Endoscopic ultrasound-guided transmural drainage for subphrenic abscess: report of two cases and a literature review.

BACKGROUND: An intra-abdominal abscess can sometimes become serious and difficult to treat. The current standard treatment strategy for intra-abdominal abscess is percutaneous imaging-guided drainage. However, in cases of subphrenic abscess, it is important to avoid passing the drainage route through the thoracic cavity, as this can lead to respiratory complications. The spread of intervention techniques involving endoscopic ultrasonography (EUS) has made it possible to perform drainage via the transmural route. CASE PRESENTATION: We describe two cases of subphrenic abscess that occurred after intra-abdominal surgery. Both were treated successfully by EUS-guided transmural drainage (EUS-TD) without severe complications. Our experience of these cases and a review of the literature suggest that the drainage catheters should be placed both internally and externally together into the abscess cavity. In previous cases there were no adverse events except for one case of mediastinitis and pneumothorax resulting from transesophageal drainage. Therefore, we consider that the transesophageal route should be avoided if possible. CONCLUSIONS: Although further studies are necessary, our present two cases and a literature review suggest that EUS-TD is feasible and effective for subphrenic abscess, and not inferior to other treatments. We anticipate that this report will be of help to physicians when considering the drainage procedure for this condition. As there have been no comparative studies to date, a prospective study involving a large number of patients will be necessary to determine the therapeutic options for such cases.

[A CASE OF SUBPHRENIC ABSCESS WITH PARADOXICAL RESPONSE CAUSED BY MYCOBACTERIUM TUBERCULOSIS].

A 40-year-old woman was admitted to our hos- pital with cough and sputum production. A chest computed tomography (CT) scan revealed a diffuse nodular shadow in the upper lung. The patient was diagnosed with pulmonary tuberculosis, based on a positive T-SPOT®.TB test result of peripheral blood and a positive polymerase chain reaction (PCR) test result for Mycobacterium tuberculosis in gastric aspirates. M.tuberculosis was subsequently isolated from the gastric aspirate specimen. After 2 months of treatment with antituberculous medication, the patient developed a low grade fever and left-sided chest pain. A CT scan revealed a left pleural effusion and a right subphrenic abscess. Tuber- culous pleurisy with paradoxical response was diagnosed on the basis of an increased lymphocyte count and increased adenosine deaminase activity in the pleural fluid exudate. A percutaneous ultrasound-guided needle biopsy of the sub- phrenic abscess was performed. Histological analysis revealed epithelioid cell granulomas with necrosis and PCR for M. tuberculosis using puncture needle washing fluid returned positive results. Based on these findings, a diagnosis of subphrenic abscess with paradoxical response, caused by M. tuberculosis, was made. Subphrenic abscess caused by M. tuberculosis is an important consideration during antituber- culous therapy.

A case of left subphrenic abscess caused by gastric ulcer penetration that was successfully treated with endoscopic transgastric drainage.

A 65-year-old male visited our hospital because of fever and difficulty in walking. He was suffering from left-sided hypochondrial pain for a month. Laboratory tests performed on admission revealed a white blood cell count of 1700/µl and C-reactive protein level of 9.51mg/dl, which were suggestive of severe inflammation. Contrast-enhanced computed tomography revealed a subphrenic abscess around the spleen, which we considered to be caused by gastric penetration into the gastrosplenic ligament. Upper esophagogastroduodenoscopy revealed a gastric ulcer together with a fistula that connected to the left subphrenic abscess. We thus performed endoscopic transgastric drainage through the fistula. Antibiotics and a proton pump inhibitor were administered, and drainage was continued. The patient's clinical and inflammatory symptoms subsequently improved. We thus consider that endoscopic transgastric drainage is an appropriate treatment option for subphrenic abscesses.

[Thoracic empyema due to subphrenic appendicitis: an infrequent presentation]. / Empiema pleural secundario a apendicitis subdiafragmática: una extraña presentación.

Acute appendicitis is the most common abdominal surgical emergency. Atypical presentations lead to a late diagnosis with a higher complication rate. Given its rarity, we report a case of a thoracic empyema due to subphrenic appendicitis.

Subphrenic abscess secondary to Actinomycosis meyeri and Klebsiella ozaenae following laparoscopic cholecystectomy.

A case is reported of a subphrenic abscess 12 months post-laparoscopic cholecystectomy in a 72-year-old male with identification of Actinomyces meyeri and the oropharyngeal commensal Klebsiella ozaenae. The first organism is exceptionally rare following laparoscopic cholecystectomy and is presumed to be a result of inadvertent gallstone spillage. The second organism has not previously been reported in a subphrenic abscess. The etiopathogenesis and management of this condition are presented.

An Unexpected Case of Perforated Acalculous Cholecystitis Caused by a Fish Bone.

Gallbladder inflammation is most often determined by the presence of gallstones. Acalculous cholecystitis usually occurs in patients with multiple comorbidities or with an immunosuppressed status, and therefore its evolution is faster and more severe compared to acute calculous cholecystitis. The presence of a fish bone into the peritoneal cavity, through a gastrointestinal fistula is not very rare, but acute cholecystitis caused by a fish bone is unexpected. Here, we present the case of a 75-year old woman who had eaten fish two months before and presented at the Emergency Room with perforated acalculous cholecystitis and a right subphrenic abscess. The laparoscopic approach permitted the evacuation of the subphrenic abscess, bipolar cholecystectomy and removal of a fish bone from nearby the cystic duct. Postoperative evolution was uneventful, with hospital discharge after five days. The patient was in good clinical condition at two months follow-up.

Thirty years' experience with balloon dilation of benign postoperative biliary strictures: long-term outcomes.

PURPOSE: To determine the effectiveness of percutaneous balloon dilation of benign postoperative biliary strictures. MATERIALS AND METHODS: We received approval from our institutional review board to undertake this retrospective HIPAA-compliant study, and informed consent was waived. From April 1, 1977, to April 1, 2007, percutaneous biliary balloon dilation (PBBD) was performed in 85 patients with benign biliary strictures. In the 75 patients with follow-up (31 male, 44 female; mean age, 56 years; mean follow-up, 8 years), 205 PBBD procedures were performed during 112 treatments of 84 biliary strictures. PBBD of the stricture was performed with a noncompliant balloon (8-12-mm diameter). PBBD procedures were repeated at 2- to 14-day intervals until cholangiography demonstrated free drainage of contrast material to the bowel and no residual stenosis. An internal-external biliary drain was left in situ for a mean of 14-22 days and removed after a clinical trial of catheter clamping and a normal cholangiogram. RESULTS: All procedures were technically successful, and 52, 11, 10, and two patients underwent a total of one, two, three, and four PBBD treatments, respectively. Four of 205 procedures (2%) led to major complications: two subphrenic abscesses, one hepatic arterial pseudoaneurysm, and one case of hematobilia treated with transfusion. Six patients died from unrelated causes and three from hepatitis C-related liver failure. The probability of a patient not developing clinically significant restenosis at 5, 10, 15, 20, and 25 years was 0.52, 0.49, 0.49, 0.41, and 0.41, respectively, after the first PBBD treatment and 0.43, 0.30, 0.20, 0.20, and 0.20, respectively, after the second PBBD treatment. No significant difference was found in the rate of clinically significant restenosis after the first PBBD between strictures at anastomotic and nonanastomotic sites (P = .75). During the follow-up period, 56 of 75 patients (75%) had successful management with PBBD. CONCLUSION: PBBD of benign strictures demonstrates long-term effectiveness. No significant difference was found in the rate of clinically significant restenosis after PBBD of biliary strictures at anastomotic and nonanastomotic sites.

The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis.

BACKGROUND: The risk of damage to the bile duct and structures in the hilum of the liver is significant when Calot's triangle cannot be safely dissected during laparoscopic cholecystectomy, and conversion to an open procedure often is performed. This is more common during emergency surgery, but may not render the procedure any easier. Traditionally, open subtotal cholecystectomy was performed, but with the advent of laparoscopic surgery, this has fallen from favor. The authors report their experience using laparoscopic subtotal cholecystectomy to avoid bile duct injury and conversion in difficult cases. METHODS: Laparoscopic subtotal cholecystectomy, performed when the cystic duct cannot be identified safely, consists of resecting the anterior wall of the gallbladder, removing all stones, and placing a large drain into Hartmann's pouch. The notes for all patients who underwent a laparoscopic subtotal cholecystectomy between 1 September 2001 and 31 December 2004 were retrospectively analyzed. RESULTS: Subtotal cholecystectomy was performed in 26 cases including 13 emergency and 13 elective procedures. The median age of the patients (15 women and 11 men) was 68 years (range, 36-86 years). The indications were severe fibrosis in 16 cases, inflammatory mass or empyema in 8 cases, and gangrenous gallbladder or perforation in 2 cases. The median postoperative inpatient stay was 5 days (range, 2-26 days). Five patients underwent postoperative endoscopic retrograde cholangiopancreatography: four for persistent biliary leak and one for a retained common bile duct stone. One patient required laparotomy for subphrenic abscess, and one patient (American Society of Anesthesiology [ASA] grade 4, presenting with biliary peritonitis) died 2 days postoperatively. One patient required a subsequent completion laparoscopic cholecystectomy for a retained gallstone. One patient had a chest infection, and two patients experienced port-site hernias. CONCLUSIONS: Laparoscopic subtotal cholecystectomy is a viable procedure during cholecystectomy in which Calot's triangle cannot be dissected. It averts the need for a laparotomy.

Drainage of a Subphrenic Abscess Followed by Two-Stage Gastrectomy and Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Perforated Gastric Carcinoma: A Case Report.

BACKGROUND Perforated gastric cancer accounts for less than 1% of patients who present with an acute abdomen and for up to 16% of all gastric perforations. A two-stage laparoscopic procedure may be the therapeutic strategy of choice in selected patients, and adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) can reduce the incidence of peritoneal recurrence. A rare case of subphrenic abscess and gastric perforation due to carcinoma of the gastric fundus, followed by two-stage gastrectomy and adjuvant HIPEC is presented. CASE REPORT A 65-year old man presented with a left subphrenic abscess secondary to perforated gastric carcinoma. Laparoscopic drainage of the abscess was performed. Ten days later, following recovery from sepsis, the patient underwent total laparoscopic gastrectomy, and adjuvant HIPEC followed by a Roux-en-Y esophagojejunostomy. Histopathology showed an intestinal-type gastric adenocarcinoma. The tumor was staged as pT4aN0. The postoperative course was uneventful except for transient atrial fibrillation. The patient was discharged home on postoperative day 11. Systemic adjuvant chemotherapy was begun one month later. At six-month follow-up, the patient had no discomfort on eating or any other symptoms. CONCLUSIONS In this case, a two-stage laparoscopic treatment for perforated gastric carcinoma combined with adjuvant HIPEC was feasible and safe and may be considered at the time of laparoscopic gastrectomy in selected patients with perforated gastric carcinoma.

Post-traumatic hepatic artery pseudo-aneurysm combined with subphrenic liver abscess treated with embolization.

A 23-year-old man with post-traumatic hepatic artery pseudo-aneurysm and subphrenic liver abscess was admitted. He underwent coil embolization of hepatic artery pseudo-aneurysm. The pseudo-aneurysm was successfully obstructed and subphrenic liver abscess was controlled. Super-selective trans-catheter coil embolization may represent an effective treatment for hepatic artery pseudo-aneurysm combined with subphrenic liver abscess in the absence of other therapeutic alternatives.

Complications of retained intraperitoneal gallstones from laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is now the gold standard procedure for the treatment of symptomatic gall bladder stones. Spillage of gall bladder stones into the peritoneal cavity may occur due to inadvertent iatrogenic gall bladder perforation during dissection of the gall bladder. We report a case of a 66 year old woman who had to return to theatre three times over two years to deal with complications from retained intra-peritoneal gallstones that were spilt at her initial laparoscopic cholecystecomy.

Subphrenic and pleural abscess due to spilled gallstones.

BACKGROUND: A 70-year-old male approximately 3 years after laparoscopic cholecystectomy presented to his primary care physician with a 4-month history of generalized malaise. METHODS: A workup included magnetic resonance imaging that revealed a perihepatic abscess. The patient underwent ultrasound-guided drainage, with the removal of 1400 mL of purulent fluid and placement of 2 drains. Computed tomographic scanning showed resolution, and he was discharged home on oral antibiotics. At 2-month follow-up, the patient was asymptomatic, denying any constitutional symptoms. However, abdominal computed tomographic scanning revealed recurrence of the abscess, which measured approximately 18 x 9 x 7.5 cm, with mass effect on the liver. The patient was placed on intravenous antibiotics and scheduled for operative drainage. The abdomen was entered with a right subcostal incision, and 900 mL of purulent fluid was drained. We also noted abscess erosion through the inferolateral aspect of the right diaphragm into the pleural space. The pleural abscess was loculated and isolated from the lung parenchyma. Palpation within the abscess cavity revealed 9 large gallstones. Following copious irrigation and debridement of necrotic tissue, 3 drains were placed and the incision was closed. RESULTS: The patient had an uneventful recovery and was discharged home on postoperative day number 6. Follow-up imaging at 3 months demonstrated resolution of the collection. CONCLUSION: Spillage of gallstones is a complication of laparoscopic cholecystectomy, occurring in 6% to 16% of all cases. Retained stones rarely result in a problem, but when complications arise, aggressive surgical intervention is usually necessary.

[Features of clinical finding, tactics and surgical treatment of patients with injuries of left subdiaphragmatic space organs].

Results of treatment of 208 patients with injuries of left subdiaphragmatic space organs are analyzed. At 130 (52.5%) patients injuries of spleen, stomach, left curve of colon, pancreas were isolated, at 78 (37.5%)--combined. Features of clinical finding depending on combination of organs injuries were revealed. In clinical finding of abdominal trauma the pancreatogenic syndrome is emphasized which does not prove itself just after trauma. At isolated trauma 2 (0.96%) patients died, at combined trauma--12 (5.77%).

Subphrenic abscess resulting in resection of the lower basal segment of the right lung: a severe complication following laparoscopic appendectomy.

We report the case of an 18-year-old boy who developed an intrathoracic abscess with rupture of the diaphragm following a laparoscopic appendectomy (LA) for a perforated appendicitis. LA is an established procedure in the treatment of appendicitis. It is a safe and efficacious technique, but several complications can occur with this procedure, and surgeons should be aware of the potential dangers. Herein, we present a previously unreported thoracic complication following an LA.

[A case of subphrenic abscess with ileal fistula caused by metastatic adenocarcinoma of unknown origin].

Usual sources of subphrenic abscess with intestinal fistula are previous abdominal operation, inflammatory bowel disease and malignancy. Reported cases of intestinal fistula caused by adenocarcinoma were complicated by direct invasion. In this report, a 70-year-old male had a subphrenic abscess with intestinal fistula and the cause was a metastatic adenocarcinoma of unknown origin. As far as we know, this has not been reported previously in the literatures. The abscess went on chronic course for six months because intermittent administration of antibiotics modified its clinical presentation. The fistulous tract between the abscess and ileum was demonstrated by tubogram via the drainage catheter in abscess. The patient underwent surgical treatment because the cause of fistula was obscure. Invasion of the ileum by metastatic adenocarcinoma was diagnosed by the histologic examination of surgical specimen. Therefore, when a fistula develops without any apparent cause, there is a possibility of malignancy, and surgical approach must be considered. An early surgical approach will prevent the delay in treatment and reduce the mortality.

Risk factors and clinical outcomes for spontaneous rupture of pyogenic liver abscess.

OBJECTIVE: To evaluate the risk factors and clinical outcomes in patients with spontaneous rupture of pyogenic liver abscess (PLA). METHODS: A total of 602 patients diagnosed with PLA between January 2004 and July 2013 were retrospectively analyzed. Among them, 23 patients experienced a spontaneous rupture of liver abscess (SRLA). RESULTS: The prevalence of SRLA was 3.8%. Using multivariate analysis, liver cirrhosis (OR 4.651, P = 0.009), gas-forming abscesses (OR 3.649, P = 0.026), abscess ≥6 cm in diameter (OR 10.989, P = 0.002) and other septic metastases (OR 1.710, P = 0.047) were risk factors for SRLA. Regarding the site of rupture, 20 (87.0%) patients had a localized rupture, specifically, subphrenic abscess in 3 (13.0%), peri-hepatic abscess in 10 (43.5%), localized peritoneal abscess in 3 (13.0%) and empyema in 4 (17.5%); and the other 3 (13%) had peritonitis. Ruptures resulting in peritonitis require urgent surgery, whereas localized ruptures were managed with surgical or percutaneous drainage in addition to appropriate antibiotics. The in-hospital mortality rate of SRLA was 4.3%. CONCLUSION: Patients with cirrhosis, having abscess ≥6 cm in diameter, gas-forming abscesses and other septic metastases in those with PLA should be monitored closely and may need early intervention for SRLA.

Cholelithoptysis and pleural empyema.

We report a case of delayed cholelithoptysis and pleural empyema caused by gallstone spillage at the time of laparoscopic cholecystecomy. An occult subphrenic abscess developed, and the patient became symptomatic only after trans-diaphragmatic penetration occurred. This resulted in expectoration of bile, gallstones, and pus. Spontaneous decompression of the empyema occurred because of a peritoneo-pleuro-bronchial fistula. This is the first case of such managed nonoperatively and provides support for the importance of intraoperative retrieval of spilled gallstones at the time of laparoscopic cholecystectomy.

Cholelithoptysis and empyema formation after laparoscopic cholecystectomy.

Thoracic complications of laparoscopic operations are rare. We describe a case of cholelithoptysis due to a gallstone sequestered in the middle lobe after laparoscopic cholecystectomy.