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.

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.

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.

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.

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.

[Endoscopic closure of a chronic colonic fistula using the over-the-scope clip (OTSC)]. / Endoskopischer Verschluss einer chronischen Fistel des Kolons unter Anwendung des "Over-the-scope"- Clips (OTSC).

HISTORY AND ADMISSION FINDINGS: A 64 year old male patient suffered from recurrent subphrenic abscesses following a complicated postoperative course after sigmoidectomy for chronic recurrent diverticulitis. Two previous attempts of abscess treatment by transcutaneous drainage had failed. Radiographic studies eventually showed a fistula of the descending colon leading to the abscess formation, which could be identified and confirmed endoscopically by installation of dye. TREATMENT AND COURSE: Endoscopic application of an "over-the-scope clip" (OTSC) onto the anchor-retracted enteric fistula orifice led to complete closure of the fistula within four days as demonstrated by radiographic studies and repeat dye installation. Subsequently the transcutaneous drainage could be gradually retracted and eventually successfully removed within 14 days of OTSC application without recurrence of abscess formation. CONCLUSION: The OTSC is a recently developed endoscopic tool, allowing the application of a large claw-like clip for endoscopic closure of full thickness enteric wall defects and cessation of large vessel bleeding within the gastrointestinal tract. It is a novel tool which can be safely and successfully employed to endoscopically close a fistula of the lower intestinal tract. Future controlled multicenter-studies should address the usefulness of OTSC in the conservative-endoscopic management of intestinal fistulizing disease.

[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.

Subhepatic appendicitis with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation: case report.

BACKGROUND: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. When these conditions are met, accurate diagnosis and early management decisions are delayed. CLINICAL CASE: We present the case of a 10-year-old male who had diarrhea without mucus or blood for 5 days. He was treated with antibiotics. Afterwards, he presented with vomiting, abdominal pain, and fever. Physical examination of the abdomen demonstrated a soft and depressible mass and pain in the lower right abdomen. Abdominal ultrasound and tomography reported image of subdiaphragmatic abscess. Percutaneous puncture and drainage were performed without results. Exploratory laparotomy was then performed, revealing a subhepatic perforation of the appendix. The patient evolved with abdominal sepsis and septic shock, resulting in a new surgical intervention for drainage of serohematic fluid. The patient improved and was discharged on day 40. DISCUSSION: It is very important to consider the position of the anatomic appendix during appendicitis because it contributes to the various clinical symptoms, of which 30% are atypical. Diagnosis is masked, leading to complications such as perforations and/or abscesses that extend the hospital stay. CONCLUSIONS: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. Delay in treatment due to atypical symptoms caused by the abnormal position of the appendix conditioned complications that implied a prolonged hospital stay, with the risk of increasing morbidity and mortality of the patient.

Apendicitis subhepática con absceso subdiafragmático en paciente pediátrico sin malrotación intestinal: informe de un caso / Subhepatic appendicitis with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation: case report

Introducción: Los cuadros de apendicitis aguda subhepática en niños son raros y no siempre se acompañan de malrotación intestinal, lo que dificulta el diagnóstico y manejo temprano. Caso clínico: Niño de 10 años de edad, con padecimiento de cinco días de evolución caracterizado por evacuaciones diarreicas, tratado con antibióticos. Posteriormente presentó vómito, dolor abdominal tipo cólico y fiebre de 39 °C. El abdomen se encontró blando y depresible, con escaso dolor en flanco derecho. El ultrasonido y la tomografía mostraron imagen compatible con absceso subdiafragmático. Se manejó con drenaje externo. Al no obtener respuesta se realizó laparotomía exploradora, encontrando apéndice inflamada, de 10 cm de longitud, en posición ascendente sobre la corredera parietocólica derecha y perforación del extremo distal a nivel subhepático. El paciente evolucionó con sepsis abdominal y choque séptico, requiriendo nueva intervención quirúrgica para drenaje de líquido serohemático. A los 40 días el paciente fue dado de alta. Conclusiones: La consideración anatómica del apéndice es importante, por las múltiples presentaciones clínicas, de las cuales 30 % son atípicas y el diagnóstico se enmascara ocasionando complicaciones como perforación y abscesos. Los casos de apendicitis aguda de localización subhepática son raros y por lo general se asocian a malrotación del intestino. El retraso del tratamiento relacionado con el cuadro atípico, ocasionado por la posición poco habitual del apéndice, implica estancia hospitalaria más prolongada y riesgo de incrementar la morbilidad y mortalidad.

BACKGROUND: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. When these conditions are met, accurate diagnosis and early management decisions are delayed. CLINICAL CASE: We present the case of a 10-year-old male who had diarrhea without mucus or blood for 5 days. He was treated with antibiotics. Afterwards, he presented with vomiting, abdominal pain, and fever. Physical examination of the abdomen demonstrated a soft and depressible mass and pain in the lower right abdomen. Abdominal ultrasound and tomography reported image of subdiaphragmatic abscess. Percutaneous puncture and drainage were performed without results. Exploratory laparotomy was then performed, revealing a subhepatic perforation of the appendix. The patient evolved with abdominal sepsis and septic shock, resulting in a new surgical intervention for drainage of serohematic fluid. The patient improved and was discharged on day 40. DISCUSSION: It is very important to consider the position of the anatomic appendix during appendicitis because it contributes to the various clinical symptoms, of which 30% are atypical. Diagnosis is masked, leading to complications such as perforations and/or abscesses that extend the hospital stay. CONCLUSIONS: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. Delay in treatment due to atypical symptoms caused by the abnormal position of the appendix conditioned complications that implied a prolonged hospital stay, with the risk of increasing morbidity and mortality of the patient.

[Aberrant gallstones--extraordinary complications of laparoscopic cholecystectomy]. / Gallensteine auf Abwegen - Ungewöhnliche Komplikationen der laparoskopischen Cholezystektomie.

About 0.2 % of patients undergoing laparoscopic cholecystetomy will suffer from complications caused by lost gallstones. Diagnostic and therapeutic measures are correlated to the symptoms. At different locations, abscesses can arise, which can be treated by direct access through the -abdominal wall, laparotomy or laparoscopy. Two cases are presented with the especially grave sequels of subphrenic abscess, infiltration of the thoracic wall, and pleural empyema, which -respectively needed several successive operations -after ten years. In laparoscopic cholecystectomy, all detected stones should be removed. In the case of a failure, conversion to laparotomy is not essential. The loss of stones has to be formally -documented, the patient and family doctor are to be informed.

Subphrenic abscess through esophageal leakage after laparoscopic initiated nissen fundoplication--case presentation.

A 56-year-old man with a large paraesophageal hiatus hernia, treated in a tforeign clinic with a Nissen fimdoplication (when a lesion of the gastric fornix during laparoscopic dissection has determined conversion to open technique) is admitted 3 weeks after surgery, being diagnosed with an esophageal leekage witch maintains a large subphrenic abscess with sepsis. The patient was cured by draining the leakage, excluding the esophagus by an "à minima" alimentary jejunostomy, under broad spectrum antibiotherapy.

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.