Safety of an intercostal approach for imaging-guided percutaneous drainage of subdiaphragmatic abscesses.

OBJECTIVE: The objective of our study was to test the hypothesis that an intercostal approach to imaging-guided percutaneous subdiaphragmatic abscess drainage is as safe as a subcostal approach. MATERIALS AND METHODS: A cohort of 258 consecutive patients with one or more subdiaphragmatic abscesses referred for imaging-guided (CT or ultrasound) percutaneous drainage was identified. Demographic characteristics and clinical outcomes were compared between patients who underwent drainage catheter placement via an intercostal approach versus those who underwent drainage catheter placement via a subcostal approach. RESULTS: Percutaneous drainage was performed for 441 abscesses in 258 patients in 409 separate procedures (214 via an intercostal approach, 186 by a subcostal approach, and nine by a combined approach). The total number of pleural complications was significantly higher in the intercostal group (56/214 [26.2%]) than the subcostal group (15/186 [8.1%]; p < 0.001). These complications included a significantly higher pneumothorax rate in the intercostal group than the subcostal group (15/214 [7.0%] vs 0/186 [0%], respectively; p < 0.01) and a higher incidence of new or increased pleural effusions (38/214 [17.8%] vs 14/186 [7.5%]; p < 0.01). The incidence of empyema was low and similar between the two groups (intercostal vs subcostal, 3/214 [1.4%] vs 1/186 [0.5%]; p = 0.63). A few of the complications in the patients who underwent an intercostal-approach drainage were clinically significant. Four of the 15 pneumothoraces required thoracostomy tubes and eight of 38 (21.1%) pleural effusions required thoracentesis, none of which was considered infected. CONCLUSION: An intercostal approach for imaging-guided percutaneous drainage is associated with a higher risk of pleural complications; however, most of these complications are minor and should not preclude use of the intercostal approach.

Revision of laparoscopic adjustable gastric banding: success or failure?

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a safe and frequently performed bariatric procedure. Unfortunately, re-operations are often necessary. Reports on the success of revisional procedures are scarce and show variable results, either supporting or declining the idea of revising LAGB. This study describes a large cohort of re-operations after failed LAGB to determine the success of revision. METHODS: By use of a prospective cohort, all LAGB revisions performed between 1996 and 2008 were identified. From 301 primary LAGB procedures in our centre, 43 patients (14.3%) required a band revision. In addition, 51 patients were referred from other centres. Our analysis included in total 94 patients with a mean follow-up period of 38 months after revision. RESULTS: Revision was mainly necessary due to anterior slippage (46%) and symmetrical pouch dilatation (36%), which could be resolved by replacing (70%) or refixating the band (27%). Weight loss significantly increased after revision (excess BMI loss (EBMIL), 37.2 ± 36.3% versus 47.5 ± 30.4%, P < 0.05). After revision, 23 patients (24%) needed a second re-operation. Patients converted to other procedures (16%) during the second re-operation showed larger weight loss than the revised group (EBMIL, 64.3 ± 28.1% versus 44.3 ± 28.7%, P < 0.05). CONCLUSIONS: We report on a large cohort of LAGB revisions with 38 months of follow-up. Revision of failed LAGB by either refixation or replacement of the band is successful and further increases weight loss.

Etiological factors for subphrenic infection after hepatectomy for patients with hepatic malignancy.

BACKGROUND: This study was to clarify the high risk factors for subphrenic infection (SI) after liver resection for patients with hepatic malignancy. METHODS: Three hundred and sixty-eight patients who had undergone hepatectomy from January 1985 through June 2002 were randomly divided into 2 groups according to resection of liver parenchyma, hepatic cirrhosis, primary liver cancer, intraoperative blood loss, and subphrenic drainage. The chi-square was used for statistical analysis. RESULTS: Thirteen patients (3.53%) of the 368 patients had SI. The high-risk factors for SI after hepatectomy were related to resection of liver parenchyma and hepatic cirrhosis; but the course or stage of primary liver cancer was not related to the incidence of SI. Intraoperative blood loss of over 1500 ml was found to be a significant risk factor for postoperative SI. Adequate drainage of the subdiaphragm and the raw surface of the liver after operation was essential to decreasing SI after liver resection. CONCLUSION: Inadequate subphrenic drainage may largely contribute to SI in patients with hepatic malignancy undergoing hepatectomy apart from other factors. Comprehensive measures should be taken to prevent the infection after hepatectomy.

Reducing early technical complications in gastric bypass surgery.

BACKGROUND: The incidence of complications following gastric bypass surgery has decreased markedly over the last 30 years; nevertheless, significant morbidity and mortality is still associated with this procedure. Much of the improved risk of this technique can be attributed to the numerous modifications that have taken place in its evolution. METHODS: We compared our series of 640 primary cases of vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RGB), a form of gastric bypass, with gastric bypass series reported in the literature from 1966 to 1996. Incidences considered were those of subphrenic abscess, gastrointestinal leaks, obstruction of the excluded segment of gastrointestinal tract, splenectomy and death. RESULTS: The overall trend during the last 30 years has been a reduction in the rate of major complications. In our series, we had one major complication, a subphrenic abscess. This compares favorably with the incidence of major complications reported in the literature. CONCLUSIONS: The gastric bypass is a significantly safer operation today than three decades ago. We believe that the relatively low complication rate of VBG-RGB results from: (1) the anatomic location of the gastric pouch; (2) the type of stapling device used in its construction; (3) a pouch outlet restricted by a prosthetic band rather than a narrow anastomosis; and (4) the construction of a retrocolic, retrogastric Roux-en-Y gastrojejunal anastomosis.

Abscesos subfrénicos / Subphrenic abscess

Una complicación séptica de la cirugía abdominal es el abscesos subfrénico (AS) que si no se lo trata presenta una alta morbimortalidad. Se analizan 16 AS acaecidos entre 1990 y 1993. El 62,5 porciento de los casos eran varones. La edad promedio fue de 53 años. La causa quirúrgica originaria más frecuente fueron el cáncer gástrico (5), apendicitis aguda (3) y la colelitiasis (3). La cirugía es el pilar del tratamiento de la infección peritoneal. Mediante técnicas convencionales de drenaje y tratamiento de la causa, mejora la mayoría. La laparostomía contenida debe reservarse para un restringido número de pacientes y el drenaje percutáneo auxiliado por imagenología, cuando es posible, ha ido ganando adeptos, dada su baja morbilidad y poca invasividad. Se suman a estas medidas un adecuado tratamiento antibiótico y un apoyo nutricional que contribuyen al éxito que en nuestra serie de 16 AS no presentó mortalidad

Gastrectomía total ampliada / Total enlarged gastrectomy

Entre los años 1983 y 1992 practicamos 104 gastrectomías totales en pacientes con cáncer gástrico. La localización tumoral fue 8,7 porciento en tercio inferior, 40,4 porciento en el tercio medio y 50,9 porciento en el tercio superior. En 81 casos hicimos esplenectomía o pancreatoesplenectomía (78 porciento). Las complicaciones postoperatorias se presentaron en el 36,5 porciento de estos pacientes. Hubo sólo 6 muertes hospitalarias (5,7 porciento), 5 fístulas de la anastomosis esófagoyeyunal (4,8 porciento), 8 abscesos subfrénicos (7,7 porciento), 16 complicaciones respiratorias (15,4 porciento) y otras complicaciones en 14 pacientes (13,4 porciento)

The retrospective study on high risk factors of subphrenic infection after hepatectomy.

In order to identify the high risk factors that determine subphrenic infection after hepatectomy, 187 liver resections performed during January, 1985 to December, 1990 in Department of Surgery of Tongji Hospital were reviewed. Thirteen patients developed subphrenic infection with the incidence of subphrenic infection being 6.95%. The results of retrospective study on 187 liver resections demonstrated that the high risk factors related to subphrenic infection after hepatectomy were as follows: (1) The extent of liver resection was associated with subphrenic infection. (2) The incidence of subphrenic infection after liver resection of primary liver cancer patients with hepatic cirrhosis was higher than that of non-cirrhotic patients. (3) Intraoperative estimated blood loss greater than 1500 ml was found to be a significant risk factor in the development of postoperative subphrenic infection. (4) Adequate postoperative drainage of subdiaphragm and the raw surface of the liver was one of critical factors of decreasing subphrenic infection after liver resection.

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.

Subphrenic abscess: a study of 241 patients at the Royal Prince Edward Hospital, 1950-73.

A series of 241 patients with subphrenic abscess was analysed to seek reasons for the continuing mortality. Aspects of pathology, clinical presentation, special investigations and management were affected by therapy with broad spectrum antibiotics to make diagnosis more difficult, particularly in relation to left subphrenic abscesses. When transperitoneal exploration and drainage were employed, high morbidity and mortality resulted. Satisfactory results followed extraserous drainage. The introduction of parenteral hyperalimentation promised control fistulas associated with abscesses, a situation hitherto associated with a poor prognosis.