Pyogenic liver abscess secondary to gastric perforation of an ingested toothpick: A case report.

BACKGROUND: Liver abscess due to foreign body-induced gastrointestinal tract perforation is a rare event that could be misdiagnosed due to low suspicion. Less than 100 cases have been reported to date. CASE SUMMARY: We report a case of a 53-year old female patient with pyogenic liver abscess secondary to ingestion of a toothpick with penetration through the lesser curvature of the stomach. The patient presented with persistent epigastric pain. Abdominal computed tomography demonstrated the presence of a linear radiopaque object associated with abscess formation in the left liver lobe. Inflammatory changes in the lesser curvature of the stomach indicated gastric wall penetration by the object. As the abscess was refractory to antibiotic treatment, laparoscopic liver resection was performed to remove the foreign body and adjacent liver parenchyma. Following surgery, symptoms fully resolved without any sequelae. CONCLUSION: This rare case demonstrates the importance of considering foreign body penetration as a cause of pyogenic liver abscess, particularly in abscesses of unknown origin that are resistant to antibiotic therapy. Clinical suspicion, early diagnosis, and prompt removal of the foreign body could lead to improved outcomes in these patients.

A multicenter prospective randomized controlled trial for preoperative biliary drainage with uncovered metal versus plastic stents for resectable periampullary cancer.

BACKGROUND/PURPOSE: Although routine preoperative biliary drainage (PBD) in patients with distal malignant biliary obstruction is generally not recommended, there are still various situations where it may be necessary. The current study aims to compare the uncovered self-expandable metal stent (uSEMS) and plastic stent (PS), where PBD may be necessary. PATIENTS AND METHODS: In this multicenter prospective randomized study, patients with resectable periampullary cancer with cholangitis, deep jaundice, or expected long waiting time for surgery were included. PBD was performed endoscopically, but percutaneous drainage was allowed if the initial endoscopic drainage was not feasible. The primary outcome was the reintervention rate; the secondary outcomes were the complication rates, rate of decrease of total bilirubin, waiting time for surgery, and postoperative hospital stay. RESULTS: Of the 60 enrolled patients, 53 were included for analysis (26 PS and 27 uSEMS). Common bile duct cancer was the most common (27, 50.9%), followed by pancreatic head cancer (20, 37.7%). Regarding PBD indication, 36 (67.9%) had cholangitis and 21 (39.6%) had a total bilirubin level of more than 10 mg/dL at randomization; 10 (18.9%) were included due to delayed surgery by more than 7 days. Fifty (94.3%) patients received pancreaticoduodenectomy, and one (1.9%) patient received palliative hepaticojejunostomy. The median waiting time for surgery was 11.0 days. There was no difference in the reintervention rate (3.8% and 3.8% in PS and uSEMS, P > .999), PBD-related complication rate (23.1% and 22.2%, P > .999), PBD- or surgery-related complication rate (57.7% and 48.1%, P = .674), and the rate of decrease of total bilirubin (P = .541). The median hospital stay after surgery was 13.0 days without significant difference. CONCLUSION: For patients who received surgery within the first 2 weeks from receiving PBD, there was no superiority of uSEMS to PS. According to the expected waiting time for surgery, selective approach for stent choice should be considered.

Effect of Polyglycolic Acid Mesh for Prevention of Pancreatic Fistula Following Distal Pancreatectomy: A Randomized Clinical Trial.

Importance: The rate of postoperative pancreatic fistula (POPF) after distal pancreatectomy ranges from 13% to 64%. To prevent POPF, polyglycolic acid (PGA) mesh was introduced, but its effect has been evaluated only in small numbers of patients and retrospective studies. Objective: To evaluate the efficacy of PGA mesh in preventing POPF after distal pancreatectomy. Design, Setting, and Participants: Prospective randomized clinical, single-blind (participant), parallel-group trial at 5 centers between November 2011 and April 2014. The pancreatic parenchyma was divided using a stapling device; no patient was given prophylactic octreotide. Perioperative and clinical outcomes were compared including POPF, which was graded according to the criteria of the International Study Group For Pancreatic Fistulas. A total of 97 patients aged 20 to 85 years with curable benign, premalignant, or malignant disease of the pancreatic body or tail were enrolled (44 in the PGA group and 53 in the control group). Interventions: Patients in the PGA group underwent transection of the pancreas and application of fibrin glue followed by wrapping the PGA mesh around the remnant pancreatic stump. Main Outcomes and Measures: The primary end point of this study was the development of a clinically relevant POPF (grade B or C by the International Study Group grading system). The secondary end point was the evaluation of risk factors for POPF. Results: The study therefore evaluated a total of 97 patients, 44 in the PGA group and 53 in the control group. Thirty-nine patients were women and 58 patients were men. There were no differences in mean (SD) age (59.9 [12.0] years vs 54.5 [14.1] years, P = .05), male to female ratio (1.0:1.3 vs 1.0:1.7, P = .59), malignancy (40.9% vs 32.1%, P = .37), mean (SD) pancreatic duct diameter (1.92 [0.75] mm vs 1.94 [0.95] mm, P = .47), soft pancreatic texture (90.9% vs 83.0%, P = .17), and mean (SD) thickness of the transection margin (16.9 [5.4] mm vs 16.4 [4.9] mm, P = .63) between the PGA and control groups. The rate of clinically relevant POPF (grade B or C) was significantly lower in the PGA group than in the control group (11.4% vs 28.3%, P = .04). Conclusions and Relevance: Wrapping of the cut surface of the pancreas with PGA mesh is associated with a significantly reduced rate of clinically relevant POPF. Trial Registration: clinicaltrials.gov Identifier: NCT01550406.