney disease (ADPKD) and autosomal dominant polycystic liver disease (ADPLD). Antimicrobial agents often fail to control infection, leading to invasive action. We aimed to identify factors predicting escalation of care. METHODS: ADPKD and ADPLD patients were identified from local/national databases (2001-2013). Records were screened for patients meeting criteria for cyst infection (positive cyst aspirate and/or clinical findings). Factors that predict escalated care were identified with multivariate modified Poisson regression. RESULTS: We screened 1773 patients. A total of 77 patients with cyst infection (4.3%) were included for analysis (hepatic 36%; male 49%; age 54 ±; 13 years; ADPKD 95%; dialysis 9%, diabetes 18%, renal transplant 56%, eGFR [IQR 24-78] ml/min/1.73 m2 (excluding patients with a history of renal transplant or receiving dialysis)). A pathogen was identified in 71% of cases. Escherichia coli was the most common pathogen and accounted for 69% of cases. Initial treatment was limited to antibiotics in 87% of patients (n = 67), 40% included a fluoroquinolone. Ultimately, 48% of patients underwent some form of invasive action (escalation of care). Increasing white blood cell count (WBC) (RR 1.04 95%-CI 1.01-1.07, p = 0.008) was associated with escalating care, whereas an increase in time between transplant and infection (RR 0.92 95% CI 0.86-0.97, p = 0.005) and E. coli isolation (RR 0.55 95% CI 0.34-0.89, p = 0.02) were protective. CONCLUSION: High serum WBC, isolation of atypical pathogens and early infection after transplantation are factors that increase the risk of escalation of care in hepatic and renal cyst infection patients.

[FOUR CASES OF THE PROSTATIC ABSCESS IN WHICH DRAINAGE WAS EFFECTIVE].

We encountered four prostatic abscess patients. Although antimicrobial therapies were ineffective, drainage was effective in all cases. Patient 1 had lung cancer and diabetes mellitus (DM), and patient 2 developed acute prostatitis after transrectal prostatic biopsy. Culture of the urine and blood revealed extended-spectrum beta lactamase (ESBL) -producing Escherichia coli (E.coli). Patient 3 had previously sustained spinal cord injury, and urinated by self-catheterization. Patient 4 had untreated, severe DM. Patient 1, 2 and 3 had been treated by transurethral resection of the prostate (TURP). Patient 2 complained of ejaculatory incompetence after the surgery, and the symptom caused mental distress. Patient 4 was a 43-year-old man who had undergone transperineal needle aspiration under ultrasound guidance to avoid ejaculatory incompetence. The prostatic abscess disappeared in all cases after drainage without recurrence.

Feasibility of radiofrequency ablation as an alternative to surgical intervention in patients with huge multiloculated pyogenic liver abscesses: A retrospective cohort study.

This retrospective cohort study investigated the feasibility of radiofrequency (RF) ablation as an alternative to surgical intervention in patients with huge multiloculated pyogenic liver abscesses (PLAs).From August 2010 to April 2016, 83 patients with PLA were admitted to Beijing Chao-Yang Hospital, China. Four of these patients had huge multiloculated PLAs and underwent RF ablation plus antibiotics. The inclusion criteria for RF ablation were as follows: multiloculated PLA confirmed by computed tomography (CT) or magnetic resonance imaging (MRI), widest diameter of the PLA ≥5 cm, failure to respond to or not suitable to treatment with percutaneous drainage (PD), and patient refusal of surgery. The safety and effectiveness of RF ablation were initially assessed. All patients were commenced on antibiotics on admission to our hospital. CT-guided percutaneous catheter drainage was attempted in one patient but was unsuccessful. The main organism isolated from cultures of these patients' blood or abscess samples was Klebsiella pneumoniae (3/4). RF ablation was performed as soon as eligibility according to the above criteria was established.RF ablation was technically successful in all 4 study patients, all PLAs being completely eradicated. The median duration of fever after RF ablation was 4.5 days. No abscesses recurred; thus, this strategy for managing PLA was 100% successful (4/4). No procedure-related deaths or major complications occurred. One patient had an asymptomatic right pleural effusion that resolved with conservative treatment including albumin infusion and diuretics.Our preliminary data indicate that RF ablation is a safe, feasible, and effective treatment for huge multiloculated PLAs. It should be considered as an alternative treatment for patients who fail to respond to or not suitable for PD plus antibiotics and refuse surgical intervention.

Complicated acute appendicitis presenting as a rapidly progressive soft tissue infection of the abdominal wall: a case report.

BACKGROUND: We report a case of a rare complication of acute appendicitis with perforation through the abdominal wall. The case points out that an intraabdominal origin should be considered in patients presenting with rapidly spreading soft tissue infections of the trunk. CASE PRESENTATION: A 58-year-old European woman presented to our hospital with a 1-week history of severe abdominal pain accompanied by rapidly spreading erythema and emphysema of the lower abdomen. On admission, the patient was in septic shock with leukocytosis and elevation of C-reactive protein. Among other diagnoses, necrotizing fasciitis was suspected. Computed tomography showed a large soft tissue infection with air-fluid levels spreading through the lower abdominal wall. During the operation, we found a perforated appendicitis breaking through the fascia and causing a rapidly progressive soft tissue infection of the abdominal wall. Appendicitis was the origin of the soft tissue infection. The abdominal wall was only secondarily involved. CONCLUSIONS: Even though perforated appendicitis as an etiology of a rapidly progressive soft tissue infection of the abdominal wall is very rare, it should be considered in the differential diagnosis of abdominal wall cellulitis. The distinction between rapidly spreading subcutaneous infection with abscess formation and early onset of necrotizing fasciitis is often difficult and can be confirmed only by surgical intervention.

CT-guided Drainage of Deep Pelvic Abscesses via a Percutaneous Presacral Space Approach: A Clinical Report and Review of the Literature.

RATIONALE AND OBJECTIVES: Some deep pelvic abscesses are not accessible through anterior or lateral approaches because of the presence of organs and structures. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous presacral space approach by reviewing our clinical experience and the literature. MATERIALS AND METHODS: The outcomes of 12 patients, who have undergone computed tomography (CT)-guided percutaneous presacral space drainage, were retrospectively reviewed, including demographic, clinical, and morphological data in the medical records. RESULTS: From August 2010 to June 2015, 98 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A percutaneous presacral space approach was adopted in 12 cases. The fluid collections were related to postoperative complications in nine patients (75%) and inflammatory or infectious intraabdominal disease in the remaining three patients (acute diverticulitis: n = 1; appendicitis: n = 1; Crohn disease: n = 1) (25%). The mean duration of drainage was 9.5 days (range 3-33). Escherichia coli was the most frequently present microorganism (in 50.0% of the all samples). No procedure-related complications were observed, either during or after the procedure. Drainage was successful in 10 patients (83.3%). Drainage failed in one patient because of massive anastomotic dehiscence. The other one died from pulmonary embolus 10 days after drainage. CONCLUSIONS: When an anterior or lateral transabdominal approach is inaccessible, CT-guided transperineal presacral space approach drainage is a safe, well-tolerated, and effective procedure, except for patients with massive anastomotic dehiscence.

"Reverse" hip spacer for massive distal femur defects in peri-prosthetic knee infections. / Espaciador de cadera «invertido¼ para defectos masivos de fémur distal en infecciones periprotésicas de rodilla.

BACKGROUND: Bone loss in the distal femur is a common problem in knee revision surgeries. The problem is exacerbated in the context of an active infection. In extreme cases this bone loss could compromise the feasibility of a two-stage exchange protocol using dynamic spacers due to the inherent instability of this type of spacers. Use of a hip prefabricated spacer in a "reverse" way forming a ball-and- socket joint is a therapeutic option in cases of massive bone defect and infection. MATERIAL AND METHODS: A retrospective review was performed of our institutional database to identify all cases of massive distal femoral defect in which this technique was used from January 2010 to December 2013. A record was made of the epidemiological data, characteristics of the infection (clinical and microbiological), and adverse event during the spacer stage. The main end-point was the infection eradication rate (minimum: 18 months of follow-up). The complications associated with the technique were also assessed. Finally, each patient completed a visual analogue pain scale, and a satisfaction questionnaire (SAPS). RESULTS: This technique was successfully used in six cases so far, controlling the infection in all cases. Mean femoral defect was 117cm (range: 32-191cm). Mean time with spacer was 7.6 months, with no major complications. All but one patient reached second stage reconstruction with a mega-prosthesis, and mean time since second stage was 34.7 months. All patients stated high levels of satisfaction with the technique employed, as well as and low pain scores (mean visual analogue pain scale: 1; range: 0-4). CONCLUSION: A reproducible and safe technique is described. Patients report a high level of satisfaction with the procedure, and there were no cases of recurrence of the infection after a minimum follow-up of 18 months.

Vacuum Sealing Drainage Treatment Combined with Antibiotic-Impregnated Bone Cement for Treatment of Soft Tissue Defects and Infection.

BACKGROUND This study aimed to evaluate the combined effect of vacuum sealing drainage (VSD) and antibiotic-loaded bone cement on soft tissue defects and infection. MATERIAL AND METHODS This prospective non-blinded study recruited 46 patients with soft tissue defects and infection from January 2010 to May 2014 and randomly divided them into experimental and control groups (n=23). Patients in the experimental group were treated with VSD and antibiotic-loaded bone cement, while the patients in the control group were treated with VSD only. RESULTS In the experimental group, the wound was healed in 23 cases at 4 weeks postoperatively, of which direct suture was performed in 12 cases, and additional free flap transplantation or skin grafting was performed in 6 cases and 5 cases, respectively. No infection reoccurred in 1-year follow-up. In the control group, the wound was healed in 15 cases at 6 weeks postoperatively, of which direct suture was performed in 8 cases, and additional free flap transplantation or skin grafting was performed in 3 cases and 4 cases, respectively. In the other 8 cases the wound was healed at 8 weeks postoperatively. Infection reoccurred in 3 cases during the follow-up. The experimental group had significantly fewer VSD dressing renewals, shorter time needed until the wound was ready for surgery, shorter duration of antibiotic administration, faster wound healing, and shorter hospital stay than the control group (p<0.01). CONCLUSIONS The combination of VSD and antibiotic bone cement might be a better method for treatment of soft tissue defects and infection.

Endoscope-Assisted Pectoralis Major-Rectus Abdominis Bipedicle Muscle Flap for the Treatment of Poststernotomy Mediastinitis.

INTRODUCTION: Various management strategies have been reported for sternal wound care; however, they exhibit limited effectiveness or are associated with severe complications. Furthermore, it is difficult for the standard pectoralis major (PM) muscle advance flap to reach the lower third of the sternum. This article examines using the PM-rectus abdominis (RA) bipedicle muscle flap to treat lower-third deep sternal wound infection. METHODS: The outcomes of patients who received a PM-RA bipedicle muscle flap harvest at our institution between 1996 and 2014 were reviewed. The method involves performing a subfascial and subperiosteal dissection of the PM to elevate the muscle flap. Blunt dissection may be performed carefully under an endoscope. Endoscope visualization enables us to identify the critical structures lateral to the PM muscle. In addition, the connective tissue to the RA muscle was preserved. Continuity was carefully preserved from the pectoral-thoracoepigastric fascia to the anterior rectus sheath. The flap could then be transposed to fill the lower-third sternal tissue defect with ease. RESULTS: A total of 12 patients, with a mean age of 71 years (45-89 years), were treated using an endoscope-assisted PM-RA bipedicle muscle flap harvest. Wound microbiology of the 12 patients revealed that 3 patients had methicillin-resistant Staphylococcus aureus, 4 had S. aureus, 1 had coagulase-negative Staphylococcus, 1 had Escherichia coli, 1 had Pseudomonas aeruginosa, 1 had Mycobacterium tuberculosis, and 1 had a mixed growth of organisms. One instance of recurrent sternal infection was identified among the patients. Moreover, 1 patient died from heart failure 5 weeks after surgery, but the coverage of the sternal wound was successful. Accidental injury to the surrounding neurovascular structure of the patients was avoided, and only 10 to 15 minutes was required to divide the PM muscle. CONCLUSIONS: Performing this harvest method under endoscopic assistance has several advantages, such as preventing excess traction of the skin edge to diminish the skin slough. This method could be an effective alternative for harvesting the PM-RA bipedicle muscle flap to reconstruct the lower-third sternal wound.

[Fournier's gangrene: Cervical and facial extension. A very rare case]. / Gangrène gazeuse périnéo-fessière à extension cervico-faciale. À propos d'un cas exceptionnel.

Fournier's gangrene is a fearsome disease with a bad prognosis and a mortality rate ranging between 10 and 80% according to the literature. It is extensive in 13 to 54% of cases. Up to date, cervico-facial extension has never been reported. We describe the case of a 51-year-old overweighed woman with a history of type 2 diabetes and a narrow lumbar canal who was referred to our institution for significant fatigue and increasingly painful legs. A diagnosis of Fournier's gangrene was made after correlating the physical findings with the results of a full body scan. Diffuse subcutaneous emphysema involving the face, neck, mediastinum, abdominal wall, right buttock, perineum and the right thigh was identified. Treatment included multiple surgical debridements, admission to intensive care unit, and an efficient antibiotic therapy that enabled preservation of the patient's life. To our knowledge, this is the first case of cervical and mediastinal extension of Fournier's gangrene to be reported. No clear guidelines exit on the management of this complication (cervico-facial and mediastinal drainage). We share our experience of this unusual case.

[Autologous mesenchymal stem cells and cutaneus autograft as a treatment for chronic ulcer secondary to diabetes mellitus 2]. / Células troncales mesenquimales autólogas e injerto cutáneo autólogo para tratamiento de una úlcera crónica secundaria a diabetes mellitus tipo2.

BACKGROUND: Diabetes mellitus 2 has become a global problem. It is estimated that 15% to 25% of patients could develop a chronic ulcer in their life, and nearly 33% of direct care costs of the diabetes mellitus 2 is spent on treating these ulcers. Mesenchymal stem cells have emerged as a promising cell source for the treatment of these ulcers. CLINICAL CASE: The case is presented of a 67 year-old male with a history of diabetes mellitus, acute myocardial infarction, and food ulcer chronic involving right foot and part of his leg. He was treated with mesenchymal stem cell management, resulting in skin graft integration and full coverage of the lesion. CONCLUSION: The implementation of mesenchymal stem cell techniques for treatment of chronic ulcer is feasible. The impact on the population would lead to a significant improvement in their quality of life and reduce healthcare spending.