Percutaneous Drain Placement Research Articles

WITHDRAWN

SESSION TITLE: COVID-19 Co-Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: PAP is a rare entity that can occur secondary to infection, malignancy, or trauma. Mucormycosis in the setting of Covid-19 pneumonia has been increasingly recognized but PAP has only recently been reported in this setting. CASE PRESENTATION: A 44 year-old man with type 2 diabetes, non-ischemic cardiomyopathy, hypothyroidism, and ulcerative colitis presented with dyspnea and cough in July 2021. He was diagnosed with Covid-19 pneumonia and initially treated with molnupiravir. Eight days later he presented to the emergency room with worsening dyspnea, hypoxemia and diabetic ketoacidosis. He required 3L of oxygen and was intubated for airway protection. CT chest revealed mild bilateral patchy opacities and dexamethasone was started. Unfortunately, persistent fevers and worsening respiratory status ensued and repeat chest CT on hospital day (HD) 8 showed a new large left upper lobe (LUL) cavitary lesion. Cultures ultimately grew Rhizopus microsporus and he was started on amphotericin then isavuconazole after acute kidney injury developed. Dexamethasone was discontinued and interval imaging after ten days showed dramatic growth of the cavitary lesion (9 x 6 x 3 cm) with new extension through the chest wall, infiltrating the intercostal spaces and pectoralis muscle. Due to ventilator dependency a tracheostomy was performed on HD 24. Despite anti-fungal therapy the cavitary lesion persisted, with evidence of osseous destruction of the third and fourth ribs, as well as new fluid collections within the cavity and hilar extension. On HD 46 he was transferred to our institution for Thoracic Surgery and Interventional Radiology (IR) evaluations. Percutaneous drain placement followed by pneumonectomy vs. staged cavernostomy was considered; however, on HD 50, the patient suddenly developed massive hemoptysis. CTA of the chest showed a 1.6 x 1.5 cm PAP with active hemorrhage from the LUL anterior segmental artery with dispersion into the cavity. Urgent coil and glue embolization was successfully performed by IR. Ultimately, thoracic surgical intervention was deemed too high risk and thus he was medically managed with a regimen of isavuconazole, amphotericin, and terbinafine. Hemoptysis did not recur and he was eventually discharged from the hospital and liberated from both mechanical ventilation and tracheostomy. Chest CT 6 months from the initial diagnosis has shown stable to mildly decreased size of the cavitary lesion. DISCUSSION: This is the first case to our knowledge of PAP as a complication of Covid-19 and Mucor superinfection in the United States. Five cases of this combination have been recently reported in other countries. Risk factors for Mucor infection after Covid appear to be uncontrolled diabetes, DKA, and steroid administration. CONCLUSIONS: A high index of suspicion should be maintained in patients with these risk factors, as PAP can present as massive hemoptysis and is often fatal. Reference #1: Hoenigl M, Seidel D, Carvalho A, et al. The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries [ 2022 Jan 25]. Lancet Microbe. 2022;10.1016/S2666-5247(21)00237-8. doi:10.1016/S2666-5247(21)00237-8 Reference #2: Pruthi H, Muthu V, Bhujade H, et al. Pulmonary Artery Pseudoaneurysm in COVID-19-Associated Pulmonary Mucormycosis: Case Series and Systematic Review of the Literature. Mycopathologia. 2022;187(1):31-37. doi:10.1007/s11046-021-00610-9 Reference #3: Coffey MJ, Fantone J 3rd, Stirling MC, Lynch JP 3rd. Pseudoaneurysm of pulmonary artery in mucormycosis. Radiographic characteristics and management. Am Rev Respir Dis. 1992;145(6):1487-1490. doi:10.1164/ajrccm/145.6.1487 DISCLOSURES: No relevant relationships by Kevin Patel No relevant relationships by Clifford Sung

S1916 A Rare Case of Small Cell Cholangiocarcinoma

Introduction: Small cell cholangiocarcinoma is a rare entity and is encountered much less frequently than most other forms of cholangiocarcinoma. This case describes a 63-year-old female who presented with abdominal pain, fatigue, and nausea and was found to have a 1.4 cm mass at the confluence of the left and right intrahepatic bile ducts. This was deemed to be unresectable small cell cholangiocarcinoma, and she was ultimately provided palliative chemotherapy. Case Description/Methods: A 63-year-old female with a history of chronic obstructive pulmonary disease presented to the hospital with right upper quadrant pain, fatigue, nausea, and bloating. Laboratory studies revealed an alkaline phosphatase (ALP) of 917 U/L, total bilirubin of 3.2 mg/dL, alanine aminotransferase (ALT) of 552 U/L, aspartate aminotransferase (AST) of 285 U/L, and a normal lipase. A magnetic resonance cholangiopancreatography showed a 1.4 cm mass at the confluence of the left and right intrahepatic bile ducts leading to biliary obstruction. Endoscopic retrograde cholangiopancreatography demonstrated a stricture of the common bile duct for which a stent was unable to be deployed. The patient underwent biliary decompression via percutaneous drain placement. A biopsy was obtained during an attempt at surgical resection, but the mass was unable to be removed due to the involvement of the main portal vein. The AFP level returned at 7 ng/mL, CA 19-9 was 6 U/mL, and CEA was 1.6 ng/mL. Biopsies showed positivity for CAM 5.2, keratin AE1/AE3, CD56, synaptophysin, and TTF1. Ki67 index was >95%. Chromogranin was negative. The patient was treated with etoposide, atezolizumab, and carboplatin, however, the disease course was complicated by refractory disease and brain metastasis (Figure). Discussion: Small cell cholangiocarcinoma is a much less prevalent form than other cholangiocarcinomas. Symptoms and signs typically mimic the more common variants of cholangiocarcinoma and often include right upper quadrant discomfort, nausea, dyspepsia, jaundice, fatigue, and weight loss. Laboratory findings include elevations in ALP and bilirubin. ALT and AST may also be elevated, especially when the tumor is intrahepatic. Treatment depends on if the tumor is amenable to surgical resection. If it is unresectable, treatment with cisplatin/etoposide +/- immunotherapy is often used. It is the hope of this case to bring attention to this rare diagnosis and prompt further research into therapies for this malignancy.Figure 1.: MRCP showing an intrahepatic mass at the confluence of the right and left biliary ducts.

S2811 Case of a Severe Cholecystocutaneous Fistula

Introduction: Cholecystocutaneous fistulae (aberrant communications of the gallbladder with the skin) have been recognized since the 17th century as possible complications of neglected gallbladder disease. However, in the era of modern medicine they remain uncommon. Case Description/Methods: An 83 year-old female with a history of anxiety, depression, and a self-inflicted abdominal gunshot wound presented to our institution 2 years ago with acute calculous cholecystitis and choledocholithiasis. She declined surgery and endoscopic management and was treated with percutaneous cholecystostomy drainage and antibiotics. Subsequent clinical course included multiple tube changes with complaints of recurrent drain dislodgement, leakage, and weight loss. Her cholecystostomy was changed to a percutaneous transhepatic biliary drain. She ultimately presented to the gastroenterology clinic for internalization of her biliary drain. On examination, a large palpable mass was seen in the right upper quadrant with serosanguinous and bloody drainage, consistent with chronic gallbladder extrusion from the abdominal wall. ERCP with removal of percutaneous drain, sphincterotomy, stone extraction, and stent placement was performed. CT abdomen showed a gallbladder mass extending into hepatic segment V as well as through the right abdominal musculature to the skin surface. Enlarged retroperitoneal adenopathy was concerning for metastatic involvement. The patient was deemed a poor surgical candidate, and she opted for hospice care. (Figure) Discussion: Cholecystocutaneous fistula is a recognized sequela of unresolved gallbladder inflammation, usually due to persistent biliary outflow obstruction. Other causes may include trauma, iatrogenic causes, gallbladder perforation, or carcinomas. Fistulae may also develop along the track of percutaneous drains following cholecystostomy for management of acute cholecystitis. Surgical management of cholecystocutaneous fistulae with either laparoscopic or open cholecystectomies and fistulae resections have been described with good success. Cholecystocutaneous fistulae in the setting of gallbladder malignancy have poor outcomes due to the spread to adjacent structures. Improved imaging diagnosis of gallstone and gallbladder disease, antibiotic therapies, early surgical intervention for gallbladder disease, and endoscopic alleviation of biliary outflow obstructions have made such a presentation of cholecystocutaneous fistula a rarely seen phenomenon.Figure 1.: A patient found to have cholecystocutaneous fistula with (A) gallbladder extruding from the abdominal wall, (B) occlusion cholangiogram post- removal of multiple common bile duct stones showing dilated CBD and cholelithiasis in an irregular, contracted gallbladder, and (C) CT scan showing a mass (star) with extrusion of gallbladder through the liver and skin (arrow).

Percutaneous endoscopic creation of a neoinfundibulum for a calyceal diverticulum: A case report and review of the literature

IntroductionCalyceal diverticula (CD) are cystic structures within the renal parenchyma that likely result from inappropriate interaction between the ureteric bud and metanephric blastema during development and, if obstructed, may cause problems that include flank pain, urinary tract infections, gross hematuria, or nephrolithiasis. Herein, we present the results of percutaneous management of an obstructed calyceal diverticulum causing recurrent flank pain and infections in a 17-year-old girl.Case summaryThe patient initially presented with febrile pyelonephritis, at which time an ultrasound was concerned about an abscess versus an infected cyst. She underwent percutaneous drain placement with IV antibiotics and improved. Three years later, she re-presented with similar symptoms. After a similar treatment course, a sinogram revealed communication of the cystic-appearing lesion with the proximal ureter, confirming a diagnosis of a calyceal diverticulum. The patient opted for endoscopic management. An initial attempt at ureteroscopy was unsuccessful due to both the small ureteral caliber as well as the stenotic infundibular os. A repeat attempt at percutaneous management revealed a stenotic infundibulum that could not accommodate a wire. A holmium laser fiber was used to create a neoinfundibulum from the diverticulum to the renal pelvis adjacent to the stenotic infundibular os. Follow-up retrograde pyelography and ultrasonography confirmed an interval decrease in size of the infundibulum, and the patient’s infectious symptoms and pain resolved.DiscussionCD is a rare anomaly and is infrequently reported in the pediatric population. Percutaneous management of CD in adults has been well described in the literature. Direct percutaneous management of CD involves access to the CD and ablation of the CD cavity to prevent re-accumulation of urine. Previous studies done in adults have suggested that stone-free rates from this management range from about 80% to 100%. Diverticular obliteration, as measured by postoperative CT scans, also appears to be feasible in a percutaneous, antegrade approach, with complete diverticular obliteration rates ranging from 60% to 100%. Our case demonstrated a successful decrease in size from the original diverticulum (9 cm) to a smaller size (2 cm). Future studies with longer follow-ups will need to ascertain if percutaneous management of symptomatic CD is effective in the pediatric population.

Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement after Pancreatic Surgery: Technical and Clinical Outcome in 133 Consecutive Patients during a 14-Year Period.

(1) Purpose: To retrospectively assess the technical and clinical outcome of patients with symptomatic postoperative fluid collections after pancreatic surgery, treated with CT-guided drainage (CTD). (2) Methods: 133 eligible patients between 2004 and 2017 were included. We defined technical success as the sufficient drainage of the fluid collection(s) and the absence of peri-interventional complications (minor or major according to SIR criteria). Per definition, clinical success was characterized by normalization of specific blood parameters within 30 days after the intervention or a decrease by at least 50% without requiring additional surgical revision. C-reactive protein (CRP), Leukocytes, Interleukin-6, and Dose length product (DLP) for parts of the intervention were determined. (3) Results: 97.0% of 167 interventions were technically successful. Clinical success was achieved in 87.5% of CRP, in 78.4% of Leukocytes, and in 87.5% of Interleukin-6 assessments. The median of successful decrease was 6 days for CRP, 5 days for Leukocytes, and 2 days for Interleukin-6. No surgical revision was necessary in 93.2%. DLP was significantly lower in the second half of the observation period (total DLP: median 621.5 mGy*cm between 2011–2017 vs. median 944.5 mGy*cm between 2004–2010). (4) Conclusions: Technical success rate of CTD was very high and the clinical success rate was fair to good. Given an elderly and multimorbid patient cohort, CTD can have a temporizing effect in the postoperative period after pancreatic surgery. Reducing the radiation dose over time might reflect developments in CT technology and increased experience of interventional radiologists.

Pure biliary leak vs. pancreatic fistula associated: non-identical twins following pancreatoduodenectomy.

Biliary leak (BL) after pancreatoduodenectomy (PD) may have diffrent severity depending on its association with postoperative pancreatic fistula (POPF). Data of 2715 patients undergoing PD between 2011 and 2020 at two European third-level referral Centers for pancreatic surgery were retrospectively reviewed. These included BL incidences, grading, outcomes, specific treatments, and association with POPF. BL occurred in 6% of patients undergoing PD. Among 143 BL patients, 47% had an associated POPF and 53% a pure BL. Major morbidity (64% vs 36%) and mortality (19% vs 4%) were higher in POPF-associated BL group (allP< 0.01). Day of BL onset was similar between groups (POD 2 vs 3;P = 0.2), while BL closure occurred earlier in pure BL (POD 12 vs 23;P < 0.01). Conservative treatment was more frequent (55% vs 15%;P < 0.01), and the rate of percutaneous and/or trans-hepatic drain placement was lower (30% vs 16%;P = 0.04) in pure BL group. Relaparotomy was more common in POPF-associated BL group (42% VS 17%;P < 0.01) but was performed earlier in pure BL (POD 2 vs 10;P = 0.02). Pure BL represents a more benign entity, managed conservatively in half of the cases.

Is the Addition of Anaerobic Coverage to Perioperative Antibiotic Prophylaxis During Soft Tissue Sarcoma Resection Associated With a Reduction in the Proportion of Wound Complications?

Wound complications are common after resection of soft tissue sarcomas, with published infection rates ranging from 10% to 35%. Multiple studies have reported on the atypical flora comprising these infections, which are often polymicrobial and contain anaerobic bacteria, and recent studies have noted the high prevalence of anaerobic bacterial infections after soft tissue sarcoma resection [ 26, 35 ]. Based on this, our institution changed clinical practice to include an antibiotic with anaerobic coverage in addition to the standard first-generation cephalosporin for prophylaxis during soft tissue sarcoma resections. The current study was undertaken to evaluate whether this change was associated with a change in major wound complications, and if the change should therefore be adopted for future patients. (1) After controlling for potentially confounding variables, was the broadening of the prophylactic antibiotic spectrum to cover anaerobic bacteria associated with a lower odds of major wound complications after soft tissue sarcoma resection? (2) Was the broadening of the prophylactic antibiotic spectrum to cover anaerobic bacteria associated with a lower odds of surgical site infections with polymicrobial or anaerobic infections after soft tissue sarcoma resection? (3) What are the factors associated with major wound complications after soft tissue sarcoma resection? We retrospectively identified 623 patients who underwent soft tissue sarcoma resection at a single center between January 2008 and January 2021 using procedural terminology codes. Of these, four (0.6%) pediatric patients were excluded, as were five (0.8%) patients with atypical lipomatous tumors and two (0.3%) patients with primary bone tumors; 5% (33 of 623) who were lost to follow-up, leaving 579 for final analysis. The prophylactic antibiotic regimen given at the resection and whether a wound complication occurred were recorded. Patients received the augmented regimen based on whether they underwent resection after the change in practice in July 2018. A total of 497 patients received a standard antibiotic regimen (usually a first-generation cephalosporin), and 82 patients received an augmented regimen with anaerobic coverage (most often metronidazole). Of the 579 patients, 53% (307) were male (53% [264 of 497] in the standard regimen and 52% [43 of 82] in the augmented regimen), and the mean age was 59 ± 17 years (59 ± 17 and 60 ±17 years in the standard and augmented groups, respectively). Wound complications were defined as any of the following within 120 days of the initial resection: formal wound debridement in the operating room, other interventions such as percutaneous drain placement, readmission for intravenous antibiotics, or deep wound packing for more than 120 days from the resection. Patients were considered to have a surgical site infection if positive cultures resulted from deep tissue cultures taken intraoperatively at the time of debridement. The proportion of patients with major wound complications was 26% (150 of 579); it was 27% (136 of 497) and 17% (14 of 82) in the standard and augmented antibiotic cohorts, respectively (p = 0.049). With the numbers we had, we could not document that the addition of antibiotics with anaerobic coverage was associated with lower odds of anaerobic (4% versus 6%; p = 0.51) or polymicrobial infections (9% versus 14%; p = 0.25). Patient, tumor, and treatment (surgical, radiotherapy, and chemotherapy) variables were collected to evaluate factors associated with overall infection and anaerobic or polymicrobial infection. Patient follow-up was 120 days to capture early wound complications. A multivariable analysis was performed for all variables found to be significant in the univariate analysis. A p value < 0.05 was used as the threshold for statistical significance for all analyses. No patients were found to have an adverse reaction to the augmented regimen, including allergic reactions or Clostridioides (formerly Clostridium) difficile infection. After controlling for other potentially confounding factors such as neoadjuvant radiation, tumor size and anatomic location, as well as patient BMI, anaerobic coverage was associated with smaller odds of wound complications (OR 0.36 [95% confidence interval (CI) 0.18 to 0.68]; p = 0.003). Other factors associated with major wound complications were preoperative radiation (versus no preoperative radiation) (OR 2.66 [95% CI 1.72 to 4.15]; p < 0.001), increasing tumor size (OR 1.04 [95% CI 1.00 to 1.07]; p = 0.03), patient BMI (OR 1.07 [95% CI 1.04 to 1.11]; p < 0.001), and tumor in the distal upper extremity (versus proximal upper extremity, pelvis/groin/hip, and lower extremity) (OR 0.18 [95% CI 0.04 to 0.62]; p = 0.01). The addition of anaerobic coverage to the standard prophylactic regimen during soft tissue sarcoma resection demonstrated an association with smaller odds of major wound complications and no documented adverse reactions. Treating physicians should consider these findings but note that they are preliminary, and that further work is needed to replicate them in a more controlled study design such as a prospective trial. Level III, therapeutic study.

Comparative study of drainage of breast abscess by conventional incision and drainage versus percutaneous placement of suction drain

Breast abscess is common in puerperal period secondary to mastitis with incidence of 4.8%-11%. The conventional method of incision and drainage of breast abscess has undergone a gradual change from invasive to minimally invasive method of percutaneous placement of suction drain. We present 50 cases of puerperal breast abscess treated by I and D and percutaneous placement of suction drain alternatively. Aims and Objectives: To compare management of breast abscess by incision and drainage v/s percutaneous suction drainage with reference to – 1. Post operative pain 2. Residual abscess 3. Duration of hospital stay 4. Time required for complete healing 5. Appearance of scar. Material and Methods: 50 patients with primary diagnosis of puerperal breast abscess were taken for this prospective study. 25 patients underwent I & D and 25 patients underwent percutaneous placement of suction drain. Results: Minimal post operative pain was observed in all the patients of percutaneous drain placement (VAS G1 and G2) compared to I and D group (G4 and G5). Residual abscess was found in one case in I and D group and two cases in PDP group which were treated by incision and drainage. Mean duration of hospital stay in I and D group was 4-6 days and in PDP group was. Mean duration of complete healing in I and D group was 10-12 days and in PDP was weeks. Patients who underwent PDP had a minimal scar at entry and exit wounds, where as the patients who underwent conventional method had a large ugly scar. Conclusion: Percutaneous placement of suction drain in puerperal breast abscess is less invasive(less pain), has faster resolving rate, heals with minimal scarring and has low complication rate as compared to the conventional method.

MP20-04 GRADE V RENAL TRAUMA: SUCCESS ROLE FOR CONSERVATIVE MANAGEMENT IN THE NATIONAL TRAUMA DATABANK

You have accessJournal of UrologyCME1 May 2022MP20-04 GRADE V RENAL TRAUMA: SUCCESS ROLE FOR CONSERVATIVE MANAGEMENT IN THE NATIONAL TRAUMA DATABANK Nizar Hakam, Nathan Shaw, Jason Lui, Behnam Nabavizadeh, Kevin Li, Patrick Low, and Benjamin Breyer Nizar HakamNizar Hakam More articles by this author , Nathan ShawNathan Shaw More articles by this author , Jason LuiJason Lui More articles by this author , Behnam NabavizadehBehnam Nabavizadeh More articles by this author , Kevin LiKevin Li More articles by this author , Patrick LowPatrick Low More articles by this author , and Benjamin BreyerBenjamin Breyer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002553.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Conservative management is now standard for most renal trauma as it decreases complications and nephrectomy rates. However, American Association for the Surgery of Trauma (AAST) grade V injuries renal injuries continue to largely require intervention and sparse data is available on conservative management. We investigate whether conservative management was pursued in patients who survive grade V renal injuries using the National Trauma Databank (NTDB). METHODS: Patients with grade V renal trauma were identified in the 2018 NTDB (n=612). Patients who survived to final hospital discharge were included (n=474). Conservative management was defined by the absence of any surgical or procedural intervention. Percutaneous or cystoscopic drain placement was exempted from procedural intervention. Characteristics of patients who underwent conservative vs non-conservative management were compared. RESULTS: Out of 474 patients, 175 (36.9%) were managed conservatively. In the 299 patients managed non-conservatively, most common interventions were surgical exploration (n=200, 66.9%), nephrectomy (n=196, 65.6%), kidney angioembolization (n=60, 20.1%), open surgical bleeding control (n=37, 12.4%), and surgical repair of the kidney or renal artery (n=22, 7.4%). Patient characteristics are depicted in Table 1, stratified by management approach. Patients managed conservatively had more favorable hemodynamic parameters compared to those managed non-conservatively, exhibiting lower mean pulse rate (99.9 vs 106.2, p=0.01). They had less hypotension on arrival (8.6% vs 17.4%, p=0.008) and received fewer blood transfusion (28% vs 67.2%, p<0.001). They also were younger (mean age 26.7 vs 30.5, p=0.01), less likely to be male (71.4% vs 91.6%, p=0.01), less likely to have sustained a penetrating injury (6.7% vs 51.2%, p <0.001), and had a significantly different distribution of trauma mechanism (Table 1). CONCLUSIONS: A conservative approach may be safe in a subset of patients with grade V renal injury, especially in those who were less likely to be in shock, receive blood transfusion, or sustain penetrating injury. Further research to identify phenotypes amenable to conservative management is warranted to improve patient outcomes. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e318 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nizar Hakam More articles by this author Nathan Shaw More articles by this author Jason Lui More articles by this author Behnam Nabavizadeh More articles by this author Kevin Li More articles by this author Patrick Low More articles by this author Benjamin Breyer More articles by this author Expand All Advertisement PDF DownloadLoading ...

Nationwide Analysis of Hospital Admissions Prior to Hartmann's Procedure for Acute Diverticulitis.

Diverticular disease is one of the most common gastrointestinal diseases that require hospital admission. This study aims to identify trends in prior hospital admissions for patients that ultimately require a Hartmann's procedure for complicated diverticulitis. The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged 18 years or older admitted with an ICD-9 code for colonic diverticulitis and end colostomy creation. Patients with prior hospital admissions were identified. The primary outcome was mortality after Hartmann's procedure. Secondary outcomes were prior hospital admission and previous percutaneous drain placement. Multivariable logistic regression was performed to control for confounding factors for each outcome and results were weighted for national estimates. There were 90,162 patients admitted with complicated diverticulitis requiring end colostomy creation. Prior hospital admissions were found in 28.1% (n = 25,307) and 14.4% (n = 12,947) had a previous percutaneous drain placed during a prior admission. The overall mortality rate was 5.9% (n = 5314) after Hartman's procedure. The mortality rate for patients with prior hospital admissions was 8.7% (P < .001), and the mortality rate for patients with previous percutaneous drain placement was 4.3% (P < .001). After controlling for confounding factors including comorbidities, patients with prior admission had an increased risk of mortality (OR 1.48 [1.40-1.58], P < .001) and patients with previous percutaneous drain placement had a decreased risk of mortality (OR .66 [.60-.72], P < .001). Hospitalizations for complications of diverticulitis are a costly burden to our healthcare system. By identifying those patients at high risk for readmission and emergency surgery, perioperative outcomes may be improved.

Insulinoma-Accurate Preoperative Localization Is the Key to Management: An Initial Experience.

Insulinoma is the commonest functioning pancreatic neuroendocrine tumor. The only curative treatment is surgical excision after preoperative localization. A retrospective analysis of nine patients (February 2017-June 2020), 2 males and 7 females, was done for clinical presentation, biochemistry, localization methods, intraoperative findings, postoperative outcome, histopathology reports, and follow-up. Techniques for localization of the tumor were pancreatic protocol triple-phase multi-detector computed tomography (MDCT), endoscopic ultrasound (EUS), Ga 68 DOTANOC PET-CT, and Ga 68 NOTA-exendin-4 PET-CT (GLP1R scan). The mean age was 38 (range 20-68) years and mean duration of symptoms 34 (range 8-120) months, and symptoms of Whipple's triad were present in all cases after a supervised 72-h fast. MDCT localized tumor in 8/9 cases. EUS before MDCT in one patient had also localized tumors. Ga 68 DOTANOC PET-CT detected tumor in 2/4 patients. In one patient, MDCT or DOTANOC PET scan could not localize tumor; GLP1R scan localized tumor accurately. Two patients had associated MEN1 syndrome. All 9 patients underwent surgical resection (four open and five laparoscopic) of tumor-enucleation (3), distal pancreatectomy with splenectomy (3), and pancreatoduodenectomy (PD) (3). The last four procedures and all three enucleations were laparoscopic. Five patients developed postoperative pancreatic fistula (POPF), only one grade B which required percutaneous drain placement. One patient, who had initial open enucleation, developed hypoglycemia after 48h; PD was performed. All patients were cured and all, except one (who died of upper GI bleed), were alive and disease-free during a mean follow-up of 26 (range 2-41) months. Preoperative localization of insulinoma is important and decides the outcome of surgery in terms of cure. MDCT can localize tumors in most patients; the last resort for localization is the GLP1R scan. Laparoscopic procedures are equally effective compared to open surgery. Considering the benign nature of the disease, enucleation is the procedure of choice.

Plastic biliary stent fracture: A rare complication of percutaneous biliary drain placement

Stent placement at the time of endoscopic retrograde cholangiopancreatography (ERCP) is standard practice for biliary obstruction. While several complications can occur with an indwelling stent, stent fracture is rare. We present a case of plastic biliary stent fracture that occurred at the time of percutaneous biliary drain (PBD) placement as well as the successful endoscopic removal of the fractured stent. Stent fracture should be considered as a possible complication of PBD placement in patients with an indwelling biliary stent.

Readmission After Pancreas Transplantation: Timing of Surgery Matters.

Pancreas transplantation is associated with good long-term outcomes, but readmissions are frequent. In this study, our objective was to understand the effects of operation start time on postoperative outcomes. We conducted a retrospective review of all patients who underwent deceased donor pancreas transplant in a single center from January 2017 to December 2018. We compared postoperative outcomes of patients in relation to operation start time, which included morning (6 AM to 3 PM), afternoon (3 PM to 7 PM), and evening (7 PM to 6 AM). Eighty-three patients were included in the study. The median age was 45 years old, 54.2% were males, and 79.5% had diabetes mellitus type 1. With regard to surgery start time, 50 patients (60.2%) had a start time in the morning, 25 patients (30.1%) in the afternoon, and 8 (9.6%) in the evening. Patients in the morning group had a significantly lower readmission rate compared with the afternoon and evening groups, respectively (50% vs 84% vs 87.5%; P = .04).There were no significant differences in reoperation rate (26% vs 32% vs 12.5%; P = .57), percutaneous drain placement (20% vs 12% vs 12.5%; P = .75), or graft failure (8% vs 4% vs 12.5%; P = .55) among the 3 groups. Morning operative start times were associated with lower readmission after pancreas transplant.

Pure vs Pancreatic Fistula-Associated Biliary Leak after Pancreaticoduodenectomy: Different Twins

Introduction: Biliary leak (BL) after pancreatoduodenectomy (PD) is a rare complication, with variable severity. We sought to evaluate the range of possible treatment strategies and outcomes for BL, according to the presence of an associated postoperative pancreatic fistula (POPF). Methods: Postoperative data of patients undergoing PD at the Verona and the Karolinska University Hospitals between 2011 and 2020 were retrospectively reviewed, including: BL incidence, grading and outcomes; BL time of onset and resolution; the presence of associated postoperative pancreatic fistula (POPF); BL-specific treatments and their timing. Results: A BL occurred in 153 out of 2715 patients undergoing PD (6%). Ten patients with BL were excluded due to missing postoperative data. Of the remaining 143, 67 (47%) had an associated POPF (POPF-BL) while 76 (53%) had a pure BL. Pancreas-specific morbidity and in-hospital mortality (19% vs 4%; P< 0.01) were higher in the POPF-BL group. Time of BL onset was similar between the groups, while BL closure occurred earlier in pure BL (12 vs 23 days; P< 0.01). Conservative treatment was more frequent in the pure BL group (55 vs 15%; P< 0.01), while the rate of percutaneous and/or trans-hepatic drain placement was similar. Relaparotomy was more common in the POPF-BL group (42% VS 17%; P< 0.01) but occurred earlier in case of pure BL (2 vs 10 days; P= 0.02). Conclusions: The association with POPF is a negative prognostic factor for BL after PD. Pure BL represents a more benign entity, which is managed conservatively in half of the cases.

Laparoscopic Management of Tubo-Ovarian Abscess Refractory to Percutaneous Drainage

<h3>Study Objective</h3> To demonstrate the feasibility and safety of a laparoscopic approach to a case of tubo-ovarian abscess (TOA) refractory to percutaneous drainage and antibiotic therapy. <h3>Design</h3> Case report. <h3>Setting</h3> Operating room with traditional laparoscopy. <h3>Patients or Participants</h3> 30-year-old female patient with refractory TOA. <h3>Interventions</h3> Laparoscopic lysis of adhesions, bilateral salpingectomy, right oophorectomy, wash out and drain placement. <h3>Measurements and Main Results</h3> The patient is a 30-year-old female who presented with a 16cm TOA, initially managed with parenteral antibiotics and percutaneous drainage. However, despite initial improvement, the abscess continued to re-accumulate, refractory to a total of three percutaneous drain placements over the course of 8 weeks. She was taken to the operating room for laparoscopic resection of the TOA. Four port sites were utilized, three 5mm ports and one 10mm port. Survey of the pelvis revealed dense adhesions, bilateral pyosalpinx, and residual large abscess encompassing the right ovary. Given the patient's prolonged pre-operative course and her consent for loss of future fertility, the decision was made to proceed with bilateral salpingectomy and right oophorectomy. The right adnexal structures were densely adherent to the pelvic side wall and cul de sac; therefore, retroperitoneal dissection was utilized to identify important landmarks including the medial umbilical ligament, uterine artery and ureter in order to safely remove the diseased tissue without injuring the surrounding vital structures. The pelvis was irrigated and a JP drain was placed. She was discharged home on the same day. She had an uncomplicated post-operative course. Final surgical pathology revealed chronic and active salpingitis as well as focal endometriosis. <h3>Conclusion</h3> Laparoscopy is a safe and feasible surgical approach to the management of tubo-ovarian abscess refractory to percutaneous drain placement. The surgeon should be adept and familiar with retroperitoneal dissection to ensure safety of surrounding structures in the setting of dense adhesive disease and inflammation.

Surgical Management of Tubo-Ovarian Abscesses That Failed Percutaneous Drainage

<h3>Study Objective</h3> Report outcomes in the management of tubo-ovarian abscesses (TOA) initially managed with percutaneous drainage. <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Tertiary University-affiliated Medical Center. <h3>Patients or Participants</h3> Patients who underwent percutaneous drain placement for TOA from 2003 to 2020 were included. Percutaneous drainage CPT codes were used to retrieve patient cases. Charts were subsequently reviewed manually. Cases with retrospective diagnoses of: Endometriosis or non-genital etiology of TOA were excluded. <h3>Interventions</h3> percutaneous drainage. <h3>Measurements and Main Results</h3> Sixty-six patients were identified, nine met exclusion criteria, and 57 were analyzed. Percutaneous drainage was successful in 42 patients, while surgery was ultimately required in 15 cases. Of 15 surgical cases only 4 occurred during the initial admission, whereas 11 were delayed and performed due to recurrence of TOA (5), persistence of symptomatic mass (3), or development of chronic pelvic pain (3). Three patients underwent salpingo-oophorectomy. Eight underwent hysterectomy with unilateral or bilateral salpingo-oophorectomy. All but one patient who underwent delayed intervention had it within 1 year of initial presentation. <h3>Conclusion</h3> Percutaneous drainage of TOA is initially successful in 93% of patients, however ultimately 26% of patients ultimately require surgical intervention.

S2843 Pyogenic Liver Abscess Presenting as Obstructive Jaundice From Klebsiella Pneumoniae in Texas

Introduction: A pyogenic liver abscess (PLA) is a suppurative infection involving the hepatic parenchyma and account for roughly 80% of all liver abscesses. Traditionally, PLA was associated with intra-abdominal infections or leakage of intrabdominal bowel contents and was polymicrobial. One organism of interest is Klebsiella pneumoniae, which is the leading cause of PLA in several parts of Asia, making up 50-85% of cases. PLA with K. pneumoniae is becoming more common globally, especially here in the Unites States. PLA from K. pneumoniae often occurs in the absence of intraabdominal or hepatobiliary disease and has been associated with diabetes mellitus and underlying colorectal cancer. Early recognition and treatment of PLA is crucial to prevent development of bacteremia. PLA at presentation often includes fever (seen in 90% of cases), abdominal pain (50-75%), and elevated alk phos (60-90%), while jaundice and compression of the biliary tree (12-27%) is rarer. Case Description/Methods: A 59-year old man visiting from the Philippines with a medical history of HTN and type 2 DM presenting with five days of worsening fatigue, nausea, non-bloody vomiting, and scleral icterus was found to be in septic shock. He had developed the symptoms while in Mexico. Physical exam was notable for jaundice and hepatomegaly with a moderately distended abdomen. Presenting labs showed an elevated lactate, hyperbilirubinemia (total bilirubin 11.4, conjugated bilirubin 7.1), and increased alk phos. CT abdomen/pelvis showed a large, 12.9 cm hypo-attenuating cystic liver mass with ill-defined septations and peripheral enhancement. Blood cultures grew Klebsiella pneumonia. Patient underwent two percutaneous drain placement procedures, both of which incompletely drained the fluid. Roughly two weeks after presentation, while still in the hospital, he underwent exploratory laparotomy and successful drainage of hepatic abscess. He was monitored a few days afterwards with down trending labs before being discharged home. Discussion: Here we presented a case of septic shock and obstructive jaundice secondary to a pyogenic liver abscess with Klebsiella pneumoniae. The patient had multiple risk factors for this disease such as diabetes and being from Southeast Asia. The treatment was complicated by multiple percutaneous and surgical interventions before being stable for discharge. Being aware of K. pneumoniae causing PLA should be included on a differential for obstructive jaundice is necessary.

Improving safety of robotic major hepatectomy with extrahepatic inflow control and laparoscopic CUSA parenchymal transection: technical description and initial experience.

Blood loss is a major determinant of outcomes following hepatectomy. Robotic technology enables hepatobiliary surgeons to mimic open techniques for inflow control and parenchymal transection during major hepatectomy, increasing the ability to minimize blood loss and perform safe liver resections. Initial experience of 20 consecutive major robotic hepatectomies from November 2018 to July 2020 at two co-located institutions was reviewed. All cases were performed with extrahepatic inflow control and parenchymal transection with the laparoscopic cavitron ultrasonic surgical aspirator (CUSA), and a technical description is illustrated. Clinical characteristics, operative data, and surgical outcomes were retrospectively analyzed. The median (range) patient age was 58years (20-76) and the majority of 14 (70%) patients were ASA III-IV. There were 12 (60%) resections for malignancy and the median tumor size was 6.2cm (1.2-14.6). Right or extended right hepatectomy was the most common procedure (12 or 60% of cases). There were 7 (35%) left or extended left hepatectomies and 1 (5%) central hepatectomy. The median operative time was 420 (177-622) minutes. Median estimated blood loss was 300mL (25-800mL). One (5%) case was converted to open. Two (10%) patients required blood transfusion. The median length of stay was 3 (1-6) days. Major complications included 1 (5%) Clavien-Dindo IIIa bile leak requiring percutaneous drainage placement. There was no 90-day mortality. Advanced techniques to reduce blood loss in robotic hepatectomy may optimize safety and minimize morbidity in these complex minimally invasive procedures.

Compression of the Right Atrium and Inferior Vena Cava from an Extrahepatic Biloma Following Liver Trauma

A 26-year-old male presented to a Level 1 trauma center following a motorcycle crash. Workup of his injuries demonstrated a grade 5 liver laceration with active extravasation, grade 5 kidney laceration, right apical pneumothorax, and a sternal fracture. The patient underwent hepatic artery embolization with interventional radiology (IR) followed by an exploratory laparotomy, liver packing, and small bowel resection with primary anastomosis. Four days post-op, the patient developed dyspnea, tachycardia, and decreasing oxygen saturation. Computed tomography pulmonary angiography demonstrated perihepatic fluid compressing the right atrium and inferior vena cava. Percutaneous perihepatic drain placement with aspiration of 700mL bilious fluid resulted in immediate resolution of the compression. He subsequently underwent endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the ampulla nine days later. The patient was discharged ten days post-ERCP with oral amoxicillin/clavulanic acid for polymicrobial coverage and follow-up with gastroenterology and IR for stent removal and drain maintenance.

Hepatic resection for hepaticolithiasis: A single-centre experience of 8 cases

Hepaticolithiasis is frequently not amenable to endotherapy, and surgery forms the mainstay of treatment. This study highlights the outcomes of major liver resection for this benign pathology. Our tertiary hepatobiliary centre performed 8 liver resections for hepaticolithiasis between January 2010 and December 2019. Demographic data, clinicoradiological data, surgical details, and outcomes were recorded. Out of 8 patients, 6 were females. Median age was 54 years. 6 patients underwent left hepatectomy, and 1 each underwent right hepatectomy and right trisectionectomy. Trisectionectomy was done after liver volumetry showed a future liver remnant volume of 48% with right posterior section atrophy. Mean intra-operative blood loss was 226 mL, median hospital stay was 11.2 days. 1 patient had Clavien-Dindo grade 3 complication in the form of intra-abdominal collection requiring percutaneous drain placement. Six patients had significant elevation of transaminases that resolved by a median duration of 8 days. No patient had post-hepatectomy liver failure. None of the patients developed recurrent hepaticolithiasis or biliary stricture, with follow-up duration of 11 to 64 months. Major hepatic resection is a safe and recommended procedure for hepaticolithiasis, especially in presence of hepatic lobar atrophy. It carries acceptable morbidity and good outcomes when performed by an experienced hepatobiliary surgical team. A tertiary care centre with good imaging and liver volumetry facilities is best suited for this line of management.