Size Of Fluid Collection Research Articles

Thirty-day prevalence and clinical impact of fluid collections at the resection margin after distal pancreatectomy: Follow-up of a multicentric randomized controlled trial

BackgroundPostoperative fluid collections at the resection margin of the pancreatic stump are frequent after distal pancreatectomy, yet their clinical impact is unclear. The aim of this study was to assess the 30-day prevalence of postoperative fluid collections after distal pancreatectomy and the factors associated with a clinically relevant condition. MethodsPatients enrolled in a randomized controlled trial of parenchymal transection with either reinforced, triple-row staple, or ultrasonic dissector underwent routine magnetic resonance 30 days postoperatively. Postoperative fluid collection was defined as a cyst-like lesion of at least 1 cm at the pancreatic resection margin. Postoperative fluid collections requiring any therapy were defined as clinically relevant. ResultsA total of 133 patients were analyzed; 69 were in the triple-row staple transection arm, and 64 were in the ultrasonic dissector transection arm. The overall 30-day prevalence of postoperative fluid collections was 68% (n = 90), without any significant difference between the two trial arms. Postoperative serum hyperamylasemia was more frequent in patients with postoperative fluid collections than those without (31% vs 7%, P = .001). Among the postoperative fluid collection population, an early postoperative pancreatic fistula (odds ratio 14.9, P = .002), post pancreatectomy acute pancreatitis (odds ratio 12.7, P = .036), and postoperative fluid collection size larger than 50 mm (odds ratio 6.6, P = .046) were independently associated with a clinically relevant postoperative fluid collection. ConclusionPostoperative fluid collections at the resection margin are common after distal pancreatectomy and can be predicted by early assessment of postoperative serum hyperamylasemia. A preceding pancreatectomy acute pancreatitis and/or postoperative pancreatic fistula and large collections (>50 mm) were associated with a clinically relevant postoperative fluid collection, representing targets for closer follow-up or earlier therapeutic interventions.

Assessing Intra-abdominal status for clinically relevant postoperative pancreatic fistula based on postoperative fluid collection and drain amylase levels after distal pancreatectomy.

The aim of this study was to evaluate the intra-abdominal status related to postoperative pancreatic fistula by combining postoperative fluid collection and drain amylase levels. We retrospectively reviewed the data of 203 patients who underwent distal pancreatectomy and classified their postoperative abdominal status into four groups based on postoperative fluid collection size and drain amylase levels. We also evaluated the incidence of clinically relevant postoperative pancreatic fistula in each group according to C-reactive protein values. The incidence of clinically relevant postoperative pancreatic fistula in the entire cohort (n = 203) was 28.1%. Multivariate analysis revealed that postoperative fluid collection, drain amylase levels, and C-reactive protein levels are considerable risk factors for clinically relevant postoperative pancreatic fistula. In the subgroup with large postoperative fluid collection and high drain amylase levels, 65.9% of patients developed clinically relevant postoperative pancreatic fistula. However, no significant difference was observed in C-reactive protein levels between patients with clinically relevant postoperative pancreatic fistula and those without it. In contrast, in the subgroup with a large postoperative fluid collection size or a high amylase level alone, a significant difference was observed in C-reactive protein values between the patients with clinically relevant postoperative pancreatic fistula and those without it. Postoperative fluid collection status and the C-reactive protein value provide a more precise assessment of intra=abdominal status related to postoperative pancreatic fistula after distal pancreatectomy. This detailed analysis may be a clinically reasonable approach to individual drain management.

S1075 Early (<4 Weeks) vs Standard (≥ 4 Weeks) Endoscopic Drainage of Pancreatic Walled-Off Fluid Collections: A Systematic Review and Meta-Analysis

Introduction: Previous studies have demonstrated that the ideal time for drainage of walled off pancreatic fluid collections is 4-6 weeks after its development. However, some pancreatic collections, including pancreatic walled-off necrosis (WON), require earlier drainage. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. The aim of this study was to evaluate clinical outcomes and safety of endoscopic ultrasound (EUS) - guided drainage of pancreatic fluid collections < than 4 weeks after its development compared to ≥4 weeks after its development. Methods: Search strategies were developed for PubMed, EMBASE, and Cochrane Library databases from inception through June 2022 in accordance with PRISMA and MOOSE guidelines. Outcomes of interest included technical success defined as successful endoscopic placement of LAMS, clinical success defined as reduction in cystic collection size, and procedure-related adverse events. A random effects model was used for analysis and results were expressed as odds ratio (OR) along with 95% confidence interval (CI). Results: A total of 6 studies (630 patients) were included in our final analysis where 182 patients (28.9%) were enrolled in the early drainage cohort and 448 (71.1%) patients in the standard drainage cohort. Age ranges were similar between groups. Alcohol was the main driver of acute pancreatitis. Infection was the most common indication for pancreatic drainage (42.6%). The mean fluid collection size was 143.4 ± 18.8 mm for the early cohort vs 128 ± 19.7 mm for the standard cohort. Most fluid collections were located in the body of the pancreas (86.7%). Overall, technical success favored standard drainage over early drainage (OR 0.01; 95% CI 0.00 – 0.15; P=0.001). Clinical success also favored standard drainage over early drainage (OR 0.46; 95% CI 0.16 – 1.32; P=0.03). With regards to adverse events, there was no statistically significant difference in overall adverse events (OR 0.76; 95% CI 0.42 – 1.39; P=0.56) or mortality (OR 1.14; 95% CI 0.29 – 4.48; P=0.23). Hospital stay was longer for patients undergoing early drainage compared to standard drainage (23.7 vs 16.0 days, respectively). (Figure) Conclusion: Compared to early drainage (< 4 weeks), endoscopic drainage of pancreatic fluid collections is significantly more efficacious when performed at least 4 weeks after development, with a shorter hospital length of stay. Therefore, pancreatic fluid collections should ideally be drained 4 weeks after development.Figure 1.: Forrest plot showing pooled rates of clinical success.

863 Peri-Implant Fluid Collection in Breast Reconstruction and Aesthetic Surgery

Abstract Introduction Peri-implant fluid more than 6 months from surgery is a known complication of breast surgery.Differential diagnosis includes infection, inflammation,implant rupture and haematoma.Other than infection raised no concern until the identification of Breast Implant Associated Anaplastic Large Cell Lymphoma(BIA-ALCL). Method Retrospective electronic data collection for women 18 years or older who met the following inclusion criteria:(a)oncoplastic and/or cosmetic reconstructive surgery with placement of implant(b)peri-implant fluid collection after 6-36 months. Results In total,17 women with implants with a mean age of 56 years were included in the study.The mean time between reconstructive surgery and the peri-implant fluid collection was 23 months.The median peri-implant fluid collection size was 143 ml.14 of the 17 peri-implant fluid collections were benign.12 of 14 had polyurethane-coated textured implants.4 of the 17 were BIA-ALCL. Conclusions The current literature suggests that late peri-implant seromas arise from friction as the implant moves within the cavity and that this friction is increased with textured rather than smooth implants.In our unit 12/14 of the benign collections appeared in reconstructions with polyurethane implants.Furthermore,BIA-ALCL should always be considered in this situation and aspirate should be sent for cytology.Is this change in polyurethane implants a new entity?

Computed tomography in planning of the treatment of complications after pancreatic surgery

Aim. To evaluate opportunity of computed tomography in diagnosis and decision making in patients with pancreatic surgery complications and possibility of interventional procedures in its treatment.Materials and methods. 50 patients underwent pancreatic surgery in 2018-2020 (45 Whipple procedure and 5 distal pancreatectomies). 45 patients underwent computed tomography in post-surgery course. The complications occur in 29 patients; complications were found by computer tomography in 26 patients.Results. The most frequent complication was pancreatic fistula (24%) in typical places: upper edge of the pancreatojejunostomy (25%) and in the bed of the resected pancreatic head (50%). Delineated fluid collections on computed tomography scans were more prevalent in patients with complicated course (57.9% vs. 26.3%). The average size of fluid collections was increased in the group of complicated courses (51,9 × 28,1 mm vs. 42,2 × 20, 6 mm). Interventional procedures were performed in 18 patients (62% of complicated patients). The average number of such interventions per patient was 2.95. Using interventional techniques as the only method of surgical treatment, 13 patients were cured (50% of complicated patients). In 14 patients, interventions were planned and performed based on control computed tomography. Postoperative bleedings were detected in 8 patients (16%). In 4 cases it revealed ongoing bleeding by computer tomography, in 3 cases – completed, which allowed us to determine further treatment tactics.Conclusion. Performing computed tomography after pancreatic surgery allows to identify postoperative complications before their clinical manifestation and plan their treatment. The optimal time for performing computed tomography is 5–6 days after surgery. Performing CT angiography for suspected bleeding in some cases allows to avoid invasive angiography and choose the method of endovascular hemostasis in appropriate situations. The combination of various interventional techniques allows to avoid relaparotomy in most patients with intraabdominal complications.

3029 Complications from Hypertriglyceridemia-Induced Acute Pancreatitis

INTRODUCTION: Pancreatitis accounts for 275,000 hospital admissions annually. While alcohol consumption and gallstones are responsible for the majority of cases, hypertriglyceridemia accounts for only 7%. Most are treated successfully with intravenous hydration, pain control and triglyceride-lowering agents but complications do occur 15% of the time. We present a case of one such complication. CASE DESCRIPTION/METHODS: A 40-year-old previously healthy female presented with a 12-hour history of nausea and severe LUQ abdominal pain. She was admitted with acute pancreatitis secondary to hypertriglyceridemia. Labs revealed a lipase of 3653 U/L and triglycerides of 6160 mg/dL. Abdominal CT scan confirmed acute pancreatitis. She was treated supportively with aggressive IV hydration. Repeat imaging 5 days later showed a large fluid collection inferior to the gastric antrum, an extensive amount of free fluid layering the abdomen and a small to moderate left pleural effusion. Eventually her symptoms due to the evolving pseudocyst improved and she was discharged on day 22 with Fenofibrate and Omega-3-Acid Ethyl Esters. Six days later she was admitted for sepsis secondary to infected pancreatic pseudocyst. CT showed an extensive multi-locular fluid collection and worsening left pleural effusion. Ultrasound-guided drainage was performed and cultures reported E. coli. Antibiotics were tailored but patient remained hypotensive and tachycardic. At that point the patient underwent a diagnostic laparoscopy, which was converted to Roux En Y pancreatic cystjejunostomy for continuous drainage. Repeat imaging on post-op day one demonstrated an interval decrease in size of fluid collection. Eventually the patient was discharged home in stable condition. DISCUSSION: While pancreatitis due to hypertriglyceridemia remains common, life threatening complications are rare. Aggressive supportive care is the mainstay of therapy with early surgical intervention as needed.

Incidence of benign and malignant peri-implant fluid collections and masses on magnetic resonance imaging in women with silicone implants.

BackgroundTo assess the incidence of benign and malignant peri‐implant fluid collections and/or masses on magnetic resonance imaging (MRI) in women with silicone implants who are being screened for silent implant rupture.MethodsThe institutional review board approved this HIPAA‐compliant retrospective study and waived informed consent. Women who underwent silicone implant oncoplastic and/or cosmetic surgery and postoperative implant‐protocol MRI from 2000 to 2014 were included. Peri‐implant fluid collections and/or masses were measured volumetrically. A benign peri‐implant fluid collection and/or mass was pathologically proven or defined as showing 2 years of imaging and/or clinical stability. A malignant peri‐implant fluid collection was pathologically proven. Incidence of peri‐implant fluid collections and/or masses and positive predictive value (PPV) were calculated on a per‐patient level using proportions and exact 95% confidence intervals (CIs). Fisher's exact test was used in the analysis to test statistical significance pre‐defined as P‐value < 0.05.ResultsA total of 1070 women with silicone implants were included (mean age, 50.7 years; range, 40.4‐53.8). Median time between reconstructive surgery and first MRI was 88.9 months (range, 0.8‐1363.3). Eighteen women (1.7%) had a peri‐implant fluid collection and/or mass: 15/18 (83.3%) had adequate follow‐up; and only 1/15 was malignant implant associated anaplastic large cell lymphoma, with a PPV of 6.7% (95% CI: 0.003‐0.0005). The median peri‐implant fluid collection size was 89 mL (range, 18‐450 mL).ConclusionPeri‐implant fluid collections and/or masses identified at silicone implant protocol breast MR imaging are rarely seen 24 months after reconstructive surgery. Image‐guided fine‐needle aspiration with flow cytometry may be warranted to evaluate for implant‐associated lymphoma.

A novel lumen-apposing metal stent with an anti-reflux valve for endoscopic ultrasound-guided drainage of pseudocysts and walled-off necrosis: A pilot study.

BackgroundPancreatic pseudocysts (PC) and walled-off necrosis (WON) are common complications of severe pancreatitis. Endoscopic ultrasound (EUS)-guided drainage has replaced surgery as the standard treatment for PC/WON. We developed a novel lumen-apposing metal stent (LAMS) with an anti-reflux valve to prevent infectious complications caused by food reflux into the cyst cavity. This retrospective study investigated the efficacy and safety of EUS-guided drainage using this LAMS.MethodsWe investigated and compared the treatment outcomes and complications rates between EUS-guided drainage using a novel LAMS (n = 10) versus plastic stents (n = 18) from December 2013 to October 2016. Technical success was defined as successful stent placement without immediate complications. Clinical success was defined as resolution of the PC/WON and disappearance of symptoms.ResultsAmong 10 patients in LAMS group, 4 patients had complicated PC and 6 patients had WON. In the plastic stent group, 15 and 3 patients had PC and WON, respectively. The median fluid collection size before treatment was 82.5 (interquartile range [IQR], 60.75–118.25) mm and 92.0 (IQR, 75.75–130.25) mm in the LAMS and plastic stent groups, respectively. There were no statistically significant differences in technical success rates (90% vs. 94.4%; p = 0.999), clinical success rates (80% vs. 77.8%; p = 0.999), and complication rates (20% vs. 27.8%; p = 0.999) between the two groups.ConclusionsTreatment outcomes of EUS-guided drainage using a novel LAMS were feasible despite the significantly high proportion of WON. The LAMS allowed acceptable treatment outcomes for EUS-guided drainage.

Endoscopic drainage of pancreatic fluid collections by use ofanovel biflanged stent with electrocautery-enhanced deliverysystem.

Endoscopic drainage of pancreatic fluid collections by use ofanovel biflanged stent with electrocautery-enhanced deliverysystem.

Tu1400 A COMPARATIVE STUDY EVALUATING LUMEN APPOSING METAL STENTS AND DOUBLE PIGTAIL PLASTIC STENTS FOR TREATMENT OF WALLED OFF NECROSIS

EUS-guided direct endoscopic necrosectomy (DEN) is effective in the management of walled off necrosis (WON), and is preferable to percutaneous and surgical approaches. Lumen apposing metal stents (LAMS) are increasingly used for DEN, however there is limited data comparing LAMS to traditional double pigtail (DP) plastic stents. To compare clinical outcomes and adverse events between LAMS and DP stents in the endoscopic management of WON. A retrospective study was conducted at an academic tertiary referral center in the United States. Subjects included patients who underwent DEN for the management of symptomatic WON from 2003-2017. Demographics, procedural and technical characteristics, and relevant clinical outcomes were recorded. Adverse events were assessed. Characteristics and clinical outcomes were compared using Fisher’s exact test and Student’s t test when appropriate. A total of 112 patients underwent DEN during the study period, of which 33 patients underwent initial LAMS placement, and 79 patients underwent initial DP placement. Mean pancreatic fluid collection size was 90.2 x 60.1 mm, and 61.8% of patients had evidence of infected pancreatic necrosis. Overall, successful resolution of the WON was seen in 90.9% of LAMS and 76.0% of DP cases (p = 0.115), and both groups required similar numbers of total procedures until resolution of the fluid collection (1.5 vs 1.5 procedures, p = 0.767). Time to resolution of the fluid collection was significantly shorter among patients who underwent initial LAMS placement compared to patients who underwent initial DP placement (76.9 vs 136.8 days, p = 0.027). Procedural failure rates were significantly higher among patients who underwent initial DP placement compared to patients who underwent initial LAMS placement (24.1% vs 6.5%, p = 0.033). Among patients who underwent initial DP placement, 5 patients required percutaneous drainage, and 9 patients required surgical necrosectomy. No patients who underwent initial LAMS placement required percutaneous drainage or surgical necrosectomy. However, overall adverse event rates were higher among patients who underwent initial LAMS placement compared to patients who underwent initial DP placement (36.4% vs 7.6%, p < 0.001). Although LAMS is associated with increased adverse event rates compared to DP placement, initial LAMS placement for endoscopic management of pancreatic fluid collections results in significantly decreased time to resolution and lower rates of procedural failure.Tabled 1Table 1: Demographicsn (%)DemographicsTotal Patients112Mean Age (± SD, yrs)52.1 (± 15.9)Female Gender43 (38.4)Etiology of Fluid Collection/PancreatitisAlcohol22 (19.8)Gallstone33 (29.7)Hypertriglyceridemia8 (7.2)Medication4 (3.6)Autoimmune2 (1.8)Idiopathic21 (18.9)Post-Pancreatectomy13 (11.7)Post-ERCP7 (6.3)Post-Colonoscopy1 (0.9)Lesion CharacteristicsLong Dimension (± SD, mm)90.2 (± 46.1)Short Dimension (± SD, mm)60.1 (± 30.2)Presence of Infection68 (61.8) Open table in a new tab

Drug-Induced Necrotizing Pancreatitis with a Focus on Canagliflozin

Introduction: Acute necrotizing pancreatitis is an inflammatory condition of the pancreas characterized by inflammation associated with pancreatic parenchymal necrosis most commonly attributed to gallstones, alcohol abuse and metabolic disorders such as hyperlipidemia and hypercalcemia. Although several drugs have been implicated in acute pancreatitis they are often overlooked. Here we present a case of necrotizing pancreatitis likely associated to canagliflozin; a new drug in the class of subtype 2 sodium-glucose transport protein inhibitors used for the treatment of type 2 diabetes mellitus (DM T2). Case: A 71 year old female with a history of DM T2 on sitagliptin-metformin 50-1000mg twice daily and canagliflozin 100mg daily (started 84days prior to presentation) presented with complaint of sharp right upper quadrant abdominal pain, radiating to her spine and right flank with severity of 9/10. She denied recent fever/chills, nausea/vomiting or night sweats. She did report a poor appetite with 20lbs weight loss over the preceding several weeks along with daily soft stools, but no melena or hematochezia. MRI abdomen revealed a 13.0cm x 5.0cm x 5.8cm air containing mass like lesion partially encasing the pancreas. The lesion was noted to be displacing the duodenum and encasing the superior mesenteric vein. These findings were most concerning for necrotizing pancreatitis although hemorrhage or neoplasm could not be excluded by the imaging. A hepatobiliary scan was also performed showing no evidence for common bile duct or cystic duct obstruction. The results of an ultrasound guided endoscopic FNA of the pancreatic lesion showed an acute inflammatory process without nuclear atypia. The patient was treated for necrotizing pancreatitis with ertapenem and subsequent repeat CT imaging of the abdomen showed interval decrease in the size of fluid collection in the pancreatic bed. Discussion: As the prevalence of DM T2 in the United States increases, the medications used to combat the disease will increase. Our case highlights canagliflozin in the treatment of DM T2 and its potential side effects. The case identifies the importance of drug-induced pancreatitis, as it is commonly neglected in patients with multiple medical comorbidities who are on numerous medications. Current literature review revealed 3 other cases of reported canagliflozin induced pancreatitis. Prompt identification can decrease morbidity and mortality in these individuals.

Endoscopic ultrasound-guided drainage of abdominal fluid collections after pancreatic surgery: Efficacy and long-term follow-up.

Endoscopic ultrasound-guided drainage (EUS-GD) of postoperative abdominal fluid collections (POFC) following pancreatic surgery is used as an alternative or complement to percutaneous drainage (PD) procedure. The present single-center retrospective study evaluates its efficacy and safety. We included consecutive cases with POFC treated by EUS-GD between September 2009 and November 2014 in our department. Technical success, long-term clinical success, recurrence rate and need for surgery were analyzed. 24 procedures in 20 patients (95 % after pancreatic resection) were assessed. Indications for surgery included tumors/lesions located in the pancreas (15/20), chronic pancreatitis (3/20) and duodenal adenoma not completely resectable endoscopically (2/20). EUS-GD was performed within a median of 30 days (IQR: 8.25) for a median fluid collection size of 72.5 mm (IQR: 46.25), requiring a mean of 1.2 sessions with placement of a mean of 2.1 plastic stents (7 Fr/10 Fr) per patient for a mean of 89 days (IQR: 127). Microbiology of aspirated fluid revealed positive cultures in 13 patients, mostly polymicrobial, isolated positive for fungal and 3 multidrug-resistant gram negative (MRGN) in 4 cases. An additional transpapillary drainage was inserted in 1/20 patients. 4/20 patients received PD, mostly before EUS-GD. Technical and clinical success was achieved in 20/20 (100 %) and 18/20 (90 %) patients, respectively, while 2 patients required re-operation. During follow-up (median 630 days after stent removal, range: 45 - 2160), recurrence occurred in 1/18 (5.5 %) patient that was referred for surgery. No death or severe adverse events were noted. EUS-GD is an effective, minimally invasive and safe method for therapy of POFC after pancreatic surgery offering long-term remission in about 95 % of cases.

P.127 Management and outcome of spontaneous sub-aponeurotic fluid collections in infants: the Hospital for Sick Children experience and review of literature

Background: Spontaneous sub-aponeurotic fluid collection (SSFC) is an uncommon and newly described entity of unknown etiology, observed in infants less than one year of age. In this paper, we report a series of 9 infants who presented to the Hospital for Sick Children with SSFC over the 2004 to 2015 period, focusing on the natural history of this rare condition. Methods: Data from the HSC was retrospectively reviewed. Patient age and gender, birth history, past medical history, laboratory findings, imaging characteristics, management, and outcome were analyzed. Results: Our case series consists of 4 males and 5 females, ranging from 5 weeks to 11 months of age. All cases of SSFC developed spontaneously over a period of days, and the infants had no history of injuries or hair manipulation. Six patients had a remote history of forceps or vacuum-assisted births. One patient experienced fluctuating fluid collection size over 4 months, but in all the cases, the collections resolved spontaneously without structural or infectious complications. Conclusions: This is the largest series describing SSFC to date, and summarizes the experience of a large academic neurosurgical center. SSFCs develop spontaneously without immediate preceding trauma, and an extensive hematology or child abuse workup is not necessary. A conservative approach with outpatient follow-up is advocated.

Risk factors for failure of percutaneous drainage and need for reoperation following symptomatic gastrointestinal anastomotic leak

BackgroundFew studies have evaluated the role of computed tomography-guided percutaneous drainage (PD) in the management of gastrointestinal (GI) anastomotic leaks. MethodsTen-year review of an interventional radiology database identified patients with symptomatic GI anastomotic leaks. Clinical, laboratory, radiographic, and operative characteristics following a technically successful PD which then failed and required reoperation for anastomotic leak were compared with those successfully treated with PD. ResultsSixty-one patients met study inclusion criteria. Fifty patients (82%) successfully underwent therapeutic PD of a perianastomotic fluid collection, with median follow-up of 16 months. Eleven patients (18%), at a median interval of 16 days, required reoperation following PD. A forward logistic regression showed cardiopulmonary disease (P = .03) and cancer surgery (P = .01) to be factors independently associated with the need for reoperation. The level of the anastomosis, initial fecal diversion/stoma, fluid collection size, and microbiology of aspirate did not predict failure of PD. ConclusionsCardiopulmonary disease and cancer surgery appear to be independent predictors for failure of PD and need for reoperation following a symptomatic GI anastomotic leak.

Mo1704 Risk Factors for Failure of Percutaneous Drainage and Need for Re-Operation Following Symptomatic Gastrointestinal Anastomotic Leak

BACKGROUND: Few studies have evaluated the role of computed tomography-guided percutaneous drainage (PD) in the management of gastrointestinal (GI) anastomotic leaks. METHODS: Ten-year review of an interventional radiology database identified patients with symptomatic GI anastomotic leaks. Clinical, laboratory, radiographic, and operative characteristics following a technically successful PD which then failed and required reoperation for anastomotic leak were compared with those successfully treated with PD. RESULTS: Sixty-one patients met study inclusion criteria. Fifty patients (82%) successfully underwent therapeutic PD of a perianastomotic fluid collection, with median follow-up of 16 months. Eleven patients (18%), at a median interval of 16 days, required reoperation following PD. A forward logistic regression showed cardiopulmonary disease (P 5.03) and cancer surgery (P 5.01) to be factors independently associated with the need for reoperation. The level of the anastomosis, initial fecal diversion/ stoma, fluid collection size, and microbiology of aspirate did not predict failure of PD. CONCLUSIONS: Cardiopulmonary disease and cancer surgery appear to be independent predictors for failure of PD and need for reoperation following a symptomatic GI anastomotic leak.

Drainage of Collections Associated with Hernia Mesh: Is it Worthwhile?

Synthetic mesh has revolutionized abdominal wall hernia repair. However, mesh infections present a clinical problem because the standard practice of surgical excision is fraught with increased morbidity. Here, single-institutional outcomes in managing mesh-related collections via percutaneous drainage are retrospectively reviewed to assess its effectiveness. A total of 21 patients underwent drainage of perimesh collections. Three types of mesh were employed: polytetrafluoroethylene (PTFE; n = 5), polypropylene (n = 14), and porcine dermal collagen (n = 3). One patient received both polypropylene and PTFE. Drainage was performed with ultrasound guidance (n = 19) or surgical drain exchange (n = 2). Mesh type, culture results, fluid collection size, and location were analyzed with respect to need for mesh excision. Sixteen of 21 patients (76%) were successfully treated with drainage. One required additional surgical capsulectomy; the mesh was salvaged. Four required mesh excision because of recurrent infection (n = 2) or lack of improvement of clinical course (n = 2). Recurrent infection occurred in six patients, with mesh salvage via conservative management or new drainage in four. Fluid cultures were positive in 68% of patients (n = 13), with Staphylococcus aureus the most common organism. Cultures did not predict mesh excision (P = .26). The PTFE excision rate trended higher compared with polypropylene (40% vs 14%; P = .27). No porcine dermal collagen mesh was excised. Neither fluid collection size nor location predicted mesh excision. Mean follow-up was 319 days (range, 6-1,406 d). Percutaneous drainage of suspected mesh-related abscess is effective. The use of PTFE mesh trended toward a higher excision rate.

Short communication: Post‐hysterectomy pelvic fluid collection: is it associated with febrile morbidity?

We evaluated the clinical significance and possible association of febrile morbidity with sonographically detected post-hysterectomy fluid collections. Transvaginal ultrasound examinations were performed to assess the presence of fluid collections and correlated to clinical data. Fluid collection was detected in 27 (64%) women at postoperative day 2, in 15 (35%) at postoperative day 7 and in 5 (12%) at the fourth to fifth postoperative week. Febrile morbidity was not related to the presence, location or size of fluid collection. Postoperative pelvic fluid collections are common sonographic findings after hysterectomy and are not associated with postoperative febrile morbidity.

Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients.

The lack of ductal continuity between a viable pancreatic tissue and the gastrointestinal tract results in the disconnected pancreatic duct syndrome (DPDS). The purpose of our study is to describe accurately the imaging features of CT scanning and endoscopic retrograde pancreatography (ERCP) that define the DPDS. We conducted a retrospective analysis of the computed tomography (CT) and ERCP examinations in 26 consecutive patients with surgically proven disconnected pancreatic ducts treated over a 5-year period at our institution. Two abdominal radiologists concurrently defined the imaging features (presence and size of fluid collection along the course of the pancreatic duct, upstream enhancing pancreatic parenchyma, and ERCP abnormalities) via consensus for both exams. Patient demographics, etiology of pancreatitis, surgical treatment, initial CT interpretation, and the delay between symptom onset to correct diagnosis were recorded. A discrete, intrapancreatic fluid collection (average size = 27 cm2 (range, 4-74 cm2) along the course of the main pancreatic duct with upstream viable pancreatic parenchyma was identified by CT in 26 cases. ERCP showed ductal obstruction at the level of the intrapancreatic fluid collection in all patients with extravasation of contrast in 14 (54%). All patients were treated by operation: 15 (58%) by internal drainage into a Roux-en-Y limb of jejunum and 11 (42%) by distal pancreatic resection. No prior CT interpretation correctly identified DPDS. The average delay between symptom onset and definitive diagnosis was 9.3 months (range, 3-36 months). A discrete intrapancreatic fluid collection along the expected course of the main pancreatic duct with viable upstream pancreatic parenchyma suggests the diagnosis of DPDS. ERCP findings of ductal obstruction at the level of this fluid collection with or without contrast extravasation confirm this diagnosis. Treatment is surgical and requires either internal drainage or distal pancreatic resection for complete resolution.

Magnetic resonance imaging of nonhealing pressure ulcers and myocutaneous flaps

Objective: To evaluate the use of magnetic resonance imaging (MRI) in making clinical decisions when assessing nonhealing pressure ulcers and nonhealing myocutaneous flaps for the presence of an abscess, osteomyelitis, sinus tracts, and fluid collections. Design: Retrospective review of patient charts and radiographic studies. Setting: Regional spinal cord injury center. Subjects: Twelve patients who had MRI as part of their evaluation for a nonhealing pressure ulcer or myocutaneous flap. Results: Seven patients had MRI for preoperative evaluation, four with a previous flap that had recurrent breakdown and three with a new grade III or IV ulcer. Five patients had MRI for postoperative evaluation of myocutaneous flaps with delayed healing. MRI was useful in identifying osteomyelitis in three patients and sinus tracts that required surgical revision in six patients. MRI was also used in two patients to assess the size of fluid collections postoperatively in determining whether the patients should be mobilized after surgery. These chronic nonhealing wounds resulted in multiple admissions and lengthy hospital stays and required multiple surgical revisions. Patients who did poorly with healing or had repeated breakdown tended to have concurrent issues such as poor self care, increased age, increased time of spinal cord injury, poor nutrition, or other medical problems. Conclusion: Chronic nonhealing pressure ulcers and myocutaneous flaps can be difficult to treat and evaluate with conventional methods. There are multiple reasons for failure to heal. MRI can be a useful tool for identifying some of these factors including osteomyelitis, fluid collections, abcesses, and sinus tracts in the perioperative period. Identifying the appropriate patient populations and clinical indications for the optimal use of MRI should be subject of further study.

Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection.

BACKGROUND: Standard treatment for pleural infection includes catheter drainage and antibiotics. Tube drainage often fails if the fluid is loculated by fibrinous adhesions when surgical drainage is needed. Streptokinase may...