[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. The new epidemiology.

Recent changes in the etiology, topography, and bacteriology of subphrenic abscess are identified in 93 patients treated between 1955 and 1975. Gastric and biliary tract operation account for 52% of abscesses. Appendicitis is now responsible for only 8% of subphrenic infections, in contrast with the 40% of previous reports. Colonic surgery (19%) and trauma (8%) are increasing in importance. Left-sided abscesses occur in 40%, and multiple space abscesses in 20% of patients. The bacterial flora consists of multiple strains of aerobic and anaerobic organisms. Since 1970, the aerobes have been Escherichia coli (96%), Klebsiella (21%), and Proteus (38%); anaerobes include Bacteroides (83%), cocci (50%), and clostridia (50%). The mean interval from the preceding operation until drainage of the subphrenic abscess was 5.5 weeks. Overall mortality was 31%, with higher mortalities for multiple space involvement (39%) and for abscesses developing after emergency procedures (35%). Recommendations based on this data are: (1) antibiotics selected should be effective against anaerobes, and (2) transperitoneal drainage is frequently indicated because of the increase in multiple abscesses and the need to evaluate the first operation.

Selective management of subphrenic abscesses.

Although extraserous drainage of subphrenic abscesses has gained wide acceptance, there is some renewed enthusiasm for the more frequent use of a transperitoneal operation because it affords the opportunity to discover unsuspected pathologic conditions, particularly heterotopic abscess. In 44 patients with postoperative subphrenic abscesses, the approach to drainage was selected on the basis of the clinical circumstances. Among 28 patients whose abscesses were drained extraserously, the incidence of heteroptic and recurrent abscesses was low. No serious complications of peritoneal or wound soilage occurred after transperitoneal drainage in 16 patients, yet the problems of inadequate drainage and heteroptic abscess were not eliminated. Celiotomy prior to definitive abscess localization was required for 13 patients. Five patients died. The operative approach should be based on the clinical assessment of the patient and particularly on the probability that multicentric intra-abdominal pathologic conditions exist.

Subdiaphragmatic abscesses: myths and realities. A report on sixty-two cases.

The main cause (60.8%) of subdiaphragmatic abscesses in a series of 62 patients (of which 46 were males), was found to be hepatobiliary in nature. Radiology proved to be helpful in correct diagnosis (61%), as did ultrasonography (60%). Right sided subdiaphragmatic abscesses were (55/62) 88.7% of the total. Mean abscess volume was 500 ml while culturing efforts were in vain in 32% of the abscess cases (able to be cultured). The incidence of morbidity was (12/62) 19.4% and mortality (3/62) 4.8% in this series, where the treatment was solely through surgical drainage. Though closed drainage using ultrasonic guidance has been popular in the past decade, it has its drawbacks. Open surgical drainage therefore, as a well established mode of treatment, is recommended.

[Post-operative subphrenic abscess. Information supplied by analysis of 62 recent unpublished cases (author's transl)]. / Les abcés sous-phréniques post-opératoires. Renseignements fournis par l'analyse de 62 observations récentes et inédites.

We have collected 62 cases of post-operative subphrenic abscess. Two thirds of these patients were sent to us by another unit for post-operative complications. Subphrenic asbcess is still very dangerous as the mortality is still 38%. They occurred after a gastro-duodenal operation (26 times), spleno-pancreatic operation (21 times), intestinal operation (15 times), hepato-bilary operation (11 times) appendicectomy (twice). They were situated usually on the right, but 11 patients had a double subphrenic abscess and 14 an associated submesocolic abscess. Gram negative bacteria were usually the cause. These abscesses often started early. They occurred in 80% of cases in patients operated under the antibiotic cover. Chest X-ray was the best method of detection, but experience is necessary to read them. The abscesses were drained by the abdominal route in order to verify th whole peritoneal cavity. 22 patients died. 11 from septicemia. 21 out of 22 had a digestive fistula. Among the factors in prognosis, the most obvious were age, type of operation, the notion of reoperation, multiple abscess, and finally the delay in starting treatment.

[Perinephric abscess: associated factors and mortality]. / Absceso perirrenal: factores asociados a su desarrollo y mortalidad.

OBJECTIVES: To determine predisposing factors in perinephric abscesses and to find events associated with unfavourable outcome. METHODS: We carried out a clinical, descriptive, retrospective and cross-sectional study, including 23 patients diagnosed of perinephric abscess admitted to our hospital. RESULTS: In patients with perinephric abscess, clinical charts included diabetes mellitus in 65.2%, history of nephrolithiasis in 43.47% and history of urological surgery in 17.38%. On hospital admission, haemoglobin greater than 10.5 g/dL and white blood cell count lower than 15 x 10(3) / microL were associated with nephrectomy, and platelet count lower than 140 x 10(3) / microL with septic shock. General mortality was 8.69%, and 78.3% if patient required nephrectomy. Patients who died had fever, anaemia, white blood cell count greater than 16 x 10(3) / microL, platelet count lower than 130 x 10(3) / microL, and hyponatremia of 125 mEq/L or lower at hospital admittance, and all of them had septic shock and required nephrectomy. CONCLUSIONS: In our series, a higher percentage of patients had diabetes mellitus and/or nephrolithiasis. Haemoglobin level and white blood cells count were associated with loss of the renal unit, thrombocytopenia was associated with septic shock and hyponatremia with mortality.

[Complications following splenectomy]. / Komplikationen nach Splenektomie.

In a retrospective (n = 570) and prospective study (n = 86) early complications following splenectomy were registered in 127/570 (22.3%) resp. 33/86 (38.4%). The mortality rate was 6.6% resp. 6.9%. Recurrent hemorrhage was the most dangerous, infections (pleuropulmonary, wound healing, subphrenic abscess) were the most frequent complications. Their rate is related only to the underlying disease or operative indication (elective splenectomy with hematological diseases; ruptured spleen; incidental splenectomy).

Factors contributing to subphrenic abscess.

Between 1969 and 1982 11 primary (without previous surgery) and 38 secondary (postoperative) subphrenic abscesses were treated out of total 20800 operations. The patients had on an average more than 4 risk factors. Causes contributing to the formation of secondary abscesses were a difficult operation in 42%, deficiencies in surgical technique in 26%, operative contamination in 21% and peritonitis in 13% of the cases. Clear problems in the primary operation were found in 23 of 38 patients and in 6 of 7 patients who died with a later secondary abscess. It seems probable that subphrenic abscesses are more likely to develop in high risk patients after a difficult and/or contaminated operation.

Upper abdominal abscess: a continuing and deadly problem.

Subphrenic and other upper abdominal abscesses continue to be associated with high mortality, even in today's era of broad spectrum antibiotics and sophisticated surgical techniques. Most cases represent complications of intraabdominal surgery. Because the clinical presentation is often subtle and nonspecific, the radiologist plays a paramount role in early diagnosis. Conventional radiography remains an effective method in the initial detection of upper abdominal abscesses. In this study, radiographs were reviewed in 82 patients. In retrospect, plain films revealed extraluminal gas or soft-tissue mass due to abscess in 58 patients (71%). Of these, the abscess was accurately reported initially in 42 patients, but it was initially missed in 16 patients. Conventional gastrointestinal contrast studies, which were underutilized, proved extremely accurate in demonstrating abnormality, especially in the left upper abdomen. Computed tomography, gallium scanning, and ultrasound were effective confirmatory procedures in many cases.

Subphrenic abscess in children.

Nineteen consecutive cases of subphrenic abscess which were treated in the Royal Hospital for Sick Children, Glasgow, from 1962 to 1972 are analyzed. This complication of intra-abdominal suppuration of surgery still carries a grave prognosis. Four of the patients died (21 per cent); 2 deaths were related to the subphrenic abscess while the remaining 2 were not directly related to the abscess. The mean hospital stay of the survivors was 59 days (range 30-122 days). The changing patterns of aetiology and presentation which have recently been emphasized in general surgical practice are not reflected in this paediatric series.

Subphrenic abscess: comparison between operative and antibiotic management.

Subphrenic abscess is still a significant hazard which complicates surgical procedures as well as certain abdominal catastrophes. This is a report of 88 patients with subphrenic abscess at St. Vincent's Hospital and Medical Center of New York from 1954 through 1971. There were 46 males and 42 females, ranging from 2 to 88 years. Operations on the stomach, duodenum and biliary tract were the major causes. The causative organisms in order of frequency were: E coli (41.6%), Staphylococcus (41.6%), Aerobacter aerogenes (23.3%), Proteus (20%), Streptococci (18.3%) and Pseudomonas (8.3%). Penicillin and tetracycline, the antibiotics most commonly chosen on an empiric basis, proved effective in only 38% of cases. On the other hand, kanamycin, chloramphenicol and cephalothin were effective in 90%, 85% and 70% of cases respectively. The overall mortality rate was 15%. Nine of the 21 patients (42.8%) treated with antibiotics alone died while 11 of 67 patients (10.6%) treated with antibiotics and surgical drainage died. Some of the latter deaths occurred in patients treated with prolonged antibiotic therapy and operated on only as a last resort. In this series subphrenic abscess was best treated by early surgical drainage combined with the use of appropriate antibiotics.