CT-guided Drainage Research Articles

Successful percutaneous computed tomography guided drainage of mediastinal abscess in esophageal perforation.

Esophageal perforation with subsequent development of a mediastinal abscess is a well-known clinical entity. Etiologies including idiopathic and iatrogenic with invasive procedures have been reported in medical literatures. This condition is seriously associated with high co-morbidity and in some cases especially if intervention has not been applied associated with high mortality. For long time, open surgical intervention was the only available treatment modality for esophageal perforation with subsequent development of a mediastinal abscess. However, recently there are some other less invasive modalities that have been used with comparable if not preferable success including; self-expandable metallic or plastic stents and imaging guided percutaneous drainage of the mediastinal abscess combined with stenting. We report a patient who presented with esophageal perforation complicated with a mediastinal abscess that was treated successfully with an imaging guided percutaneous drainage of the mediastinal abscess. This case is to emphasize on the fact that endoscopic stent placement is safe and effective for esophageal perforations. Percutaneous CT-guided drainage of associated mediastinal abscesses is an uncommon procedure, but the results suggest that it is associated with high technical and clinical success rates. There should be increased involvement of interventional radiology in the management of those cases.

A tubo-ovarian abscess mimicking an appendiceal abscess: a rare presentation of Streptococcus agalactiae.

A tubo-ovarian abscess (TOA) is a relatively rare medical complication that results from an untreated/unrecognized ascending pelvic infection of the female genital tract. In a right-sided TOA, this clinical entity may mimic appendicitis on computed tomography (CT). In addition, both disease processes can present with pelvic pain, leukocytosis and fever. We present the case of a 47-year-old female with mid right-sided abdominal pain that was diagnosed on CT scan with an appendiceal abscess. She underwent CT-guided percutaneous drainage with interventional radiology. On Day 8, a CT limited study involving a contrast injection was performed to evaluate for abscess resolution. The contrast within the drain filled the fallopian tube, endometrial cavity and contralateral fallopian tube. These findings demonstrated that the initial diagnosis actually represented a TOA. To the authors’ knowledge, this is the only reported case involving a TOA secondary to Streptococcus agalactiae (GBS) mimicking an appendicitis with abscess formation.

Familial Polyposis Coli: The Management of Desmoid Tumor Bleeding.

BackgroundThere is currently no standard treatment for desmoid tumors (DTs) associated with familial polyposis coli (FAP). Familial adenomatous polyposis in DT patients is sometimes a life-threatening condition.MethodsWe enrolled all consecutive patients with FAP treated at Unit of General Surgery and Transplant, University of Naples Federico II and evaluated the incidence of DTs on FAP between 1996 and 2016.ResultsWe observed 45 consecutive patients with FAP; of these 5 were DT-FAP-associated. All 5 cases with FAP were young women, age 25 to 65 years, previously treated by colectomy. Of these, 4 patients presented a parietal localization and had been treated with a wide surgical exeresis; one patient had an intra-abdominal, mesenteric tumor that was unresectable at laparotomy. We performed CT-guided drainage, ureteral stenting, medical therapy (sulindac+tamoxifene), and chemotherapy (dacarba-zine+doxorubicine).All patients were alive and underwent follow-ups for 5 years post-surgery; only 1 patient with parietal localization showed a local relapse after 2 years.ConclusionsWe propose a modulated approach to the single patient with FAP, with surgery as treatment of choice for parietal localization disease and integrating different kinds of therapies (surgery alone or associated with RT, CT) for the intra-abdominal tumor.

CT-guided percutaneous catheter drainage of pancreatic postoperative collections

Objective: To examine the clinical characteristics of fluid collections after pancreatic surgery and evaluate the safety and effectiveness of CT-guided percutaneous catheter drainage (CT-PCD).Material and methods: A retrospective, cross-sectional study was carried out. 51 patients enrolled in this study underwent CT-PCD for collections after pancreatic surgery. The clinical and imaging data were collected and analysed.Results: In all 51 cases, CT scans showed that the samples were collected from the upper abdomen in 94.1% (48/51) of the patients. Apparent clinical symptoms before puncture manifested in 88.2% (45/51) of the patients. The average interval between surgery and puncture was 14.3 ± 7.9 days. In 76.4% (39/51) of the patients, the abdominal drainage catheter inserted during surgery was still not removed during CT-PCD. Amylase levels in drainage fluid were more than three times that of serum amylase in 66.7% (24/36) of the patients. The drainage fluid of 37 patients was sent for bacterial cultures; of these, 64.9% (24/37) tested positive. Full recovery after single puncture procedure occurred in 84.3% (43/51) of the patients. The incidence of puncture-related complications was 3.9%.Conclusions: Pancreatic postoperative collections requiring clinical puncture were mostly located in the upper abdomen. CT-PCD is a safe technique with good therapeutic effects in patients with collections.

Impact factors for safety, success, duration and radiation exposure in CT-guided interventions.

We aim to compare factors influencing safety, success rate and radiation dose of CT-guided biopsies and drainages in a non-teaching setting with experienced operators vs a teaching setting with residents. A total of 1021 cases were retrospectively analyzed regarding lesion size, distance from skin, procedure duration, radiation dose, complications and clinical success. Procedures were grouped into biopsies of lung, liver, (remaining) abdomen, musculoskeletal system (MSK) and drainages of any region. Procedures in non-teaching setting were performed by experienced operators (full time interventional radiology staff), teaching setting consisted of residents under supervision of interventional radiology staff. Overall clinical success rate was 93.6 % [experienced (exp.) vs teaching setting: 93.5 and 93.6 %, p = 0.97]. Overall complication rate was 7.2% (5.7% minor, 1.6% major; exp. vs teaching: 8.0 and 6.5 %, p = 0.67]. Experienced operators performed chest and liver biopsies faster even though they were facing smaller lesions. Multiple regression analysis revealed that depth from skin significantly increased procedure duration by 36.8 s per cm (p < 0.001) and also radiation dose by 5.4 mGy per cm (p < 0.001) in all interventions. On average, teaching setting increased the duration of an intervention by 209.8 s and total radiation dose by 10.6 mGy (p < 0.001, p < 0.001 respectively). CT guided interventions can be performed safe und successful disregarding anatomical parameters or teaching setting. Depth from skin and teaching setting should be taken into account both from a clinical and a time-conscious point of view since they increase radiation dose and prolong operations. This is the first study with >1000 interventions which shows and quantifies the impact of lesion depth and teaching setting in CT-guided interventions.

03:45 PM Abstract No. 408 Comparative effectiveness and safety of CT-guided percutaneous pericardial drainage versus subxiphoid surgical pericardial drainage

03:45 PM Abstract No. 408 Comparative effectiveness and safety of CT-guided percutaneous pericardial drainage versus subxiphoid surgical pericardial drainage

An air-containing mediastinal mass in a patient with a primary adenocarcinoma of the right lung

Objective: The following case report elicits the treatment of a 55-year-old male who was diagnosed with a surinfected mediastinal chyloma as a complication of mediastinoscopy and radiotherapy for a primary adenocarcinoma of the right lung (cT2aN2M0).Methods: The patient was admitted to the hospital after radiographical imaging showed a surinfected mediastinal chyloma. CT-guided percutaneous drainage was performed and via gastroscopy a fistula was diagnosed for which a full covered stent was placed. Then, a right thoracotomy was performed to wash out the chylous cavity, to seal the thoracic duct and to cover the other end of the fistula with an intercostal muscle flap.Results: Postoperative imaging showed a clear reduction of the mediastinal mass with no residual air-fluid level. Realimention was possible three days after placement of the stent. The patient was discharged after 11 days. There was no recurrence of the chyloma. Fistulisation did recur after removal of the stent.Conclusion: Surinfected mediastinal chyloma due to oesopagho-mediastinal fistula is an extremely rare complication after cervical mediastinoscopy and radiotherapy. Open drainage of the chyloma and total coverage of the fistula can control infection and prevent recurrence on short term.

Canceled or aborted CT-guided interventions: 13-year clinical experience at a tertiary care center.

To determine the frequency and causes of canceled or aborted CT-guided interventions (biopsies, cytological aspirations, hookwire localizations, and catheter drainages), associations with patient and procedural variables, and subsequent management. This study included 3052 consecutive CT-guided interventions (2487 biopsies, 80 cytological aspirations, 223 hookwire localizations, and 262 catheter drainages) performed in a single institution within a 13-year period. Fifty-two of 3052 CT-guided interventions were canceled or aborted, corresponding to a frequency of 1.7% (95% confidence interval [CI] 1.3-2.2%). Main causes in order of decreasing frequency included pain, lack of a safe window for intervention, impossibility to position the co-axial or biopsy needle in or near the target, inability to lie still, dyspnea and low oxygen saturation levels, non-discontinuation of anticoagulant therapy, impossibility to aspirate fluid or pus when attempting drainage, and impossibility to advance the drainage catheter in a fluid collection or abscess. On multivariate analysis, only catheter drainages and head-neck interventions were significantly at risk (p = 0.019 and p = 0.004) to be canceled or aborted, with odds ratios of 2.677 (95% CI 1.178-6.083) and 6.956 (95% CI 1.883-25.691), respectively. Of 52 canceled or aborted CT-guided interventions, 14 (26.9%) were repeated, 19 (36.5%) underwent a different non-CT-guided interventional procedure on the same target, and 19 (36.5%) did not undergo any subsequent intervention. The frequency of canceled or aborted CT-guided interventions is low, but is not negligible. Awareness of causes and circumstances under which they are more likely to occur may reduce the number of canceled or aborted CT-guided interventions. • Approximately 1.7% of CT-guided interventions, for which the patient physically shows up at the CT room and which are considered useful by the radiologist, are eventually canceled or aborted. • Main causes (of which some may be prevented) are pain, lack of a safe window, impossibility to position the co-axial or biopsy needle, inability to lie still, dyspnea, non-discontinuation of anticoagulant therapy, and impossibility to aspirate liquid or advance the catheter when attempting drainage. • CT-guided catheter drainages and head-neck interventions are particularly prone to being canceled or aborted.

Treatment of Pericardial Effusion Through Subxiphoid Tube Pericardiostomy and Computerized Tomography- or Echocardiography - Guided Percutaneous Catheter Drainage Methods.

ObjectiveIn this retrospective study, we aimed to observe the efficacy of pericardial effusion (PE) treatments by a survey conducted at the Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University.MethodsIn order to get comparable results, the patients with PE were divided into three groups - group A, 480 patients who underwent subxiphoid pericardiostomy; group B, 28 patients who underwent computerized tomography (CT)-guided percutaneous catheter drainage; and group C, 45 patients who underwent echocardiography (ECHO)-guided percutaneous catheter drainage.ResultsIn the three groups of patients, the most important symptom and physical sign were dyspnea and tachycardia, respectively. The most common causes of PE were uremic pericarditis in patients who underwent tube pericardiostomy, postoperative PE in patients who underwent CT-guided percutaneous catheter drainage, and cancer-related PE in patients who underwent ECHO-guided percutaneous catheter drainage. In all the patients, relief of symptoms was achieved after surgical intervention. There was no treatment-related mortality in any group of patients. In patients with tuberculous pericarditis, the rates of recurrent PE and/or constrictive pericarditis progress were 2,9% and 2,2% after tube pericardiostomy and ECHO-guided percutaneous catheter drainage, respectively.ConclusionCurrently, there are many methods to treat PE. The correct treatment method for each patient should be selected according to a very careful analysis of the patient's clinical condition as well as the prospective benefit of surgical intervention.

ERCP-associated infected intrahepatic pancreatic pseudocyst.

IntroductionPancreatic pseudocysts are abnormal mature collections of pancreatic fluid that can develop in association with acute or chronic pancreatitis. Here, we share the discovery of an infected hepatic subcapsular pseudocyst of the pancreas causing septic shock following endoscopic retrograde cholangiopancreatography (ERCP).Presentation of CaseA 55-year-old woman with ethanol-related chronic pancreatitis and biliary stricture was transferred to the ICU for hypotension 8 hours following ERCP. Examination revealed mild right upper quadrant tenderness without sign of peritonitis. Laboratory studies were notable for leukocytosis (14.6 k/L) and slightly elevated serum lipase (489 U/L). Abdominal CT scan revealed a previously undescribed subcapsular fluid collection. She underwent CT-guided percutaneous subcapsular drainage with return of opaque yellowish fluid. Fluid analysis showed elevated lipase of 62,901 U/L with cultures positive for ESBL Escherichia coli, Streptococcus constellatus, and Enterococcus faecium.DiscussionA majority of pancreatic pseudocysts develop in peripancreatic regions, while, in a recent study, over a quarter of cases were found in usual sites. The management of subcapsular pseudocysts has not been standardized and often involves endoscopic or percutaneous drainage. Operative intervention is reserved for severe infection or rupture in patients with intrahepatic pseudocysts. Rarely do subcapsular pseudocysts become infected. In this case, we postulate the pseudocyst became seeded by bacteria during ERCP resulting in infection and then sepsis.ConclusionThis case report highlights an atypical presentation of pancreatic pseudocyst as well as a rare septic complication of ERCP.

Treatment of postoperative chyle leak after pancreatic surgery – A single center experience

Background: Postoperative chyle leak (CL) is a common complication in pancreatic surgery, where extensive soft tissue clearance is indispensable. Currently, the efficacy of different treatment options for CL is unclear. The aim of the present study was to evaluate treatment options of patients with CL after pancreatic surgery. Methods: CL was defined according to the recently published definition of the International Study Group of Pancreatic Surgery. 228 patients with CL or serous drainage after pancreatic surgery between 01/2014 and 03/2016 were included in this retrospective analysis. Early (≤5 days) and late drain removal were compared regarding the risk for CL and morbidity. A subgroup analysis on those patients who had drain removal despite of persistent CL with respect to the need of subsequent CT-guided drainage within three months postoperatively was performed. Results: At total of 60 patients with CL was identified. 41 patients with CL were treated with medium-chain triglyceride-diet, with a median duration of therapy of 12 days. Early drain removal is associated with a decreased risk or detection rate of CL (p = 0.008) and is not associated with an increased morbidity. After drain removal despite of persistent CL, none of the patients had CT-drainage with proof of CL within three months postoperatively. Conclusion: Early drain removal and removal of the surgical drains despite of persistent CL may be as safe as continuous drainage until complete resolution of CL.

Sacral Tuberculosis: An Atypical Manifestation

Sacral tuberculosis (TB) is extremely rare and its unusual entity might delay the diagnosis and treatment of this treatable disease. A 38-year-old lady presented with a 1 year history of lower back pain with radiculopathy more to right lower limb. The patient was initially treated as Prolapsed Intervertebral Disc (PID), but showed no improvement despite regular physiotherapy and medication. Subsequently, the pain was confined to the right gluteal area and became more severe. Quality of life was impaired in which patient started using walking aids and stopped working. There was a weight loss of 20kg. No other symptom of TB infection or history of contact with TB patient. Bowel and urinary functions were normal. Examination showed localized tenderness at the right gluteal area. Neurological assessment of both lower limbs were MRC grade 5. Blood investigations were normal including the ESR level (17mm/hour). Mantoux test was positive with 18mm induration. MRI revealed a large rim enhancing paravertebral collection at pre-sacral space which extended into bilateral piriformis and gluteal muscles. The patient underwent CT-guided drainage of both gluteals and specimens taken to confirm the diagnosis of TB. Patient showed significant improvement clinically within 1 week after the drainage procedure and initiation of antituberculous chemotherapy. The initial presentation of this patient mimics PID due to irritation of sciatic nerve at piriformis level. However a change in the presentation and failure of conservative treatment should raise a high index of suspicion and necessitates further investigation to establish correct diagnosis hence proper treatment can be initiated.

An Unexpected Masquerader: A Case of Acute Fulminant Colitis Secondary to Ulcerative Colitis

Inflammatory bowel disease (IBD) has a bimodal age distribution with a second peak between 50 and 80 years. We report a case of fulminant colitis in a 74-year-old Caucasian Male presenting with diarrhea and intermittent left lower quadrant pain. His medical history was pertinent for an episode of acute complicated sigmoid diverticulitis with perforation, and abscess formation 2-months prior. A CT-guided drainage was performed then and he was treated with a course of piperacillin-tazobactam and amoxicillin-clavulanic acid. A sigmoidoscopy was performed 4 weeks later and findings included a sigmoid stricture, pseudo-membranes and a 4 cm sigmoid tubular adenoma; which was resected. A Clostridium Difficile test was positive and the patient was started on oral vancomycin. The patient reported worsening of his symptoms and developed hematochezia. His repeat diagnostic evaluation was remarkable for a mild neutrophilic leukocytosis of 13,200 cells/mm3, marked lactic acidosis and negative C. Difficile testing. A CT-scan of the abdomen revealed diffuse colitis and a repeat flexible sigmoidoscopy demonstrated ischemic changes and multiple areas of friable mucosa. The patient further deteriorated and underwent a total colectomy with ileostomy given concern for ischemic colitis. Saccharomyces Cervisiae IgA and IgG titers were positive and ANCA testing was negative. Pathology results revealed chronic active colitis with cryptitis, crypt abscesses, and absence of granulomas with multiple diverticula. Morphology was consistent with a diagnosis of fulminant colitis secondary to ulcerative colitis. The patient underwent a complicated post-operative course with the development of postoperative pneumonia, pulmonary edema and ventilator dependent respiratory failure requiring tracheostomy placement. This case serves to illustrate the importance of recognizing the bimodal distribution of inflammatory bowel disease (IBD), entertaining the diagnosis in elderly patients presenting with colitis, and the importance of a multi-disciplinary approach to establishing a diagnosis of IBD involving clinicians and pathologists. The presence of an anchoring bias to the diagnosis of acute diverticulitis when the first sigmoidoscopy was performed and the attribution of the patient's colitis to C. Difficile colitis and later ischemic colitis led to a late diagnosis of IBD with significant morbidity noted. The case also highlights the utility of serologies in diagnosing IBD.

Persistent Iliopsoas Abscess Due to Fistulizing Crohnʼs Disease: Can Biologic Agents Play a Role?

Iliopsoas abscesses are a rare yet fatal complication of Crohn's Disease with an incidence of 0.4% to 4.3% and morality rate of almost 100% in untreated cases. Treatment currently relies on antibiotics and procedural intervention for refractory cases. We present an intriguing case of a persistent iliopsoas abscess resistant to antibiotics and percutaneous drainage, but responsive to combination of biologics induction therapy and surgery. A 20-year-old male with Crohn's Disease presented to the hospital with fevers, right-sided hip pain, and malaise. White blood cell count was 17.45 K/uL (ref: 4.0-10.80 K/uL), C-reactive protein 45 mg/L (ref: 0-5 mg/L), and sedimentation rate was 42 mm/hour (ref: 0-15 mm/hour). Contrast enhanced computed tomography (CT) revealed a 5 X 3 cm abscess along the medial aspect of the right iliopsoas muscle and incidental ipsilateral hydroureteronephrosis (Image 1). Patient underwent CT-guided right iliopsoas percutaneous drain placement. He was empirically started on ceftriaxone and metronidazole but fluid cultures grew Pseudomonas aeruginosa. He continued to remain febrile despite being switched to piperacillin-tazobactam and later, meropenem. Patient subsequently underwent exploratory laparotomy with ileocecectomy and primary anastomosis for 45 cm of diseased terminal ileum. He remained hemodynamically stable and was discharged. Four weeks post-operatively, he was started on combination infliximab and methotrexate induction therapy with good response. Repeat CT for surgical follow-up showed marked improvement in the right iliopsoas abscess (Image 2). Crohn's Disease is the most common cause of secondary iliopsoas abscesses. Terminal ileum disease can cause iliopsoas abscesses by direct extension of a sinus tract through the mesentery into the retroperitoneal space overlying the iliopsoas sheath. Hydroureteronephrosis and deep vein thrombosis may occur due to mass effect. Patients must be promptly started on broad-spectrum antibiotics targeting anaerobes and gram-negative bacilli. CT-guided percutaneous drainage is the procedure of choice, requiring surgical intervention only in refractory cases. Our patient remained febrile despite broad-spectrum antibiotics and percutaneous drainage, making him the ideal candidate for surgical resection in combination with starting biologic agents. The role of biologics in mitigating the progression of persistent iliopsoas abscesses in Crohn's Disease needs to be explored further.2097_A Figure 1. 5 x 3 cm iliopsoas abscess with ipsilateral hydroureteronephrosis2097_B Figure 2. Improvement in abscess with biologic therapy and surgery

P3.CR-30 Pleural Diseases on Single Lung After Pneumonectomy for Cancer

After pneumonectomy for cancer, the residual lung can be affected by pleural disorders, which usually produce severe respiratory distress and impose emergency treatment. Between 2000 and 2016 we identified 11 patients with previous pneumonectomy for cancer, who presented with pleural disease; 9 of them needed emergency treatment. There were 2 cases of pneumothorax: one developed in first postoperative day after left completion pneumonectomy with chest wall re-resection (for relapsed squamous cell carcinoma); the second pneumothorax developed after CT-guided needle biopsy of a left pulmonary nodule (single left lung after right pneumonectomy for cancer) – in both cases the pneumothorax needed emergency chest tube drainage. Also, there were 8 cases with liquid pleural effusions – 6 malignant, 1 tuberculous and 1 empyema. We performed 2 thoracoscopies and 6 chest drain insertions; in one case the patient with previous left pneumonectomy presented with right pleural and pericardial effusion, for which a pericardial percutaneous left parasternal drainage with ultrasound guidance, and a right pleurotomy, were performed. In another case a left tension loculated pleural effusion needed CT-guided percutaneous drainage. In 3 cases talc pleurodesis was performed. Finally, one patient with previous pneumonectomy presented with left pulmonary nodule and he was prepared for resection. At thoracotomy a pleural entrapment of the inferior lingular segment was found and a decortication was performed; no pulmonary nodule was found neither intraoperatory nor at postoperatory CT-scan. The pleural disease developed on single surgical lung (pneumonectomy for cancer) may be malignant or benign, correlated or not with the primary malignancy which imposed previous pneumonectomy. In endemic areas for TB specific pleural effusions and pleural retraction may appear and surgical treatment is necessary. Special attention is needed for nodules on single lung proposed for CT-guided biopsy – the pneumothorax on single lung has indication for drainage.

Pyogenic Liver Abscess Secondary to Bowel Perforation by Ingested Fish Bone

Accidental ingestion of foreign bodies is a common clinical occurrence in medical practice, but hepatic abscess caused by said ingested foreign bodies is rather uncommon. Pre-operative diagnosis is difficult due to lack of patient awareness of the foreign body as well as non-specific symptoms and imaging findings. We hereby report a rare case of a 68-year-old African male who was admitted with fever and abdominal pain. Further investigation revealed a pyogenic liver abscess caused by an ingested fish bone penetrating the second part of the duodenum, without resolution despite initial antibiotic therapy. Final diagnosis and treatment included a combined endoscopic and surgical approach to remove the fish bone and repair the duodenal perforation along with CT-guided drainage of the abscess by interventional radiology.

Pancreatic Panniculitis: A Harbinger of Systemic Inflammatory Response Syndrome From Spontaneous Rupture of Massive Pancreatic Pseudocyst

Introduction: Pancreatic panniculitis (PP) is an uncommon manifestation of pancreatic diseases. PP in association with spontaneous rupture of a pancreatic pseudocyst has been rarely reported in the literature. Case: A 34-year-old female with history of acute alcoholic pancreatitis presented to the ED with abdominal pain, nausea and vomiting. She reported alcohol use a few days prior to the onset of symptoms. Lipase was 2,040 IU/L (normal 11-82 IU/L). CT of the abdomen/pelvis showed peripancreatic fat stranding and fluid, consistent with acute pancreatitis, and a few cystic structures adjacent to the pancreas believed to be developing pseudocysts. Her symptoms improved slowly with conservative management and she was discharged on day 6. A week later, she returned to ED with recurrent pain, nausea, vomiting, and new erythematous tender nodules on lower extremities (Figure 1A). CT abdomen/pelvis now revealed a new massive pseudocyst within the left side of the abdomen, anterior to the body and tail of the pancreas, measuring 20 x 12 x 15 cm (Figure 2). During CT-guided drainage of the pseudocyst, it was discovered that the pseudocyst had already spontaneously ruptured into the peritoneum. Trans-gastric drainage of the residual pseudocyst was unsuccessful; 1659 cc of ascites was drained. Following the procedure, she developed worsening pain, tachycardia and leukocytosis. She had emergent diagnostic laparoscopy, irrigation and lavage of abdomen, and placement of abdominal drains. She was discharged 8 days post-operatively. Three days later, she was re-hospitalized for recurrent gastrointestinal symptoms. The painful skin nodules had progressed to the upper extremities (Figure 1B). CT abdomen/pelvis now revealed hemorrhagic transformation of the remaining cyst and necrotic changes in the pancreatic head. After stabilization, she underwent skin biopsy which showed dense inflammation with many neutrophils and necrosis, consistent with PP (Figure 3). Her symptoms improved slowly over 2 weeks with conservative management and she was discharged home with subsequent resolution of her skin lesions a week later.1388_A.tif Figure 1: Erythematous tender skin nodules on the legs (A) and arms (B) bilaterally in a patient with massive pancreatic pseudocyst after recurrent acute alcoholic pancreatitis.1388_B.tif Figure 2: Computerized tomography of the abdomen and pelvis with intravenous contrast showing a massive pseudocyst within the left side of the abdomen.1388_C.tif Figure 3: Skin biopsy showing dense inflammation with many neutrophils necrosis, some eosinophils and macrophage/giant cells, consistent with pancreatic panniculitis, in a patient with spontaneous rupture of pancreatic pseudocyst.Discussion: PP is an uncommon necrosis of subcutaneous fat that, may be a harbinger of an underlying pancreatic disorder (including pancreatitis, cancer and pseudocyst). Prompt recognition and appropriate management, by addressing the underlying pancreatic disease, may allow for earlier treatment that could improve clinical outcomes.

Etiology and clinical manifestations of bacterial liver abscess: A study of 102 cases.

This study aimed to analyze the clinical manifestations of patients with pyogenic liver abscess and characteristics of pathogenic that caused their infections, in order to provide guidance for the identification of the pathogens that cause liver abscess and selection of antibiotics for treatment of this disease.In the present study, the clinical characteristics, laboratory results, as well as the species and drug resistance of pathogens in patients with bacterial liver abscesses admitted to our hospital from January 2013 to December 2015 were retrospectively analyzed. The patients were treated by ultrasound or CT-guided percutaneous portal vein catheterization and drainage combined with intravenous infusion of antibiotics (the third-generation cephalosporins, the coformulation of carbapenem and dehydropeptidase-I inhibitors, or the coformulation of tazobactam and piperacillin).A total of 178 patients were diagnosed with liver abscess by B ultrasound or CT. The abscesses mostly occurred in elderly male patients and patients with diabetes mellitus. The major clinical and hematological features were fever (163/178, 91.2%), single focal abscess (146/178, 82.0%), elevated white blood cell count, and percentage of neutrophils (136/178, 76.4%). A total of 102 nonrepetitive strains of bacteria were isolated, including Klebsiella pneumoniae (82 strains, 80.3%), Escherichia coli (8 strains), Pseudomonas aeruginosa (2 strains), Acinetobacter baumannii (1 strain), and Gram-positive cocci (9 strains). Susceptibility to antimicrobial drugs was determined by analyzing the minimum inhibitory concentration, and among the 8 cultured E coli strains, 5 strains that could produce extended-spectrum β-lactamase (ESBLs) were among the most commonly seen nosocomial infections. In the present study, bacterial liver abscesses were mostly community-acquired, and K pneumoniae was highly susceptive to the commonly used antibiotics. Five patients had poor outcomes due to infectious shock or the accompanying liver cancer. In other patients, after treatment, the body temperature and the inflammatory indices, such as the total white blood cell count and C-reactive protein, returned to normal levels, and the area of abscess decreased.Most of the bacterial liver abscesses were caused by K pneumoniae, in which only a few strains exhibited resistance to the commonly used antibiotics. The use of ultrasound- or CT-guided percutaneous drainage combined with antibiotics was an appropriate way to treat the liver abscesses of these patients.

Identification of Bacterial and Fungal Pathogens in Patients with Post-Laparoscopic Sleeve Gastrectomy Leakage.

Post-laparoscopic sleeve gastrectomy (LSG) leak leads to serious complications, and death may occur. The microbial pattern should be established in order to plan empirical antimicrobial therapy. The intra-abdominal leaks post-LSG were cultured and reviewed. Microbial cultures collected from all post-sleeve leakage cases managed at the King Khalid University Hospital (KKUH) from May 2011 until April 2016 were reviewed. A total of 31 patients with positive leak post-LSG were included. The mean presentation time was postoperative day 12. Computed tomography (CT) was done for all patients on presentation with CT-guided aspiration and drainage next day. Samples from the collection were aspirated first for culture then a pigtail drain was kept in place. The average time of drain removal was on the 75th postoperative day. A total of 28 patients (90.3%) had positive culture results. Candida species were the most common organism isolated from 19 patients (61.2%), among them, 10 (32.2%) were positive for Candida species only. Positive bacterial cultures were found in 18 patients (58%). Majority of which single bacterial pathogen isolate, only seven patients had two organisms, and four patients had three organisms. Klebsiella pneumoniae was the most frequent isolated bacteria [8 patients (44.4%)] followed by Streptococcus and Pseudomonas species. Candida albicans was the most common Candida species isolated, 13 patients (68.4%). Fungal microbes isolated from post-LSG leak collection are common and could be considered in the primary empirical therapy. The antibiotic choice for the leak should cover Klebsiella, Streptococcus, and Pseudomonas until definitive culture results are obtained.

Spleen-preserving versus spleen-sacrificing distal pancreatectomy in adults with blunt major pancreatic injury.

BackgroundThe aim of this study was to analyse outcomes of spleen‐preserving (SPDP) and spleen‐sacrificing (SSDP) distal pancreatectomy in adults with severe blunt pancreatic injuries.MethodsThis was an observational study of adult patients who underwent distal pancreatectomy for grade III or IV blunt pancreatic injury between 1991 and 2015. Outcomes of SPDP and SSDP were compared.ResultsFifty‐one patients were included, of whom 23 underwent SPDP and 28 SSDP. The median Injury Severity Score (ISS) was 13·0 (i.q.r. 9·0–18·0). No significant differences were observed between the groups regarding sex, trauma mechanism, shock at triage, laboratory data, location, ISS, associated injury, length of stay, mortality or morbidity. Age (27·0 versus 36·5 years; P = 0·012) and time interval from injury to distal pancreatectomy (15·0 versus 44·0 h; P = 0·022) differed significantly between SPDP and SSDP groups respectively. The mortality rate was 4 per cent (1 of 23) versus 11 per cent (3 of 28) respectively (P = 0·617). Nine patients (39 per cent) developed abdominal morbidity after SPDP, compared with 17 (61 per cent) after SSPD (P = 0·125). In the SPDP group, eight patients had grade B postoperative pancreatic fistula (POPF), two of whom required further intervention. In the SSDP group, six of ten patients with grade B POPF required CT‐guided drainage, and a further five patients required reoperation for other causes. There were more reinterventions after SSDP: 11 of 28 (39 per cent) versus 3 of 23 (13 per cent) in the SPDP group (P = 0·037).ConclusionSPDP was performed more often in younger patients and at a shorter interval after severe blunt pancreatic injury. SPDP was associated with fewer reinterventions.