Definitive Drainage Research Articles

Practice Patterns of Endoscopists Performing Endoscopic Gallbladder Drainage

Background and AimsThe standard of care for treatment of patients with acute cholecystitis is cholecystectomy. However, many patients are unfit for surgery due to substantial medical comorbidities, or surgery is technically challenging due to anatomic considerations. Options for patients who are not surgical candidates include percutaneous cholecystostomy tube placement by interventional radiology, endoscopic gallbladder drainage (EGBD), or conservative management. Over the last decade, techniques of EGBD have been employed for temporary or definitive gallbladder drainage in patients with acute cholecystitis who are not surgical candidates. Despite growing interest and clinical use of EGBD, little is known about practice patterns of EGBD. Our aim was to survey endoscopists to evaluate the practice patterns and technical considerations regarding EGBD. MethodsAn 18-item survey was distributed to all members of the American Society of Gastrointestinal Endoscopy. Each response was included in the final analysis. Descriptive statistics were calculated using frequencies and percentages. ResultsResponses were received from 217 endoscopists. Of these, 178 perform endoscopic ultrasound-guided gallbladder draining and 178 perform endoscopic transpapillary gallbladder drainage. The preferred approach for EGBD was endoscopic ultrasound-guided gallbladder drainage in 58.8%, endoscopic retrograde cholangiopancreatography (ERCP)-guided transpapillary gallbladder stent placement in 30.2%, and no preference in 11%. ConclusionDespite growing interest in EGBD, significant heterogeneity in practice patterns exists. Further study is needed to better understand these differences and provide data for future guidelines.

Postpneumonectomy Empyema Following SARS-CoV-2 Infection in a Patient with Metastatic Lung Cancer

Abstract We present a case of a male patient who underwent right-sided pneumonectomy due to central low-grade squamous cell carcinoma of the right lung, chemo-, radio-, and immunotherapy. However, the disease progressed. In addition the patient got SARSCoV-2 pneumonia in the left lung, followed by postpneumonectomy empyema. Right-sided uniportal video-assisted thoracoscopy, debridement, and definitive drainage of the pleural cavity were performed.

P-P09 Salvage transgastric necrosectomy as a part of a step-up approach to managing acute necrotising pancreatitis

Abstract Background The use of EUS (endoscopic ultrasound) guided drainage with endoscopic LAMS (lumen apposing metal stent) necrosectomy is an emerging treatment option for walled-off pancreatic necrosis (WOPN) secondary to acute severe pancreatitis. It can delay or remove the need for surgical necrosectomy, which can be associated with high morbidity and mortality. However, the endoscopic approach is not always successful due to a multitude of factors and salvage transgastric necrosectomy can be performed using the tract created by the LAMS to achieve internal drainage and remove necrotic pancreas. Methods We describe our unit’s experience in managing WOPN in two patients. We suggest a treatment pathway of WOPN which includes a step-up approach including salvage transgastric necrosectomy in patients where multiple endoscopic necrosectomies and washouts have failed. Results Two patients, aged 67 and 69, were admitted as intensive care transfers for gallstone and alcohol pancreatitis respectively. They underwent a step-up approach to treat their infected WOPN, starting with the deployment of LAMS and endoscopic necrosectomy. They both showed brief clinical improvement after repeated endoscopic necrosectomy but further imaging showed ongoing large collections that could not be treated endoscopically. Both patients underwent successful transgastric open necrosectomy where necrotic pancreatic tissue was accessed surgically through the already created cyst-gastrostomy. This had the advantage of internal drainage of the collection into the stomach without the need for external surgical drains. Conclusions The emphasis in the treatment of WOPN has shifted to minimally invasive percutaneous or endoscopic drainage modalities. Endoscopically inserted LAMS may not always achieve definitive drainage of the WOPN but should be employed in the first instance as they are associated with reduced morbidity and mortality compared to surgery. Ultimately, open necrosectomy with washout remains the definitive management strategy in the step-up approach. We believe that the trans-gastric open necrosectomy approach can be used successfully in patients where the minimally invasive approach has failed.

Laparoscopic Choledochoduodenostomy in Bile Duct Stone Diseases

Common bile duct (CBD) stones are present in 5–15% of patients with gallstones. Some of these patients are candidates for a definitive biliary drainage procedure for prevention of stone recurrence. The aim of our study was to ascertain the outcome of laparoscopic choledochoduodenostomy in choledocholithiasis. After obtaining ethical clearance from the institutional ethical committee, the present prospective and observational study was conducted on 32 patients over a period from September 2017 to September 2020 in the tertiary care hospital. In our study, the total number of patients was 32, of whom 26 (81%) were females. The mean and range of age were 54.44 SD 10.827 and 24–70 years, respectively. The most common presenting feature was jaundice (53.125%). The mean CBD diameter was 24.59 SD 2.564 mm with multiple stones in CBD in 90.625% of our patients. The mean duration of surgery and intraoperative blood loss was 147.94 SD 9.732 and 76.25 SD 12.636 ml, respectively. The mean hospital stay was 6.34 SD 0.827 days with 90.6% of the patients returning to work in the 3rd week. In our study, there was no conversion to open and a single patient developed postoperative ileus which was managed conservatively. There was complete resolution of symptoms on follow-up. Laparoscopic choledochoduodenostomy is safe for benign bile duct diseases. It is physiological, with minimal intraoperative blood loss, less operative time, and fewer postoperative complications and is safe with faster recovery.

Bacterial Pericarditis Causing Cardiac Tamponade in a Patient with No Primary Source of Infection

Introduction Bacterial Pericarditis is a rare entity accounting for Case Description 73 year old male with history of coronary artery disease presents with pleuritic chest pain and dyspnea since 2 days. On arrival, he was hemodynamically stable. EKG showed changes consistent with acute pericarditis. Echo showed moderate pericardial effusion without tamponade and normal systolic/diastolic function. Patient was treated with colchicine, NSAIDS could not be given due to acute kidney injury. His home dose of aspirin and clopidogrel were continued. Overnight, patient decompensated with persistent tachycardia, tachypnea and hypoxia. He started spiking fevers with worsening leucocytosis. Echo showed moderate pericardial effusion with signs of cardiac tamponade. Urgent pericardiocentesis was done and 250 mL of serosanguinous fluid was removed and a pigtail catheter was left in situ. His antiplatelet agents were discontinued to prevent hemorrhagic pericardial effusion. Methicillin sensitive Staphylococcus aureus was detected in cultures of pericardial fluid and blood. His antibiotic was deescalated to intravenous nafcillin. Echo post procedure showed small pericardial effusion with fibrinous echogenic material. His pericardial drain was not draining enough and was removed the next day. He started developing moderate left sided pleural effusion, likely an extension of pericardial inflammation. A small bore pleural catheter was placed in left pleural space for drainage. He had to undergo pericardectomy for definitive drainage and a chest tube was placed in right pleural cavity for drainage. Transesophageal echocardiogram demonstrated no further pathology. Repeat echo and CT-chest did not show any effusions, so pleural drains were removed on 6th day and patient was doing well. Discussion Purulent pericarditis presents as an acute illness characterized by fever in all patients, chest pain in 25-37% of patients. Bacterial pericarditis is usually not a primary infection, but occurs as a complication of underlying infection. Risk factors are immunosuppression, chest injuries, and chronic kidney disease with hemodialysis, diabetes mellitus and alcoholism. About 15% of patients with purulent pericarditis can develop cardiac tamponade. Typically small effusions accumulate quickly and develop tamponade. Large effusions can accumulate slowly allowing the pericardial sac to expand. Treatment is drainage of pus along with antibiotic therapy. Pericardiocentesis may be sufficient but in case of recurrent effusion or poor drainage of thick loculated fluid, pericardiotomy and pericardial window with manual lysis of adhesions and loculations allowing complete drainage is required. Survival in purulent pericarditis depends on early empiric antibiotic therapy and pericardial drainage.

Incidence and management of post-operative bile leaks. A prospective cohort analysis of 467 liver resections

Bile leaks from the parenchymal transection margin are a major cause of morbidity following major liver resections. The aim of this study was to benchmark the incidence and identify the risk factors for postoperative bile leakage after hepatic resection.A prospective database of 467 consecutive liver resections performed by the University of Cape Town HPB surgical unit between January 1990 and January 2016 was analysed. The relationship of demographic, clinical and perioperative factors to the development of bile leakage was determined. Bile leak and postoperative complications severity were graded using the International Study Group of Liver Surgery and Accordion classifications.Overall morbidity was 24% (n = 112), with bile leaks occurring in 25 (5.4%) patients. Significantly more bile leaks occurred in patients who had major resections (≥ 3 segments) and longer total operative times (p < 0.05). There were 5 Grade A bile leaks which stopped spontaneously. Seventeen Grade B leaks required a combination of percutaneous drainage (n = 15), endoscopic biliary stenting (n = 8) and percutaneous transhepatic biliary drainage (n = 3). All 3 Grade C leaks required laparotomy for definitive drainage. Median hospital stay in the 442 patients without a bile leak was 8 days (IQR 1-98) compared with 12 days (IQR 6-30) for the 25 with bile leaks (p < 0.05) with no mortality. Major resections (≥ 3 segments) and total operative time (> 180mins) were significantly associated with bile leaks.The incidence of bile leakage was 5.4% and occurred after major liver resections with longer operative times and resulted in significantly extended hospitalisation. Most were effectively treated nonoperatively by percutaneous drainage of the collection and/or endoscopic or percutaneous biliary drainage without mortality.

Pleural catheters after thoracoscopic treatment of malignant pleural effusion: a randomized comparative study on quality of life.

Malignant pleural effusion (MPE) complicates many neoplasms and its incidence is expected to rise in parallel with the aging population and longer survival of cancer patients. Although a clear consensus exists on indwelling catheters in patients with poor performance status, no study has hitherto compared different devices in patients requiring temporary or definitive drainage following talc poudrage. This is a prospective, two-arm, pilot study on patients with MPE undergoing talc poudrage, comparing two different catheters (PleurX® versus Pleurocath®) positioned because of the inefficacy of the procedure or the high risk of short-term failure. End points of the study were quality of life (QoL), median dyspnea and chest pain assessment by EORTC questionnaires and a 100 mm visual analog scale, total in-hospital length of stay and frequency of serious adverse events. No difference was observed between the two groups in in mean dyspnea and mean chest pain in any questions of the EORTC QLQ-C30 and QLQ-LC13 questionnaires. Duration of the procedure was significantly longer in the PleurX® group versus the Pleurocath® group (72±33 versus 44±13 minutes; P=0.03). No difference was observed between the two groups in total length of hospital stay (P=1.00) or complication rate (P=1.00). For the cohort of patients still needing indwelling pleural catheters (PC) after thoracoscopic talc poudrage, PleurX® is suggested when drain removal is unlikely due to short life expectancy or the high chance of pleurodesis failure. Conversely, Pleurocath® should be recommended in all other patients as it is faster to place and easier to remove. Malignant pleural effusion (MPE); talc poudrage; indwelling pleural catheter (indwelling PC).

Respiratory and Circulatory Failure From Abscess-Related Pneumomediastinum and Overflow Pneumoperitoneum

SESSION TITLE: Fellow Case Report Slide: Disorders of the Mediastinum SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Tuesday, October 25, 2016 at 07:30 AM - 08:30 AM INTRODUCTION: Gastroesophageal perforation is an infrequent but serious complication following laparoscopic hiatal hernia repair1, which can lead to mediastinal abscess. CASE PRESENTATION: A 64 year old male presented with esophageal food impaction from an intrathoracic gastric volvulus. Four days following disempaction and laparoscopic hiatal hernia repair he developed hypoxia and sepsis. After intubation he had unanticipated severe hypotension. Testing confirmed a large gas-forming mediastinal abscess from a gastric perforation, which was treated with endoscopic stitching and stenting with complete defect closure. The next day he had worsening abdominal distention, rising airway pressures, and hypotension. CT scan showed enlargement of the mediastinal abscess with pneumomediastinum and new pneumoperitoneum from the diaphragm to the scrotum (Figure). Surgical debridement, mediastinal chest tube placement, and needle paracentesis for abdominal air dramatically improved peak airway pressures and hemodynamics. DISCUSSION: The patient suffered an iatrogenic gastric perforation with a large gas-producing mediastinal abscess. While intrathoracic displacement explains his respiratory failure, the hemodynamic collapse after positive pressure ventilation was likely from a critical increase in intrathoracic pressure impeding venous return. Perforation closure exacerbated this problem by eliminating the enteral drainage mechanism resulting in overflow pneumoperitoneum and further decline in respiratory mechanics, finally relieved by definitive external drainage. Historically, most iatrogenic gastroesophageal perforations merit surgical management, especially when recognized >24 hours after the injury2, but endoscopic drainage techniques can be considered in primary management of mediastinal abscess3. CONCLUSIONS: Without adequate drainage, gas-forming mediastinal abscess can rapidly expand causing pneumomediastinum and overflow pneumoperitoneum leading to respiratory and circulatory collapse, which is exacerbated by positive pressure ventilation. Reference #1: Brinster, Clayton J., et al. “Evolving options in the management of esophageal perforation.” The Annals of Thoracic Surgery 77.4 (2004): 1475-1483. Reference #2: Bufkin, Bradley L., Joseph I. Miller, and Kamal A. Mansour. “Esophageal perforation: emphasis on management.” The Annals of Thoracic Surgery 61.5 (1996): 1447-1452. Reference #3: Wehrmann, Till, et al. “Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series.” Gastrointestinal Endoscopy 62.3 (2005): 344-349. DISCLOSURE: The following authors have nothing to disclose: Matthew Nolan, John Park No Product/Research Disclosure Information

Surgical Success in Chronic Pancreatitis: Sequential Endoscopic Retrograde Cholangiopancreatography and Surgical Longitudinal Pancreatojejunostomy (Puestow Procedure)

Introduction Chronic pancreatitis (CP) can be a cause of recurrent, severe, disabling abdominal pain in children. Surgery has been suggested as a useful therapy, although experience is limited and the results unpredictable. We reviewed our experience of a two-stage protocol-preliminary endoscopic retrograde cholangiopancreatography (ERCP) and duct stenting, and if symptoms resolved, definitive surgical decompression by longitudinal pancreatojejunostomy (LPJ) (Puestow operation). Patients and Methods This is a single-center, retrospective review of children with established CP who underwent an LPJ between February 2002 and September 2012. A questionnaire was completed (incorporating visual analog scale pain and lifestyle scores) to assess functional outcome. Data are expressed as median (range). Results In this study, eight (M:F ratio of 4:4) children underwent an LPJ and one female child had a more limited pancreatojejunostomy anastomosis following preliminary ERCP and stent placement where possible. Diagnoses included hereditary pancreatitis (n = 3), idiopathic or structural pancreatitis (n = 5), and duct stricture following radiotherapy (n = 1). Median duct diameter presurgery was 5 (4-11) mm. Endoscopic placement of a Zimmon pancreatic stent was possible in six with relief of symptoms in all. Median age at definitive surgery was 11 (range, 7-17) years with a median postoperative stay of 9 (range, 7-12) days and a follow-up of 6 (range, 0.5-12) years. All children reported markedly reduced episodes of pain postprocedure. One developed diabetes mellitus, while three had exocrine deficiency (fecal elastase < 200 µg/g) requiring enzyme supplementation. The child with limited LPJ had symptomatic recurrence and required restenting and further surgery to widen the anastomosis to become pain free. Conclusion ERCP and stenting provide a therapeutic trial to assess possible benefit of a definitive duct drainage procedure. LPJ-the modified Puestow operation was safe and complication-free with good medium-term relief of symptoms. We were not able to identify a consistent etiology-associated outcome.

Polymorphism of heat shock protein 70-2 and enterocutaneous fistula in Chinese population.

To investigate whether the heat shock protein 70-2 (HSP70-2) polymorphism is associated with enterocutaneous fistulas in a Chinese population. This study included 131 patients with enterocutaneous/enteroatmospheric fistulas. Patients with inflammatory bowel disease or other autoimmune diseases were excluded from this study. All patients with enterocutaneous/enteroatmospheric fistulas were followed up for three months to observe disease recurrence. In addition, a total of 140 healthy controls were also recruited from the Jinling Hospital, matched according to the sex and age of the patient population. Genomic DNA was extracted from peripheral blood from each participant. The HSP70-2 restriction fragment length polymorphism related to the polymorphic PstI site at position 1267 was characterized by polymerase chain reaction (PCR). First PCR amplification was carried out, and then PCR products were digested with PstI restriction enzyme. The DNA lacking the polymorphic PstI site within HSP70-2 generates a product of 1117 bp in size (allele A), whereas the HSP70-2 PstI polymorphism produces two fragments of 936 bp and 181 bp in size (allele B). The frequency of the HSP70-2 PstI polymorphism did not differ between patients and controls; however, the A allele was more predominant in patients with enterocutaneous fistulas than in controls (60.7% vs 51.4%, P = 0.038, OR = 1.425, 95%CI: 1.019-1.994). Sixty-one patients were cured by a definitive operation, drainage operation, or percutaneous drainage while 52 patients were cured by nonsurgical treatment. There was no significant difference in the frequency of the HSP70-2 PstI polymorphism between the patients who had surgery compared to those who did not (P = 0.437, OR = 1.237, 95%CI: 0.723-2.117). Moreover, 11 patients refused any treatment for economic reasons or tumor burden, and 7 patients with enterocutaneous fistulas (5.8%) died during the follow-up period. However, there was no significant difference in the frequency of the HSP70-2 PstI polymorphism between the patients who survived compared to those who died (P = 0.403, OR = 0.604, 95%CI: 0.184-1.986). The A allele of the HSP70-2 PstI polymorphism was associated with enterocutaneous fistulas in this Chinese population.

Clinical outcomes of temporary shunting for infants with cerebral pseudomeningocele

Although in the case of subdural collections temporary shunting has been suggested as a viable alternative for definitive drainage of the accumulated fluid until restoration of the normal CSF dynamics, there is no agreement on the best management strategy for pseudomeningocele. The authors performed a retrospective chart review in order to evaluate the clinical outcomes of infants temporarily shunted for pseudomeningocele without encephalocele at our institution (The University of Illinois at Peoria/Illinois Neurological Institute) in the period from 2004 to 2012. The epidemiological characteristics, clinical management, and final outcomes of such subpopulation were compared with a control group which received temporary shunting for subdural hematomas (SDH) during the same period. Four patients (100% male) ranging in age from 8.9 to 27.1 months (mean = 13.88) with pseudomeningocele and 17 patients (64.7% male) ranging in age from 1.9 to 11.8 months (mean = 4.15) with SDH were identified. Although the initial management included sequential percutaneous subdural tapping in 82% of the patients, all children ultimately failed such strategy, requiring either subdural-peritoneal (81% of the cases) or subgaleal-peritoneal (19% of the cases) shunting. The mean implant duration was 201 days for the pseudomeningocele group and 384 days for the SDH one. Mean post-shunt hospitalization was 2 days for patients with pseudomeningocele and 4 days for patients with SDH. There was no statistical difference in terms of complications, length of hospitalization post-shunting, or clinical outcomes between the patients with pseudomeningocele and those with SDH. Temporary shunting of infants with pseudo-meningocele constitutes a viable therapeutic alternative with favorable clinical outcomes and a low risk of shunt dependency similar to those of children with SDH.

Tularaemia presenting as parapharyngeal abscess: case presentation

We report an extremely rare case of the oropharyngeal form of tularaemia, causing a parapharyngeal abscess. A 48-year-old woman presented with fever, sore throat, breathing difficulty and a right-sided neck swelling. This mass had previously been treated with penicillin without response, and had already been surgically drained once in another hospital. On physical examination, the tonsils were exudative and hypertrophic and the pharynx was hyperaemic. A fluctuant, 4 × 4 cm mass was seen on endoscopic examination, originating from the left parapharyngeal area and protruding towards the pyriform sinus, and partly obstructing the airway. Microagglutination test antibody titres for Francisella tularensis were positive (1/1280). The patient healed completely after definitive drainage of the abscess and antimicrobial therapy for 14 days (streptomycin, 2 × 1 g intramuscularly). Tularaemia should be considered in the differential diagnosis of patients presenting with tonsillopharyngitis, cervical lymphadenitis and parapharyngeal abscess who do not respond to treatment with penicillin, even if they do not live in an endemic region.

Management of excluded bile ducts in paediatric orthotopic liver transplant recipients of technical variant allografts

BackgroundA strategy to increase the number of size- and weight-appropriate organs and decrease the paediatric waiting list mortality is wider application of sectional orthotopic liver transplantation (OLT). These technical variants consist of living donor, deceased donor reduced and split allografts. However, these grafts have an increased risk of biliary complications. An unusual and complex biliary complication which can lead to graft loss is inadvertent exclusion of a major segmental bile duct. We present four cases and describe an algorithm to correct these complications. MethodsA retrospective review of the paediatric orthotopic liver transplantation database (2000–2010) at Washington University in St. Louis/St. Louis Children's Hospital was conducted. ResultsSixty-eight patients (55%) received technical variant allografts. Four complications of excluded segmental bile ducts were identified. Percutaneous cholangiography provided diagnostic confirmation and stabilization with external biliary drainage. All patients required interval surgical revision of their hepaticojejunostomy for definitive drainage. Indwelling biliary stents aided intra-operative localization of the excluded ducts. All allografts were salvaged. DiscussionAggressive diagnosis, percutaneous decompression and interval revision hepaticojejunostomy are the main tenets of management of an excluded bile duct. Careful revision hepaticojejunostomy over a percutaneous biliary stent can result in restoration of biliary continuity and allograft survival.

Laparoscopic cystogastrostomy via the posterior approach for pancreatic pseudocyst drainage.

The treatment of pancreatic pseudocysts is still being debated. Laparoscopic treatment of pancreatic pseudocysts enables definitive drainage with faster recovery. Moreover, the best drainage technique for pseudocysts located adjacent to the posterior gastric wall is pseudocystgastrostomy. Although, drainage via the anterior approach has been frequently reported, reports on the posterior approach are rare. Here, we evaluated the efficacy of the posterior approach technique for pancreatic pseudocyst drainage. We retrospectively studied 28 patients who underwent cystogastrostomy for pancreatic pseudocysts: they were divided into the conventional cystogastrostomy group (CCG group) and the laparoscopic cystogastrostomy via the posterior approach group (LCGP group). The mean operative time was significantly shorter, blood loss was significantly reduced, and the duration of hospitalization after surgery was significantly shorter in the LCGP group than in the CCG group. Recurrence was observed in 1 patient (5.6%) in the CGP group; it was an asymptomatic recurrence that did not require additional treatment. In contrast, there was no recurrence in the LCGP group patients. We think that our technique of performing laparoscopic cystogastrosotmy via the posterior approach is easy and feasible for pancreatic pseudocyst drainage.

Percutaneous Abdominal Abscess Drainage: A Historical Perspective

AJR:191, September 2008 introduced with a trocar technique after a positive preliminary aspiration. Given that this was early in their experience, the results were encouraging. Of nine attempted aspira­ tions using methods 1 and 2, eight were reported successful. Method 3 was attempted twice and was successful in one case. More im portant, there were no complications other than the aspiration failures. Haaga and colleagues [2] accurately concluded that CT is an excellent diagnostic and guidance tool for the percutaneous treatment of abdominal fluid collections. They recognized that CT, despite its ability to show gas and the extraluminal nature of the collection, is somewhat limited in its ability to fully characterize the fluid. Finally, they suggested that for definitive drainage the abscess must be superficial to avoid undesired peritoneal contamination and injury to adjacent structures. In short, the seed had been planted for percutaneous CT­ guided drainage procedures. Two years later, Gerzof and associates [3] reported their experience with percutaneous drainage procedures using both sonographic and CT guidance. In this study, they reviewed their experience in 23 patients in whom they used one of two drainage techniques: Seldinger (over guidewire)—with delivery of an 8­French angiographic pigtail catheter for drainage and trocar—with placement of 12­ or 16­French Argyle­Ingram catheters. They used sonographic guidance in 20 of 24 cases and CT guidance in the remaining four cases. The catheters were kept in place an average of 14 days in 22 patients, and only one patient required an open operation after failure of percutaneous drainage. Gerzof and associates [3] reported two major complications—one empyema and one hemorrhage—as well as three minor complications—chills, fever, and cutaneous sinus tract. Similar to the Haaga et al. [2] Percutaneous Abdominal Abscess Drainage: A Historical Perspective

Factors Associated with Definitive Peritoneal Drainage for Spontaneous Intestinal Perforation in Extremely Low Birth Weight Neonates

Peritoneal drainage (PD) constitutes a definitive therapy for a subset of extremely low birth weight (ELBW) infants with spontaneous intestinal perforation (SIP). We investigated the factors which may differentiate these patients from those who require a laparotomy (LAP) after initial PD. A retrospective chart review of all ELBW infants (<1000 grams) who underwent PD at two tertiary neonatal intensive care units over a 42-month period was performed. Demographic, clinical, laboratory, and radiological data of the entire patient cohort were collected. Patients who underwent definitive PD were compared to those who required LAP following PD. Statistical comparisons were performed using independent samples T-tests for continuous variables, and Fisher's exact test for categorical variables. Sixteen ELBW infants with SIP underwent PD. Five patients (31%) had definitive PD and 11 (69%) subsequently required LAP. Patients who had definitive PD had a lower percent band count at diagnosis (3.2+/-1.5 vs. 18.0+/-4.8; p=0.01), and were less likely to require vasopressor therapy at diagnosis and drain placement (40% vs. 91%, p=0.06), 24 hours later (40% vs. 100%, p=0.02), and 48 hours later (20% vs. 91%, p=0.01). There were no other statistically significant differences in any of the measured variables. Survival to discharge was 80% for PD and 82% for LAP (p=1.0). Peritoneal drainage for spontaneous intestinal perforation in ELBW neonates is more likely to be definitive in the absence of bandemia and vasopressor requirement. These may be important factors in deciding whether to proceed to laparotomy.

Hepatobiliary Scintigraphy in Detecting Lesser Sac Bile Leak in Postcholecystectomy Patients

Cholecystectomy is one of the most commonly performed abdominal surgeries in which bile duct injury and bile leaks are the most important complications. Imaging plays an important role in the prompt diagnosis and management of bile leaks. The more common sites of bile leak are the gallbladder bed, subhepatic, in a bilioma, right paracolic gutter, or diffusely in the peritoneal cavity. Bile leak into the lesser sac (LS) is uncommon but is a special entity posing difficult problems in management. We have described in this study the clinical presentation, imaging findings, and management of 6 patients with biliary leakage into the LS postcholecystectomy. The clinical presentation of this condition was varied, ranging from patients with asymptomatic or with vague complaints resulting in difficulties in clinical suspicion or symptomatic but minimal enough not to be detected by ultrasonogram. Hepatobiliary scintigraphy played an important role in the diagnosis and management, and all patients required definitive therapeutic drainage procedures. Any persistent focal radiotracer activity in the anatomy of the LS, increasing with time and not diffusing into the general peritoneal cavity is diagnostic of bile leak into the LS.

Idiopathic fibrosing pancreatitis and spontaneous resolution of pancreatic masses in children

A symptomatic pancreatic mass poses both a diagnostic and therapeutic conundrum. First, benign conditions may mimic malignancy and second, the management of benign lesions has not been well defined. We reviewed four such cases and discuss the management of juvenile idiopathic fibrosing pancreatitis in the light of these. In four children with symptomatic pancreatic masses/enlargement (three with jaundice) all resolved spontaneously without definitive intervention. Histopathology, obtained in two cases, revealed a fibrotic chronic inflammatory reaction. Pancreatic masses in children may not be malignant. Resolution of symptoms including obstructive jaundice and a mass secondary to juvenile idiopathic fibrosing pancreatitis may occur spontaneously, avoiding the need for resection or definitive drainage procedures.

Aspiration of peritonsillar abscess in severe trismus

We present a novel method of aspirating a peritonsillar abscess in a patient with severe trismus. In our experience, this method is efficient, allows good access to the peritonsillar area and facilitates rapid resolution of the trismus before definitive drainage can be performed.

A Comparison of Anterior and Posterior Approaches for the Surgical Treatment of Pancreatic Pseudocyst Using Laparoscopic Cystogastrostomy

Laparoscopic treatment of pancreatic pseudocyst allows for definitive drainage with faster recovery. Although many groups have reported their experience with an anterior approach, only a few have done so with a posterior approach. This paper compares the approaches, analyzing their potential benefits and pitfalls. Seven females and one male underwent laparoscopic cystgastrostomy to treat pancreatic pseudocysts. The anterior approach was performed by opening the stomach anteriorly, localizing the pseudocyst ultrasonographically, draining the cyst with a needle and, via the same opening, using a stapler to form a cystgastrostomy. The posterior approach was performed by directly visualizing the posterior gastric wall and the pseudocyst, opening and draining the cyst with a needle, and using a stapler and running sutures for closure. All patients had gallstone pancreatitis. Cystgastrostomy via the anterior approach was used in 4 patients and via the posterior approach in 4 patients. Dense adhesions required one attempted posterior cystgastrostomy to be converted to an anterior approach. The mean age of the anterior group was 38 years (range, 18-58 years) and hospital stay was 6 days (range, 4-8 days): for the posterior group, mean age was 42 years (range, 40-44 years) and length of stay was 3 days (range, 2-4 days). Although both approaches had good results with no complications and short hospital stays, the posterior approach is safer, with a more precise cyst visualization and dissection that permits more tissue to be sent for histopathologic examination. Furthermore, the posterior approach?s larger anastomosis would seem to yield fewer occlusions, which are commonly seen with the anterior approach. The anterior approach is easier to learn, but it requires the opening of the anterior stomach and the use of ultrasound.