Drainage Of Intra-abdominal Abscesses Research Articles

Tsukamurella Bacteremia in a Surgical Patient: Case Report and Review of the Literature.

Background: Tsukamurella species were first isolated in 1941. Since then, 48 cases of Tsukamurella bacteremia have been reported, a majority of which were immunosuppressed patients with central venous catheters.A case is described and previous cases of Tsukamurella bacteremia are reviewed. Patients and Methods: A 70-year-old total parenteral nutrition (TPN)-dependent female with recurrent enterocutaneous fistula (ECF), developed leukocytosis one week after a challenging ECF takedown. After starting broad-spectrum antibiotic agents, undergoing percutaneous drainage of intra-abdominal abscess, and subsequent repositioning of the drain, her leukocytosis resolved. Blood and peripherally inserted central catheter (PICC) cultures grew Tsukamurella spp. The patient was discharged to home with 14 days of daily 2 g ceftriaxone, with resolution of bacteremia. Conclusions: Tsukamurella spp. are a rare opportunistic pathogen predominantly affecting immunocompromised patients, with central venous catheters present in most cases. However, there have been few reported cases in immunocompetent individuals with predisposing conditions such as end-stage renal disease and uncontrolled diabetes mellitus.

Watchful Waiting After Radiological Guided Drainage of Intra-abdominal Abscess in Patients With Crohn's Disease Might Be Associated With Increased Rates of Stoma Construction.

Management of spontaneous intra-abdominal abscess (IAA) in patients with Crohn's disease (CD) with radiologically guided percutaneous drainage (PD) was debated. This is a secondary analysis from a multicenter, retrospective cohort study of all the patients with CD who underwent PD followed by surgery at 19 international tertiary centers. Seventeen patients (4.8%) who did not undergo surgery after PD were compared to those who had PD followed by surgical intervention 335/352 (95.2%). Patients who had PD without surgery were those with longer disease duration, more frequently had previous surgery for CD (laparotomies/laparoscopies), enteric fistula, on steroid treatment before and continue to have it after PD. Patients who had PD without subsequent surgical resection had a higher risk of stoma construction at later stages 8/17 (47.1%) versus 90/326 (27.6%) (P < .01). Patients with PD with no subsequent surgery had numerically higher rates of abscess recurrence 5/17 (29.4%) compared to those who had PD followed by surgery 45/335 (13.4%) the difference was not statistically significant (P = .07). Even with the low number of patients enrolled in this study who had PD of IAA without subsequent surgery, the findings indicate a markedly worse prognosis in terms of recurrence, length of stay, readmission, and stoma construction. Watchful waiting after PD to treat patients with spontaneous IAA might be indicated in selected patients with poor health status or poor prognostic factors.

Comparative Analysis of Percutaneous Drainage versus Operative Drainage of Intra-Abdominal Abscesses in a Resource-Limited Setting: The Tanzanian Experience.

Intra-abdominal abscesses (IAAs) are a major cause of morbidity and mortality worldwide. While image-guided percutaneous abscess drainage (PAD) has become the standard of care in many countries, over half of the global population does not have access to interventional radiology (IR) and are left with surgery as the only option for source control. The purpose of this study is to evaluate the development, implementation, and role of a PAD service in a resource-limited setting. A retrospective cohort study was performed on all patients who underwent percutaneous or surgical abscess drainage (SAD) of IAAs at Tanzania's national referral hospital from 10/2018 to 4/2021. Patients were identified through a match case search of institutional records and inclusion was confirmed through manual chart review. Demographics, patient presentation, procedural data, and clinical outcomes were recorded in a password-encrypted database and compared between groups. Sixty-three patients underwent abscess drainage: 32 percutaneously and 31 surgically. In the PAD group, there was a 100% technical success rate and a 0% complication rate. In the SAD group, there was a 64.5% technical success rate and ten deaths within 30 days (32.3%), and one additional complication requiring major therapy (3.2%) (p < 0.001). Results from this study demonstrate that PAD can be performed with high technical success and without complication by trained IR physicians in Tanzania. The development of a successful PAD program exemplifies the drastic need to support the growth of IR services in this setting.

Peritoneal antiseptic irrigation to prevent surgical site infection after laparotomy for hepatobiliary or gastrointestinal surgery (PAISI)—protocol for a randomized controlled study

BackgroundPostoperative surgical site infections (SSIs) remain common after laparotomy for resections of the gastrointestinal or hepatobiliary tract. Especially organ/space infections (CDC class III SSI) can be life-threatening, require relaparotomy, intensive care or interventional drainage of intraabdominal abscesses. The PAISI study aims to investigate whether the use of prophylactic peritoneal irrigation with NaOCl/HOCl solution can reduce the SSI rates following laparotomy for resections of the gastrointestinal or hepatobiliary tract, compared to standard irrigation with physiological electrolyte solution (Ringer’s solution). Secondarily, to evaluate whether the use of prophylactic peritoneal irrigation with NaOCl/HOCl solution can reduce postoperative morbidity and mortality as well as the rate of re-operations and length of hospital stay.MethodsPAISI is a prospective, randomized, observer- and patient-blinded, monocentric, two-arm surgical study in an adaptive parallel groups design, comparing peritoneal and wound irrigation with NaOCl/HOCl (50/50ppm) solution to irrigation with Ringer’s solution. The primary endpoint of the study is the SSI rate within 30 days postoperatively. Since there is no data on incidence rates from randomized clinical trials, the rates for sample size calculation were estimated according to the clinical experience at our institution. Therefore, the study design includes one unblinded look at the data by a second statistician, which will be performed after half of the patients reached the primary endpoint. This interim information will be used to check the assumptions and if needed, the sample size will be adjusted. The O’Brien-Fleming spending function is used to determine the efficacy test boundary and the non-binding futility boundary. The one-sided z-test (Group sequential test of two proportions) at the 2.5% significance level with a total of two looks at the data will have overall 80% power.DiscussionThe results of this study will provide high-level evidence for future research and clinical recommendations regarding the use of NaOCl/HOCl solution in abdominal surgery and provide the participating patients the opportunity of a potentially improved treatment.Trial registrationGerman Clinical Trials Register (DRKS) DRKS00028037. Registered on 27 May 2022.

Collapsed Woman With a D-Shaped Left Ventricle on Echocardiogram

A 45-year-old woman presented to the emergency department with unwitnessed out-of-hospital cardiac arrest with asystole rhythm. After intubation, transesophageal echocardiography was performed to search for possible etiologies of cardiac arrest. It showed a D-shaped left ventricle at the midventricular level in the transgastric short-axis view (Figure A and Video, available at http://www.annemergmed.com). After the return of spontaneous circulation, transesophageal echocardiography revealed the resolution of the D-shaped left ventricle (Figure B). Dilated right ventricle because of cardiac arrest. The right ventricle to left ventricle ratio was described as an echocardiographic sign suggesting pulmonary embolism with high specificity in previous studies.1Fields J.M. Davis J. Girson L. et al.Transthoracic echocardiography for diagnosing pulmonary embolism: a systematic review and meta-analysis.J Am Soc Echocardiogr. 2017; 30: 714-723.e4Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar In our case, right ventricle dilation with septal flattening was also observed during resuscitation, which returned to normal size after the return of spontaneous circulation. In Aagaard's porcine studies,2Aagaard R. Caap P. Hansson N.C. et al.Detection of pulmonary embolism during cardiac arrest—ultrasonographic findings should be interpreted with caution.Crit Care Med. 2017; 45: e695-e702Crossref PubMed Scopus (27) Google Scholar,3Aagaard R. Granfeldt A. Bøtker M.T. et al.The right ventricle is dilated during resuscitation from cardiac arrest caused by hypovolemia: a porcine ultrasound study.Crit Care Med. 2017; 45: e963-e970Crossref PubMed Scopus (32) Google Scholar the right ventricle size showed no correlation with the causes of arrest. The right ventricle dilation might be inherent to cardiac arrest. Our case supported Aagaard’s studies; therefore, the dilated right ventricle noted on the echocardiography during resuscitation must be interpreted cautiously. Other differential diagnoses should be considered if the dilated right ventricle resolves after the return of spontaneous circulation. In patients with cardiac arrest, thrombus visualized in the proximal pulmonary arteries or right heart might be a more specific sign to diagnose pulmonary embolism and guide further treatment, such as thrombolytic therapy.4Konstantinides S.V. Meyer G. Becattini C. et al.2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).Eur Heart J. 2020; 41: 543-603Crossref PubMed Scopus (1340) Google Scholar Gastric ulcer perforation was diagnosed following the return of spontaneous circulation by computed tomography. Gastrorrhaphy and drainage of intra-abdominal abscess were done; however, the patient died the next day because of a profound septic shock. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0ODMwZGY4ZmNmZjg3MWZkNjRiYzVkNTgyMjQ1YTNhNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwOTg5Mzc1fQ.GE5j2RbdtAaHLdnx_AuVeAXfSftnIEpj1OAn9NZU9Stpu06w5LMVtZlgBhaB1tMFs6TOjMwr5LfsP17MhOD7AgBQr4O2BAy1vl0OVBHuhL5TuNK8RFAIVShVmQL_BYFiB4Py1xh8kiU5JsL9kuInpRDAEX4P1ANaxTL9CyTD4X3O9sFEHJLh6LgERT2fq6XjhXu3qODqLCmCDR5S7EOiP8HuU5Mt_PONO5bLGStTYYHOK1vIP7OlT_nLlacBrdeUxJqIHmLdtMZCEkZLFAPedhLGI0Tok-ncrbC-qlUnk1JI2PIYwPtgdKEJrxh6SHIK4D0haEmqAqE7Fbj6EggPDw Download .mp4 (2.92 MB) Help with .mp4 files VideoThe transesophageal echocardiography showing a D-shaped left ventricle at the midventricular level in the transgastric short-axis view during resuscitation, which turned back to a normal shape after the return of spontaneous circulation was achieved.

A Retrospective Comparative Study Assessing Patients With Acute Appendicitis During the Pre and Through Lebanese Financial Crisis.

IntroductionIn the past three years, Lebanon, a country located in the Middle East, has faced a severe financial crisis. This crisis had many effects on several sectors in Lebanon, including the healthcare sector. The authors expected an increase in the rate of complicated appendicitis after the crisis due to the shortage of medical supplies. The aim of the study was to compare the rate of complicated acute appendicitis before and after the Lebanese crisis.MethodsThe study included two groups of patients with acute appendicitis. The first group included patients admitted in the period between November 2018 and November 2019 (before the crisis). The second group included patients admitted between November 2020 and November 2021 (during the crisis). The data were collected retrospectively and analyzed using SPSS software (version 25.00) (SPSS Inc., Chicago, IL). Ethical approval was obtained and the study was registered at Al Zahraa hospital, University Medical Center in Beirut, Lebanon.ResultsThe study included 49 patients in the first group (before the crisis) and 46 patients in the second group (after the crisis). The percentage of complicated appendicitis has increased from 22.4% before the crisis to 28.3% during the crisis. The study showed a statistically significant difference between the two groups in the white blood cell count (10,831 versus 7180 cu.mm, respectively, p=0.006), the operating time (59.9 versus 79.0 minutes, respectively; p=0.004), the need to obtain an intra-peritoneal swab for bacterial culture (83.7% versus 58.7%, respectively; p=0.007), and the need for intra-abdominal abscess drainage (6.1% versus 28.3%, respectively; p=0.004). There were no significant differences in the demographics, the duration of postoperative antibiotic use, the duration of stay in the hospital, and the postoperative complications in the first month following surgery.ConclusionDue to the decreased financial income, the high cost of medical care during the Lebanese crisis, and the delay of patients’ presentation to the hospital, the rate of complicated appendicitis increased during the crisis.

High complication rate in Crohn’s disease surgery following percutaneous drainage of intra-abdominal abscess: a multicentre study

IntroductionIntra-abdominal abscesses complicating Crohn’s disease (CD) present an additional challenge as their presence can contraindicate immunosuppressive treatment whilst emergency surgery is associated with high stoma rate and complications. Treatment options include a conservative approach, percutaneous drainage, and surgical intervention. The current multicentre study audited the short-term outcomes of patients who underwent preoperative radiological drainage of intra-abdominal abscesses up to 6 weeks prior to surgery for ileocolonic CD.MethodsThis is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing ileocolic resection for primary or recurrent CD from June 2018 to May 2019. The outcomes of patients who underwent radiological guided drainage prior to ileocolonic resection were compared to the patients who did not require preoperative drainage. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes.ResultsAmongst a group of 575 included patients who had an ileocolic resection for CD, there were 36 patients (6.2%) who underwent abscess drainage prior to surgery. Postoperative morbidity (44.4%) and anastomotic leak (11.1%) were significantly higher in the group of patients who underwent preoperative drainage.ConclusionsPatients with Crohn’s disease who require preoperative radiological guided drainage of intra-abdominal abscesses are at increased risk of postoperative morbidity and septic complications following ileocaecal or re-do ileocolic resection.

A STUDY BETWEEN PERCUTANEOUS ASPIRATION AND PIGTAIL DRAINAGE IN 70 CASES OF LIVER ABSCESS

INTRODUCTION: Liver abscess, both amoebic and pyogenic, continue to be an important cause of morbidity and mortality in tropical countries. nd India has the 2 most burden of liver abscess amongst all the other countries. The advances in radiology like ultrasonography (USG) and CT-scan resulted in introduction of radiological guided aspiration and drainage of intra-abdominal abscesses as many cases are refractory to medical therapy. AIMS AND OBJECTIVES:To evaluate: demographic prole, etiology, clinical presentation and its management. MATERIALS AND METHODS: Study size and period: 70 cases, March 2021 – 2022 Study conducted at: S.V.PHOSPITAL, Ahmedabad Needle aspiration Guidelines: abscess size &gt;5cm or &gt;65cc volume Pig Tail Catheter drainage Guidelines: abscess size &gt;8 cm or &gt;120cc volume. USG done: on Day 1,3,7,30. Patients above 18 years and willing for long follow-up were included in study. Regular follow up with USG on every visit of the patient was done. RESULTS: The mean hospital stay of Percutaneous aspiration (2.8 days) was less as compared to pigtail drainage (4.6 days) and hence the patient compliance is more in aspiration. But for the complete resolution of abscess cavity especially for large abscesses pigtail drainage offers better advantage than percutaneous needle aspiration provided the cavity is adequately liquied. CONCLUSION: Percutaneous needle aspiration is minimally invasive and readily acceptable but not useful in large abscess. And pigtail catheter drainage of abscess under USG guidance is better, safe and effective in larger abscesses but required longer hospital stay. As there is no signicant difference in cavity resolution rate, Both Procedures could be used with equal efcacy in properly selected cases.

Personalized Health Care Technology in Managing Postoperative Gastrointestinal Surgery Complications: Proof of Concept Study

Background: Advances in three-dimensional (3D) printing technology have allowed the development of customized medical devices. Endoscopic internal drainage (EID) is a novel method to facilitate drainage of an abscess cavity into the lumen of the gastrointestinal tract by placing a double pigtail biliary stent through the fistula opening, originally designed for biliary drainage. They are available in manufacture-determined sizes and shapes. The aim of this study is to explore the feasibility of 3D printing personalized internal drainage stents for the treatment of leaks following gastrointestinal surgery over a sequential period. Methods: We retrospectively identified patients who underwent gastrointestinal anastomotic surgery complicated by postoperative leaks and underwent serial EID for treatment. Computerized Tomography scans were reviewed over a period of time, abscess cavity dimensions and characterizations were evaluated, and 3D reconstructions were obtained. The stents were designed, their shape and size were customized to the unique dimensions of the abscess and lumen of the patient. Stereolithography (SLA) 3D printing technique was used to produce the stents. Results: A total of 8 stents were produced, representing 3 patients. These stents corresponded to 2 or 3 stents per patients. Each patient underwent several endoscopic treatments, before resolution of leak. Conclusions: Customized stents may improve drainage of intra-abdominal abscesses after gastrointestinal surgery, if based on unique anatomy. This proof-of-concept study is a real-world application of personalized health care, which introduces the novel description of customizable 3D printed stents to manage complications following gastrointestinal surgery and may advance therapy for this complex clinical condition. Research Ethics Committees (REC) number is A-2021-012.

P265 Open approach for ileocolic resection in Crohn’s disease in the era of minimally invasive surgery: indications and perioperative outcomes in a referral centre

Abstract Background Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in patients with Crohn’s disease (CD) and it is safe and feasible even in complex cases. However, an open approach is still required, but indications to open ileocolic resection for CD are not well described. Methods All consecutive adult patients with CD who underwent elective ileocolic resection in the Departments of Colon and Rectal Surgery at Mayo Clinic Rochester, Minnesota and Jacksonville, Florida between September 2014 and March 2021 were included and divided into “open” and “MIS” groups. Open approach was defined as upfront laparotomy, MIS included laparoscopic and robotic approaches, and conversion was defined as incision made earlier than planned. Indications to open approach were retrospectively reviewed by two authors, and any incongruity was resolved. Analogous indications were also assessed in the MIS group, as appropriate. Indications, baseline, perioperative characteristics, and short-term postoperative outcomes were compared between open and MIS. Results Among 319 ileocolic resections for CD, 45 (14.1%) were open and 274 (85.9%) MIS. Indications for open approach were severe disease, adhesions at previous surgery, history of abdominal sepsis, multifocal and extensive disease, abdominal wall involvement, concomitant open procedures, small bowel dilatation, and anaesthesiologic contraindications (Table 1). In addition, two or more of the above indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p&amp;lt;0.001). Compared to MIS patients, patients undergoing open ileocolic resection were older, with longer CD duration, more previous surgery and preoperative intra-abdominal abscess drainage (Table 2). Nine patients were converted in the MIS group (3.3%). Intraoperatively, open group had more adhesiolysis ≥45 min, more intraoperative complications, more blood loss, more primary stoma, less anastomosis, and longer operative time (Table 3). Postoperatively, they had more overall postoperative complications, ileus, surgical site infections, dehydration, vascular thromboembolism, higher severity by Clavien-Dindo classification, and longer length of stay (Table 4). Conclusion Overall rate of open approach ileocolic resection for CD was 14 % during a 7-years period in a referral centre. Open approach was the only operation performed in cases of abdominal wall involvement, concomitant open procedures, and anaesthesiologic contraindication. In addition, the presence of at least two indications,predicting high technical complexity, may be considered as a no-go for the MIS approach in ileocolic resections for CD.

Antibiotic resistance is common in the cultures of intraabdominal abscess drainage after appendectomy

IntroductionIntraabdominal abscesses (IAA) are a common complication following appendectomy. Empiric antibiotic regimens may fail to prevent IAA due to changes in bacterial resistance. We aim to describe the bacteriology of pediatric patients requiring drainage of an IAA after an appendectomy for appendicitis. MethodsWe performed a retrospective study of patients ≤18 years who underwent percutaneous drainage of an IAA following appendectomy a single U.S. children's hospital between 2015 and 2018. Patient demographics, appendicitis characteristics, antibiotic regimens, and culture data were collected. ResultsIn total, 71 patients required drainage of an IAA of which 48 (67%) were male, the average age was 9.81 (SD 3.31) years and 68 (95.7%) having complicated appendicitis. Ceftriaxone/metronidazole was the most common empiric regimen prior to IAA drainage occurring in 64 (90.1%) patients. IAA cultures isolated organisms in 34 (47.9%) patients. Of those with positive cultures, 17 (50%) cases demonstrated an antimicrobial resistant organism. Most notably, 20% of Escherichia coli was resistant to the empiric regimen. Empiric antimicrobial regimens did not appropriately cover 92.3% of Pseudomonas aeruginosa cultures or 100% of Enterococcus species cultures. Antimicrobial regimens were changed following IAA drainage in 30 (42.2%) instances with 23 (32.4%) instances due to resistance in culture results or lack of appropriate empiric antimicrobial coverage. ConclusionsIAA culture data following appendectomy for appendicitis frequently demonstrates resistance to or lack of appropriate coverage by empiric antimicrobial regimens. These data support close review of IAA culture results to identify prevalent resistant pathogens along with local changes in resistance. Level of evidenceLevel III

S2946 A Rare Case of COVID-19 Infection Presenting With Devastating Intestinal Perforation Requiring Emergent Surgical Intervention: A Case Report

Introduction: COVID-19 pandemic is believed to be a systemic disease that affects not only the lungs but also other vital organs however, current available literature mainly focuses on acute respiratory symptoms. Symptoms include fever, myalgia and dyspnea. However gastrointestinal (GI) symptoms were reported in 3-50% of cases, including nausea, vomiting, abdominal pain, and diarrhea. Here we report a case of COVID-19 presenting with intestinal perforation. Case Description/Methods: 52-year-old female with a remote history of Roux-en-Y gastric bypass surgery who was diagnosed with COVID-19 three days prior to admission presented with epigastric pain, nausea, vomiting, and constipation for 2 days. Vital signs were normal. Laboratory workup was remarkable for non-anion gap metabolic acidosis and elevated inflammatory markers. Chest X-Ray showed air under the diaphragm. Abdominal CT scan showed pneumoperitoneum in the right subdiaphragmatic and mid abdomen/pelvis. Surgery was consulted and patient underwent emergent diagnostic laparoscopy and subsequent exploratory laparotomy with findings of large perforation at gastrojejunostomy, Intra-abdominal abscess. Patient underwent revision of gastrojejunostomy, drainage of intra-abdominal abscess with perotinel lavage. Intraabdominal cultures isolated Klebsiella pneumonia, Citrobacter freundii, Prevotella melaninogenica,Enterococcus faecalis and several Candida. Blood cultures isolated Clostridium subterminale bacteremia. Patient was started on IV antibiotics. The patient was discharged to be followed by surgery for resolution of symptoms and drainage removal. Discussion: Gastrointestinal symptoms of COVID-19 disease were reported in accumulated literature. Moreover, COVID-19 virus has been isolated in stool specimens. The question becomes, are those GI manifestations considered part of systemic symptoms of an airborne infection, or COVID-19 itself can potentially be transmitted feco-orally. Pathophysiology is yet unclear, suggested hypothesis includes direct invasion of intestinal cells by the SARS-CoV-2 RNA, as GI cells express ACE2. Another theory is imbalance of autonomic innervation of GI tract given the neuroinvasive tendency of COVID-19. It is not clear whether patients with past GI diseases like inflammatory bowel disease, peptic ulcers, and prior GI surgery are more prone to GI complications. This case highlights GI complications in Covid-19-positive patients especially those with GI history for early diagnosis and prevention of possible complications.Figure 1.: Figure (A): CT shows free air, Figure (B): CT abdomen shows air-fluid level, Figure (C): Abdominal X-ray shows air under the diaphragm.

Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease.

BackgroundIn patients with active Crohn’s disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD.MethodsA multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1–14 days, 15–30 days and more than 30 days) for comparison of outcomes.ResultsThe cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24–44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6–15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042).ConclusionSmoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.

Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series.

Aim:Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS).Methods:All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence.Results:Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9).Conclusions:Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.

Factors influencing cumulative radiation dose from percutaneous intra-abdominal abscess drainage in the setting of inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) are at risk for intra-abdominal abscesses requiring CT-guided drainage. These patients are at baseline risk of high cumulative radiation exposure from imaging, which may be exacerbated by CT-guided drainage. This study aimed to determine the radiation dose associated with percutaneous drainage in the setting of IBD and identify risk factors associated with high exposure. An IRB-approved single-center retrospective study was performed to identify patients with IBD who underwent percutaneous abscess drainage over a 5-year period. An episode of drainage was defined from drain placement to removal, with all intervening procedures and diagnostic CT scans included in the cumulative radiation dose. The mean cumulative effective dose for a drainage episode was 47.50mSv. The mean duration of a drainage episode was 68.7days. Patients with a cumulative dose greater than 50mSv required higher number of follow-up visits compared to patients with less than 50mSv (6.9 vs. 3.5, p = 0.003*). Patients with higher cumulative dose were also more likely to require drain upsize (54% vs. 13%, p = 0.01*) or additional drain placement (63% vs 24%, p = 0.03*) compared to patients with lower dose. Intra-abdominal abscess drainage may be associated with significant cumulative radiation exposure. Requirement of drain upsizing or additional drain placement were associated with higher cumulative radiation dose, which may be related to more severe underlying inflammatory bowel disease.

S1525 Bilothorax: A Rare Complication of Transarterial Chemoembolization of Hepatocellular Carcinoma

INTRODUCTION: A Bronchobiliary fistula (BBF) is an abnormal communication between the bronchial system and the biliary tree. When this occurs, the direct flow of bile from the biliary system to the pleural space can lead to increased lung parenchymal irritation and subsequent inflammatory response with coughing up of bile, also known as bilioptysis. CASE DESCRIPTION/METHODS: A 71-year-old man presented with a five-day history of coughing up greenish watery fluid. He was diagnosed with Hepatocellular Carcinoma years prior and underwent transarterial chemoembolization a month prior. Work up revealed polymicrobial bacteremia and computed tomography (CT) of the chest revealed right lower lobe patchy consolidations. He had minimal improvement with aggressive antibiotics thus repeat CT was done which revealed a right lower lobe abscess immediately adjacent to the hepatic tumor along the liver (Figure 1). Subsequent hepatobiliary iminodiacetic acid scan then confirmed a communication between the biliary tract and lungs as evidenced by leakage of the radiotracer in the bronchi and trachea (Figure 2). Symptoms resolved after targeted antibiotic therapy, fistula resection, adhesiolysis, and intraabdominal abscess drainage. Repeat Imaging showed resolution of bilothorax (Figure 3). DISCUSSION: Bronchobiliary fistula is the most reported cause of Bilothorax. The mechanism of BBF remains unclear however, biliary obstruction and adhesions may be contributing factors. In our case, the common bile duct and pancreatic duct were likely dilated due to a mechanical effect from a mass in the head of the pancreas or ductal strictures from radioablative therapy. Local inflammation causes adhesions from multiple TACE procedures which promotes recurrent sub-diaphragmatic collections. The increased intraluminal pressure in the biliary system with an adjacent hepatic abscess may have caused diaphragmatic invasion with rupture into the pleural space and subsequent erosion into the bronchial tree causing bilothorax and eventual bilioptysis. Resection of the tumor and fistula tract is recommended but it is associated with a high mortality rate. Decompression of the biliary system can be achieved by endoscopic placement of biliary stents, percutaneous transhepatic biliary drainage or percutaneous drainage of hepatic collections. In cases of recurrent BBF despite non-surgical interventions, percutaneous bronchial embolization shows promise with closure of the distal bronchi near abscess.Figure 1.: Computed tomography of the chest: Right lower lobe pneumonia with air fluid levels indicating an abscess (arrow) immediately adjacent to a hepatic tumor with abscess (arrowhead) along the dome of the liver.Figure 2.: Hepatobiliary iminodiacetic acid scan showing radiotracer uptake in the bronchi and trachea. This is consistent with a fistula between the hepatic and pulmonary abscess.Figure 3.: Computed tomography of the chest demonstrating radiologic resolution of findings after surgical intervention.

Alternative uses of lumen apposing metal stents.

The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.

974 SUCCESSFUL ENDOSCOPIC MANAGEMENT OF GASTRIC SLEEVE LEAK COMPLICATED BY ABSCESS AND TRANSFASCIAL DRAINAGE

A 66 year-old female underwent a sleeve gastrectomy complicated by postoperative bleed requiring laparotomy. She developed a postoperative sleeve dehiscence with intraabdominal abscess and transfascial drainage. Surgical options were morbid and included gastric resection or gastrointestinal diversion. As the patient was stable, endoscopic therapy was attempted. Initial upper endoscopy revealed a proximal staple line dehiscence, and a large abdominal abscess that could be traversed with the scope out of the midline wound. Endoscopic debridement was followed by negative pressure would therapy (NPWT) in an endoluminal fashion (eVAC). Transoral eVAC placement across the dehiscence into the abscess was placed in communication with NPWT from external wound. Serial treatments were completed until the abscess cavity and staple line closed. Subsequent upper GI study did not demonstrate ongoing leak and diet was resumed. Endoscopic management of gastric sleeve leaks is a safe and reliable technique to manage enteric defects. Though endoluminal vacuum therapy requires inpatient hospitalization, it can successfully close gastric sleeve leaks, especially in combination with abdominal NPWT in the setting of transfascial abscess drainage. This endoscopic therapy avoids morbid surgical operations.

Use of Tissue Plasminogen Activator in Abdominal Abscesses in Children-A Single-Center Randomized Control Trial.

To establish the efficacy of once-per-day intracavitary tissue plasminogen activator (tPA) in the treatment of pediatric intra-abdominal abscesses. A single-center prospective, double-blinded, randomized controlled trial of the use of intracavitary tPA in abdominal abscesses in children. Patients were randomized to either tPA-treatment or saline-treatment groups. Primary outcome was drainage catheter dwell (hours). Secondary outcomes were length of hospital stay, times to discharge, clinical and sonographic resolution, and adverse events (AEs). Twenty-eight children were randomized to either group (n = 14 each). Demographics between groups were not significantly different (age P = .28; weight P = .40; gender P = .44). There were significantly more abscesses in the tPA-treated group (P = .03). Abscesses were secondary to perforated appendicitis (n = 25) or postappendectomy (n = 3). Thirty-four abscesses were drained, 4 aspirated, 3 neither drained/aspirated. There was no significant difference in number of drains (P = .14), drain size (P = .19), primary outcome (P = .077), or secondary outcomes found. No procedural or intervention drug-related AEs occurred. No patient in the saline-treated group required to be switched/treated with tPA. No significant difference in the length of catheter dwell time, procedure time to discharge, or time to resolution was found. Intracavitary tPA was not associated with morbidity or mortality. The results neither support nor negate routine use of tPA in the drainage of intra-abdominal abscess in children. It is possible that a multicentre study with a larger number of patients may answer this question more definitively.

Abstract No. 576 Factors influencing cumulative radiation dose for percutaneous intra-abdominal abscess drainage in patients with inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) are at risk for penetrating disease complications and intra-abdominal abscesses requiring CT-guided drainage. These patients are at baseline risk of high cumulative radiation exposure from diagnostic imaging, which may be exacerbated by CT-guided drainage. This study aimed to determine the radiation dose associated with percutaneous drainage and follow-up in the setting of IBD and identify risk factors associated with high exposure. An IRB-approved single-center retrospective study was performed to identify patients with IBD who underwent abscess drainage over a five-year period (2013-2018). An episode of drainage was defined from drain placement to removal, with all procedures and diagnostic CT scans included in the cumulative radiation dose. Radiation dose was reported by a monitoring database, Radimetrics (Whippany, NJ). Patients were divided into cohorts based on a cumulative effective dose of 50 mSv. Statistical analysis was performed with GraphPad Prism 8 (La Jolla, CA). Patient demographics (n = 40) are reported in Table 1. The mean cumulative effective dose for the percutaneous drainage episodes was 47.50 mSv. The mean total duration of drainage episodes was 68.7 days, with an average of 4.48 CT scans or repeat interventions during that period. Patients with a total dose greater than 50 mSv (group A) required higher number of follow-up visits compared to patients with less than 50 mSv (group B) (6.9 vs. 3.5, P = 0.003). Group A patients were more likely to require drain upsize (54% vs. 13%, P = 0.01) or repeat drain placement (63% vs. 24%, P = 0.03) after initial drainage compared to group B patients. Group B patients had significantly higher number of drains placed at initial drainage compared to group A (1.8 vs. 1.2, P = 0.002). Intra-abdominal abscess drainage may be associated with significant cumulative radiation exposure. Drain upsizing, fewer initial drains, and repeat drain placement were associated with higher dose, which demonstrates the importance of catheter caliber selection and catheter positioning at the time of initial drainage to potentially reduce overall radiation exposure.Table 1Male:female ratio20:20Average age (years, mean ± SD)42.83 ± 16.65Crohn’s disease:ulcerative colitis33:7Drainage of postoperative complication24/40 (53%) Open table in a new tab