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.

Minimally invasive video-assisted trans-diaphragmatic drainage of a subphrenic complicated abscess.

Intra-abdominal abscesses usually originate from the gastrointestinal tract, with 70% occurring in the postoperative period. The mortality rate can reach 50%. These abscesses most commonly develop in the subphrenic and subhepatic spaces. Treatments include percutaneous drainage or surgical drainage. In this report, we present a minimally invasive video-assisted trans-diaphragmatic drainage (MIVTD) method through a simple incision using a right intercostal approach. This method was successfully performed on a patient who underwent Graham patch repair with laparotomy due to a diagnosis of peptic ulcer perforation and subsequently developed a right subphrenic multiloculated collection after unsuccessful percutaneous drainage.

[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.

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.

Retroperitoneal abscess: an uncommon localization of tubercular infection.

We describe a rare case of a 29-year-old immunocompetent Nigerian male affected by an abdominal abscess due to Mycobacterium tuberculosis infection. Diagnosis was achieved with cultures from surgical drainage. No pulmonary, renal, or gastrointestinal involvement was identified. The patient was successfully treated with standard four-drug antitubercular therapy.

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.

The use of surgical drains in laparoscopic splenectomies Consideration on a large series of 117 consecutive cases.

BACKGROUND DATA: The use of surgical drains after traditional splenectomy has been largely debated and several Authors have been unfavorable to their use. With the advent of laparoscopic splenectomy, their role has been re-discussed. The increased risk of undetectable pancreatic, gastric or colon injury in challenging laparoscopic removal of the spleen have induced some surgeons to reconsider the advantages related to their use. METHODS: One hundred seventeen consecutive cases of laparoscopic splenectomy with routine use of surgical drains have been reviewed. Indications for surgery, length of operations, post-operative day of drain removal, post-operative complications were retrospectively analyzed. RESULTS: Laparoscopic splenectomy was performed for idiopathic thrombocytopenic purpura in 77 patients (65,8%), splenic lymphoma in 11 (9,4%), hereditary spherocytosis in 12 (10,2%), ß-thalassemia in 6 (5.1%), other diseases in 11 (9,4%) cases. Conversion to open surgery was necessary in 11,1% of cases. Drains were removed 2-3 days after surgery in 95,8%, within 10 days in 3.4%, within 2 months in 0,8% of cases. In 2 cases a post-operative bleeding, detected through the drainage, required re-operation. One patient with myelofibrosis and massive splenomegaly developed a late post-operative subphrenic abscess, successfully treated by a percutaneous drainage. CONCLUSIONS: In Authors' experience, the use of drains after laparoscopic splenectomy helped detect early post-operative bleeding. Surgical drains could reduce the incidence of fluid intra-abdominal collections and infections. Their use should be recommended in the laparoscopic approach, especially in technically demanding surgical procedures. KEY WORDS: Laparoscopy, Surgical drainage, Splenectomy.

Transphrenic fistulization of a subphrenic abscess to lung parenchyma.

A 53-year-old woman was admitted with respiratory distress. For several years, she had chronic alcoholic pancreatitis with ductal stones that were treated with a stent and with shockwave lithotripsy. Both treatments were unsuccessful, and the pancreatitis was complicated with an infected pseudocyst. The pancreatic head had to be resected, which was complicated with recurrent subphrenic abscesses. She then was admitted with respiratory distress and initially diagnosed with pneumonia of the right lower lobe. Further investigations showed supradiaphragmatic and subdiaphragmatic air-fluid levels. In both collections Streptococcus milleri was cultured, and subsequently the patient was diagnosed with a fistula connecting the subdiaphragmatic abscess with pulmonary tissue. This was treated with intravenous amoxicillin/clavulanate and drainage of the subdiaphragmatic collection. She did not develop a pulmonary empyema, because multiple adhesions, which were due to recurrent abscesses after pancreatic surgery, prevented breakthrough into the pleural cavity.

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.

When is pneumonia not pneumonia?

A 34-year-old man was admitted to hospital via the accident and emergency department with severe right-sided abdominal pain and raised inflammatory markers. His pain settled with analgaesia and he was discharged with a course of oral co-amoxiclav. He was readmitted to the hospital 7 days later reporting cough and shortness of breath. His chest X-ray showed a raised right hemi-diaphragm, presumed consolidation and a right-sided effusion. As a result, he was treated for pneumonia. Despite antibiotic therapy his C reactive protein remained elevated, prompting an attempt at ultrasound-guided drainage of his effusion. Finding only a small amount of fluid, a CT of the chest was performed, and this showed a subphrenic abscess and free air under the diaphragm. A CT of the abdomen was then carried out, showing a perforated appendix. An emergency laparotomy was performed, the patient's appendix was removed and the abscess drained.

Twelfth rib resection. Preferred therapy for subphrenic abscess in selected surgical patients.

OBJECTIVE: To assess the role of 12th rib resection in the treatment of postoperative, subphrenic abscesses. DESIGN: Consecutive case series. SETTING: University hospital, level I trauma center. PATIENTS: Operative logs for a 13-year period were reviewed for all patients undergoing 12th rib resection for drainage of a postoperative subphrenic abscess. Each individual medical record was reviewed for demographic data, primary diagnosis, computed tomographic scan findings, and clinical status (temperature, white blood cell count, and Acute, Physiologic, Age, and Chronic Health Evaluation II score) at the time of rib resection. MAIN OUTCOME MEASURES: Operative results, microbiological data, complications, and outcomes. RESULTS: Twenty-six patients underwent 27 rib resections for a secondary left subphrenic (23) or a right subhepatic (4) abscess. All patients had undergone at least 1 prior laparotomy (average, 1.5; range, 1-4). Sixteen patients had traumatic injuries, and 7 had complicated pancreatitis. Twelve patients had undergone prior failed attempts at percutaneous drainage before rib resection. Fourteen patients underwent operative drainage without attempted percutaneous drainage, mainly for peripancreatic (7) or multiloculated (3) abscesses. There were 3 postoperative complications (3/27 [11%]): a gastrocutaneous fistula, a gastrocolic-cutaneous fistula requiring laparotomy and temporary colostomy, and fasciitis in the resection site. Four (15%) of the 26 patients died: 3 died of progressive multiple system organ failure, and 1 died of an unrelated injury. The remaining 20 (77%) of the patients were discharged from the hospital with healing wounds and no further episodes of intra-abdominal infection. CONCLUSIONS: Twelfth rib resection is an effective alternative therapy for secondary subphrenic abscesses. The nature of the incision allows for open, dependent drainage; avoids subsequent laparotomy; and effectively controls intra-abdominal infections. Twelfth rib resection remains a useful tool in the treatment of subphrenic abscess and may be the preferred approach when other attempts at abscess drainage have failed.

Biliary-bronchial fistula after right hepatic lobectomy.

Biliary-bronchial fistula is an extremely unusual complication of thoracoabdominal trauma or suppurative hepatobiliary disease. We treated a patient with a biliary-bronchial fistula that developed after right hepatectomy for an infected traumatic intrahepatic hematoma. The diagnosis of biliary-bronchial fistula was confirmed by percutaneous transhepatic cholangiography. Surgical therapy included a primary transabdominal choledochostomy, with the insertion of a T-tube, sphincteroplasty, and open marsupialization of the chronic subphrenic abscess.

Intra-abdominal abscess caused by Staphylococcus epidermidis.

An immunologically compromised patient was found to have a postoperative intra-abdominal abscess from which Staphylococcus epidermidis was the sole isolate. Studies of the isolate in a rabbit and in mice showed no evidence for unusual virulence of the organism. The S epidermidis probably was introduced into the peritoneal cavity during surgery and, because of the patient's neutropenia, produced a serious infection within a few weeks. To our knowledge, this is the first case of a intra-abdominal abscess associated with S epidermidis to be described in the literature.

Eclectic drainage of subphrenic abscesses.

In 196 cases of subphrenic abscess from 1964 through 1979, 56% were attributable to gastric, hepatic, and colonic disease or surgery. Posttraumatic abscesses in younger patients became more frequent. Synchronous suprahepatic and subhepatic abscesses or bilateral abscesses accounted for 19%. Streptococci, Escherichia coli, Klebsiella, and Bacteroides species were the most frequently isolated organisms. Although the overall mortality rate was 40%, the surgical mortality rate decreased from 33% initially to 17% recently. The mortality rate of transperitoneal drainage decreased from 41% to 16%. From 1980 through early 1983, a success rate of 84%, with no fatalities, was achieved in percutaneous radiologic drainage of 25 unilocular abscesses. At present, radiologically guided drainage should be considered for unilocular abscesses and some bilocular ones. Although extraperitoneal, extrapleural surgical drainage remains an expeditious form of treatment, it may give way to radiologic drainage. Transperitoneal drainage is preferable for multifocal abscesses and for many abscesses secondary to complications of intraabdominal surgery.