Residual Abscess Research Articles

Risk stratification of residual abscess after surgical treatment for gastroduodenal perforation

AbstractAimsResidual abscess is a major complication after emergency surgery for gastroduodenal (GD) perforation. However, there is little evidence regarding potential risk factors contributing to its development. Establishing a risk stratification strategy would be valuable for the entire management process.MethodsThis single‐center, retrospective study analyzed 115 consecutive patients who underwent surgery for GD perforation between 2010 and 2023 at a secondary emergency care hospital. Patients were divided into two groups based on the presence or absence of residual abscesses. Potential risk factors for abscess formation were evaluated from various aspects.ResultsThe incidence of residual abscesses was 19.1% (22 of 115). Multivariable analysis revealed that current use of nonsteroidal antiinflammatory drugs (odds ratio [OR] 3.76, p = 0.037), cancer chemotherapy (OR 13.56, p = 0.005), and preoperative renal dysfunction (OR 4.72, p = 0.018) were independent predictors. A potential scoring model could be created using these three parameters, and the number of risk factors correlated with the likelihood of developing a residual abscess (0 vs. 1 vs. ≥2; 6.2% vs. 29.4% vs. 50.0%, p < 0.001). From a bacteriological point of view, the presence of Enterococcus in the ascites culture was closely related to its occurrence with 100% probability. Moreover, regarding early detection of this complication, C‐reactive protein on postoperative d 5 had the highest predictive ability with an area under the curve of 0.818.ConclusionThe risk of residual abscess formation after surgical treatment of GD perforation can be assessed utilizing both preoperative and postoperative information.

Clinical and microbiological characteristics and follow-up of invasive Listeria monocytogenes infection among hospitalized patients: real-world experience of 16 years from Hungary

PurposeInvasive Listeria monocytogenes infection is rare, but can lead to life-threatening complications among high-risk patients. Our aim was to assess characteristics and follow-up of adults hospitalized with invasive L. monocytogenes infection.MethodsA retrospective observational cohort study was conducted at a national referral center between 2004 and 2019. Patients with proven invasive listeriosis, defined by the European Centre for Disease Prevention and Control criteria, were included. Data collection and follow-up were performed using the hospital electronic system, up until the last documented visit. The primary outcome was in-hospital all-cause mortality, secondary outcomes included residual neurological symptoms, brain abscess occurrence, and requirement for intensive care unit (ICU) admission.ResultsAltogether, 63 cases were identified (57.1% male, median age 58.8 ± 21.7 years), and 28/63 developed a complicated disease course (44.4%). At diagnosis, 38/63 (60.3%) presented with sepsis, 54/63 (85.7%) had central nervous system involvement, while 9/63 (14.3%) presented with isolated bacteremia. Frequent clinical symptoms included fever (53/63, 84.1%), altered mental state (49/63, 77.8%), with immunocompromised conditions apparent in 56/63 (88.9%). L. monocytogenes was isolated from blood (37/54, 68.5%) and cerebrospinal fluid (48/55, 87.3%), showing in vitro full susceptibility to ampicillin and meropenem (100% each), gentamicin (86.0%) and trimethoprim/sulfamethoxazole (97.7%). In-hospital all-cause mortality was 17/63 (27.0%), and ICU admission was required in 28/63 (44.4%). At discharge, residual neurological deficits (11/46, 23.9%) and brain abscess formation (6/46, 13.0%) were common.ConclusionAmong hospitalized adult patients with comorbidities, invasive L. monocytogenes infections are associated with high mortality and neurological complications during follow-up.

A Comparative Study of Drainage of Breast Abscesses by Conventional Incision and Drainage vs Ultrasound-Guided Needle Aspiration/Re-Aspiration in A Tertiary Health Care Centre.

Breast abscesses are localized purulent collections, often arising from bacterial mastitis, and pose significant health risks, especially for lactating women. The aim of this study was to compare the efficacy and outcomes of two different treatment approaches: Traditional incision and drainage (I&D) versus ultrasound (USG)-guided aspiration in breast abscess management. Fifty female patients with breast abscesses were enrolled and divided into two groups: Group A (n = 25, I&D) and group B (n = 25, USG-guided aspiration). Group A underwent I&D under general anaesthesia and group B underwent USG-guided aspiration under local anaesthesia. The patients were followed up for two weeks after the procedure. Patient demographics, abscess characteristics, treatment outcomes, and complications were analyzed. The mean age of patients was 36.4 and 31.8 in group A and B, respectively and the mean abscess size was 5.7 cm. The study found that USG-guided aspiration was associated with several advantages over I&D. Patients in group B experienced shorter healing times (5 days vs. 13 days, p = 0.001), lower rates of residual abscesses (12% vs. 36%, p = 0.047), and no recurrence after two weeks vs. 28% in group A (p = 0.012). Notably, the resumption of lactation was significantly greater in group B (91.67% vs. 20%). Importantly, patients in group B had no scarring, while 37% in group A healed with scars. These results highlight that USG-guided aspiration offers a minimally invasive and effective method for managing breast abscesses, leading to quicker recovery, better cosmetic outcomes, and higher patient satisfaction compared to the traditional I&D approach. Early diagnosis and intervention with USG-guided aspiration can prevent complications and reduce the need for open surgery. Based on these findings, USG-guided aspiration is a safer and more efficient method for treating breast abscesses, particularly when initiated promptly after diagnosis.

Full-Endoscopic Transforaminal Debridement and Decompression for Brucellar Thoracic Spinal Epidural Abscess: A Minimally Invasive Alternative to Open Surgery.

Thoracic spinal epidural abscess (SEA) is a rare but dangerous condition, and traditional surgical methods are accompanied by extensive trauma and approach-related complications. Here we introduce the technique of full-endoscopic transforaminal debridement and decompression and evaluate its feasibility for treating brucellar thoracic SEA. We performed thoracic full-endoscopic transforaminal decompression and debridement on two patients with neurological deficits caused by brucellar SEA, which is mainly composed of granulation tissue rather than pus. Postoperative MRI was conducted to confirm the presence of any residual abscess compressing the nerves. Frankel grading was employed to assess the recovery of neurological function, and complications were documented. There were no occurrences of dural tear, postoperative hematoma, or pulmonary complications. Their neurological function had significantly improved after surgery, and postoperative MRI confirmed no residual abscess compressing the spinal cord. During the 2-year follow-up, one patient achieved complete recovery (from Frankel-C to Frankel-E), while another patient improved from Frankel-A to Frankel-D. Neither patient experienced infection recurrence, instability, nor kyphotic deformity. We described the novel application of transforaminal endoscopic surgery in brucellar thoracic granulomatous SEA and preliminarily indicated the feasibility of this technique as a minimally invasive alternative to open surgery.

Tetralogy of Fallot complicated by multiple cerebral abscesses in a child: a case report

IntroductionBrain abscesses are rare but potentially fatal condition and can be associated with cyanotic congenital heart disease of which 5–18.7% of these patients that develop cerebral abscess commonly have tetralogy of Fallot (TOF).Case presentationWe report a case of 3-year-old Muganda male that presented with convulsions, cyanosis and difficulty in breathing. The patient had a combination intervention of medical treatment and surgical drainage of the abscess. Post-operative Computerized tomography scan images and pre-operative brain Computerized tomography scans were compared. The multiple rings enhancing lesions were reduced in number and sizes. The largest measured ring was 44 × 22.5×16mm compared to the previous; 42 × 41×36mm. The mass effect had reduced from 16 mm to 7.5 mm. The periventricular hypodensities persisted. Findings showed radiological improvement with residual abscesses, subacute subdural hematoma and pneumocranium. The patient was treated with intravenous ceftriaxone 1 g OD for six weeks and he showed marked improvement and was discharged home after 3 months.ConclusionA comprehensive strategy involving medications, surgical drainage, and early neurosurgical consultation is vital in treating brain abscesses in uncorrected TOF. Early identification of the pathogen, appropriate antibiotic therapy, and vigilant follow-up through clinical assessments and imaging are crucial, potentially spanning a 4–8-week treatment.

A case in which endoscopic ultrasound-guided transrectal drainage was effective for pelvic abscess

The patient, a 33-year-old female, presented to her local doctor with lower abdominal pain. She was referred to our hospital for a plain CT scan, which revealed signs of ileitis. Because acute appendicitis could not be ruled out, the patient was hospitalized. On the third day of hospitalization, she underwent laparoscopic appendicectomy for perforated appendicitis. However, the inflammatory response persisted despite continued antibacterial treatment; we diagnosed this to be due to the formation of a postoperative residual abscess. Since drainage of the abscess was deemed necessary, the patient underwent EUS-guided transrectal drainage on the 26th day of hospitalization. The patient had a favorable postoperative course and was discharged on the 31st day of hospitalization. Along with some literature review, this report details a case in which transrectal drainage under ultrasound endoscopy was effective in treating a pelvic abscess. We report a case of a pelvic abscess that was drained through the rectum under EUS guidance and an internal and external fistula tube was placed. The abscess resolved without complications.

A Randomized Controlled Trial Comparing Ultrasonography-Guided Needle Aspiration and Surgical Drainage for the Management of Breast Abscess.

Background A breast abscess is a localized collection of inflammatory exudate in breast tissue. It is more common in lactating women. Treatment of the breast abscess is usually by incision and drainage, which is accompanied by extensive trauma, lengthy surgical incisions, psychological distress, surgical scar, and discomfort during dressing changes. Recent research has shown that ultrasonography-guided needle aspiration is an alternative to incision and drainage for breast abscess treatment, has superior cosmetic outcomes, and has fewer costs. However, there are no clear guidelines for the same. The primary objective of this study was to assess and contrast the outcomes and efficacy of two approaches in the treatment of breast abscesses: ultrasonography-guided needle aspiration and conventional incision and drainage. Methods This was a single-center, prospective, randomized, controlled, non-inferiority trial. Patients with breast abscesses were randomized either to receive needle aspiration or incision drainage. Patients with lactational breast abscesses were encouraged to breastfeed from either breast. The antibiotic was given for 10 days to all the patients. The study's main focus was on the primary outcome, which was the failure rate. Additionally, several secondary outcomes were examined, including postoperative pain, time required for healing, presence of residual abscess or recurrence, formation of fistulas, and the assessment of scar appearance. Results A total of 44 patients were randomized to 23 and 21 in each arm. There was no statistical difference in treatment failure (p-value=0.862), fistula formation (p-value=1.00), and recurrence (p-value=1.00). There was a significant statistical difference in healing period (p-value <0.001), scar formation (p-value <0.0001), continuation of breastfeeding (p-value=0.005), and clinical resolution (p-value=0.002). There was a significant reduction in post-intervention pain in the needle aspiration group than in the other group (p-value <0.001). Conclusion This study showed a significant difference in postoperative pain, healing time, the continuation of breastfeeding, and scar formation in the needle aspiration group, favouring minimally invasive treatment for breast abscess. However, due to the small sample size, we could not conclude that ultrasonography-guided needle aspiration of the breast abscess is non-inferior to the conventional incision and drainage.

Incidence, clinical profile and short term outcome of cerebral abscess in cyanotic congenital heart diseases

BackgroundBrain abscess is a serious infection of brain parenchyma in patients with cyanotic congenital heart disease (CCHD) and around 25–46 % of unrepaired CCHD patients develop brain abscess. Aim of this study was to determine the incidence, clinical features, microbiology and factors associated with early and short term outcome of cerebral abscess in CCHD. Methodology: This is a retrospective study, conducted at Pediatric cardiology department, National Institute of Cardiovascular Diseases (NICVD) Karachi. The data was collected from January 2019 to December 2021. All CCHD patients between 1 and 25 years of age were included. Data of patients with cerebral abscess was reviewed. ResultsAmong the 544 pediatric patients hospitalized in the last two years, brain abscesses were identified in 51 (9.3 %). Polycythemia (31.4 %) was the most significant contributing factor, especially in patients aged above 10 years. The most frequently seen CCHD was tetralogy of fallot (TOF) 60.8 %. Majority of the patients (84.3 %) had a single abscess while 15.7 % had multiple abscesses. E coli (9.7 %) was the most common isolated pathogen. Immediate complication identified was cerebral edema in 22 (43.1 %). Four patients (7.8 %) died, 47 (92.2 %) patients completed treatment course. 45.1 % had complete recovery however, 17 (33.3 %) had neurological deficits, 8 (15.7 %) had seizures and 2 (3.9 %) patients had residual abscess. Prolonged hospitalization was observed in patients of age group <10 years. ConclusionIn patients with underlying CCHD,early referrals and intervention are key to mitigating the severe consequences of cerebral abscesses and can drastically improve patient outcomes.

Post-myomectomy omental infarction: a case report

BackgroundOmental Infarction (OI) is uncommon and mimics common causes of acute abdomen. It is important to differentiate it from other abdominal conditions that require emergency management. It was first reported in literature in 1896 and about 400 cases have been reported till date.Case presentationWe reported on a 41 year-old Para 0+0 Ibo house wife who presented with 10 years history of supra-pubic mass and five months history of excessive menstrual flow. After physical examination, a diagnosis of symptomatic uterine fibroid was made. She had myomectomy and the raw surface created after the excision of the myomas was covered with omentum. Wound infection developed on the 8th post-operative day leading to a wound breakdown and later partial extrusion of infarcted omental tissue through the dehisced wound. During re-exploration, the infarcted omental tissue was extracted and the residual abdominal abscess was drained. Surgical site wound infection occurred on the 3rd day after re-operation and a sub-acute intestinal obstruction developed on the 4th day thereafter which responded to conservative management.ConclusionCareful surgical technique is imperative when utilizing the omentum for reconstructive abdominal surgery. Torsion of the omentum and creation of excess tension while using the omentum for reconstructive procedures should be avoided and increase awareness of this uncommon disease condition by the surgeon is also important. This case is to report a rare finding of omental infarction following myomectomy.

Perforation Peritonitis: Clinical Insights from a Three-Year Experience

Background: Peritonitis caused by gastrointestinal perforation is a frequent surgical emergency globally. Early detection and treatment are vital in reducing complications and death. Surgical intervention and good perioperative care improve outcomes. A clinical trial assessed the outcome of perforation peritonitis at a tertiary healthcare institute to identify factors contributing to morbidity and mortality. Materials and Methods: The study conducted at IMS, BHU, was a Prospective Observational Study for 3 years. Patients of all ages presenting with acute abdominal pain and gas under the diaphragm were enrolled. After examination through different methods, after resuscitation, Laparotomy was performed in all patients, followed by thorough peritoneal lavage. The site, size, type, and number of perforations were documented, and biopsy was taken from the edge of the perforation when necessary. Results: The study showed that duodenal ulcer perforation was the leading cause of gastrointestinal perforation, followed by appendicitis, typhoid perforation, and malignancy. Primary closure was the most common surgical procedure, followed by appendectomy, gut resection, and exteriorization. Mortality rate was , and observed morbidity included wound infection, fever, respiratory complications, residual abscess, electrolyte imbalances, burst abdomen, sepsis, cardiac complications, and anastomotic disruption. Conclusion: Gastrointestinal perforation is a common complication of acid peptic disease and typhoid. To control acid peptic disease, NSAIDs and triple therapy for H. pylori eradication can be used. Early and primary treatment for typhoid should be prioritized on a larger scale, and common practitioners should be educated to increase awareness about the disease.

Association between radical versus conservative surgery and short-term outcomes of hepatic cystic echinococcosis in Nyingchi, China: a retrospective cohort study

BackgroundRadical or conservative surgical treatment for hepatic Cystic Echinococcosis (hepatic CE) is controversial. We aimed to measure the association between radical surgery (RS) versus conservative surgery (CS) and short-term outcomes in our cohort.MethodsMedical records of hepatic CE patients’ demographic, clinical, radiological, operative and postoperative details who underwent surgical treatment between January 3, 2017 and January 3, 2018 at the Department of General Surgery, Nyingchi People's Hospital, Nyingchi, China, were retrieved and analyzed. The primary outcome was overall morbidity. The secondary outcomes included: (i) bile leakage; (ii) complications of lung, pleura, heart, liver, pancreas and biliary tract; (iii) incision infection and residual cavity abscess formation; (iv) anaphylactic reaction and shock; (v) tear of surrounding tissues; (vi) hospital and post-operative length of stay (LOS); (vii) length of surgery; (viii) blood loss during surgery. Multivariable logistic/linear regression models with various adjustment strategies for confounders were performed to evaluate the association.ResultsA total of 128 hepatic CE patients were included with 82 (64.1%) and 46 (35.9%) receiving CS and RS, respectively. After fully adjusted, RS was associated with 60% lower risk of overall complication (aOR 0.4; 95%CI, 0.2–0.9) and 0.6-h shorter surgical time (aβ 0.4; 95%CI,-0.0–0.8) comparing to CS. However, RS was associated with more blood loss during surgery (aβ 179.3; 95%CI, 54.2–304.5).ConclusionTo conclude, RS was associated with a 60% reduction in developing overall complication in the short term, but may result in more blood loss during surgery than CS.

Locally Advanced Rectal Cancer Invading the Gluteus Maximus Muscle Completely Responded to Total Neoadjuvant Therapy.

A 70-year-old male with anal pain and fever was diagnosed with rectal cancer perforation and abscess in the right gluteus maximus (GM) muscle. He underwent a transverse colon colostomy followed by preoperative capecitabine+oxaliplatin. Some local control was achieved but a residual abscess was observed in the right GM muscle. To secure circumferential resection margin by tumor reduction, he received chemoradiotherapy as total neoadjuvant therapy (TNT) and underwent laparoscopic abdominoperineal resection, D3 lymph node dissection, combined coccyx resection, and partial resection of the right GM muscle. The skin defect and pelvic dead space were filled with a right lateral vastus lateral great muscle flap. Histopathologically, the resected specimen showed no tumor cells in the primary tumor or lymph nodes, indicating a pathological complete response (pCR). This case suggests that TNT might improve the R0 resection and pCR rates and overall survival.

Comparison between laparoscopic versus open appendectomy in morbid obese patients

Purpose To evaluate the laparoscopic approach advantages for the management of acute appendicitis in morbidly obese patients. Methods A prospective study included all morbidly obese patients who had presented to the emergency department at Sohag University Hospitals and were diagnosed with acute appendicitis between the 1st of June 2022 and the 31st of January 2023. All those patients were invited to participate in the research by randomization. The authors informed patients and their first-degree relatives about both techniques, signed a consent form for participation in the study. The authors categorized them into two groups; laparoscopic approach (group I) and open approach (group II). Comparisons were based on operative time, intraoperative complications, length of hospital stay, postoperative complications, and time until return to normal daily activities. Results The study enrolled 64 patients: 33 had a laparoscopic appendectomy, and 31 had an open appendectomy. The groups were similar in terms of clinicopathologic characteristics. The operating time was significantly shorter for Group I patients than Group II (Group I, 49.09±16.21 min vs. Group II, 68.03±15.78 min; P value less than 0.05). Regarding the length of hospital stay, twenty-six patients (78.8%) were discharged within the 1st 24 h in the laparoscopic group versus 17 patients (54.8%) in the open group (P value 0.041). The time until return to the routine daily work was significantly shorter in the laparoscopic group (11.27±2.6 days) than in the open group (17.23±4.8 days) (P value less 0.05). Four postoperative complications were reported in the study population: wound complications (infection, seroma formation), residual abdominal abscess, paralytic ileus, and thromboembolic complications (Deep venous thrombosis and pulmonary embolism). Group II had a statistically significant higher complication rate (32.3%) than Group I (9.09%) (P value 0.007). Conclusion Laparoscopic appendectomy had superior clinical outcomes than an open appendectomy in morbidly obese patients. In addition to minimal invasiveness and better cosmetic results, it has a great advantage as a diagnostic and therapeutic tool in morbidly obese patients with suspected appendicitis. It is also a safe and feasible approach with a low rate of complications with a well-trained expert surgeon.

Pyogenic liver abscess following endoscopic retrograde cholangiopancreatography procedure for choledocholithiasis

Pyogenic liver abscess (PLA) is a condition in which there is pus accumulation in the liver. It usually develops in the context of portal pyemia, through hematogenous seeding as well as via biliary disease. PLA is a rare, but important complication following biliary instrumentation such as endoscopic retrograde cholangiopancreatography (ERCP). We report a case of a 44-year-old man who initially presented with clinical features of ascending cholangitis. Laboratory investigations revealed leukocytosis as well as hyperbilirubinemia. Diagnosis of choledocholithiasis was then confirmed with an ultrasound examination, showing a 1×1 cm stone in the common bile duct. ERCP was performed and achieved stone clearance. However, the patient returned 1 month later with similar symptoms of right upper quadrant pain, fever and jaundice. Suspecting recurrent choledocholithiasis, an emergency ERCP was performed and showed pooling of radio-opaque contrast in the extra-biliary space. There were also multiple CBD stones seen. An urgent CT Abdomen was done and revealed multiple liver abscesses in bilateral liver lobes, with the largest measuring 4.5x5.9x2.1cm. The patient was treated conservatively with Augmentin and repeat ultrasound at 4 weeks interval showed no residual liver abscess.

Diagnóstico por imagen de abscesos hepáticos y pulmonares por estreptococos del grupo viridans. Presentación de caso

Streptococcus viridans is more commonly known as an infectious agent in endocarditis, however, little is known about its infectious potential in other organs or systems, where it has shown high mortality. The recognition of Streptococcus viridans as an abscess-producing agent in other locations, such as the liver or lungs, will allow timely diagnosis using different imaging methods, reducing serious consequences for the patient and hospitalization times. We present the case of a 33-year-old male patient with no chronic degenerative history, who started symptoms 7 months prior to admission, with intermittent fever, fatigue, asthenia, anorexia and weight loss, on physical examination he presented pain at the medium and deep palpation in the right hypochondrium, in the laboratory panel I present striking neutrophilia, in the tomography of the thorax and abdomen a cavernous lesion in the lung and complicated hepatic cysts are shown, to which percutaneous drainage guided by ultrasound is performed, with sending of cultured samples with a positive result for Streptococcus viridans. Thus, allowing treatment to be provided to the patient, thereby achieving remission of the disease. Key words: Liver abscess; lung abscess; streptococcal infections; residual abscess; cavitary lung injury; Streptococcus viridans.

＜Editors' Choice＞ Advantages of gasless single-port transumbilical extracorporeal laparoscopic-assisted appendectomy in the treatment of uncomplicated acute appendicitis in children in China: a multi-institutional retrospective study.

Gasless transumbilical extracorporeal laparoscopic-assisted appendectomy is an approach used increasingly to treat uncomplicated acute appendicitis (UAA). However, there is limited information on its clinical effects and value in the Chinese pediatric population. This study retrospectively reviewed patients with UAA treated in two pediatric institutions from January 2018 through October 2021. Enrolled patients were divided into two groups by operative technique: gasless transumbilical laparoscopic-assisted appendectomy (gasless-TULAA, n=142) and conventional laparoscopic appendectomy (CLA, three-port, n=126). The perioperative clinical data, including age, sex, body mass index (BMI), operation time, time to postoperative ambulation, time to first postoperative exhaust, hospitalization expenses, and postoperative complications (incision infection, intestinal obstruction, and residual abdominal abscess), were compared between the two groups. Operations in both groups were successfully conducted without converting to open surgery. There were no significant differences (p > 0.05) in age and BMI in the two groups. Compared with CLA, gasless-TULAA showed significantly shorter operation time, earlier postoperative ambulation, shorter postoperative exhaust time, and lower hospital cost (p < 0.001). All patients were followed for 3 months, and postoperative complications were observed in three patients: two patients in the gasless-TULAA group (one with surgical wound effusion, one with intra-abdominal abscess), and one patient in the CLA group (surgical wound infection); there was no significant difference between the groups. Notably, 38 patients initially treated by gasless-TULAA were converted because of intraoperative factors. The gasless-TULAA technique had potential benefits: shortened operation time, better outcome, and greater cost-efficiency. These superiorities are worthy of future large-scale prospective study.

S2812 Cholelithiasis Resulting in Partial Mirizzi Syndrome and Liver Abscess

Introduction: Mirizzi syndrome is defined as common hepatic duct (CHD) obstruction caused by extrinsic compression from an impacted stone in the cystic duct or gallbladder infundibulum. Failure to recognize it prior to cholecystectomy, can result in intraoperative bile duct injury and subsequently in significant morbidity. Patients present with one or more of the following: right upper quadrant pain, fever and jaundice; classically with elevated bilirubin and alkaline phosphatase. Case Description/Methods: A 67-year-old female presented with fever, right upper quadrant abdominal pain and emesis. Workup revealed leukocytosis, bilirubin 0.4 mg/dL (≤1.2), alkaline phosphatase 226 IU/L (35-104), aspartate aminotransferase 42 IU/L (< 32) and alanine transferase 86 IU/L (< 33). CT scan followed by magnetic resonance cholangiopancreatography showed a 7.2 x 6.1 cm heterogenous lesion in the right hepatic lobe of the liver consistent with a liver abscess, contracted gallbladder with cholelithiasis, and a large gallbladder neck/cystic duct stone externally compressing the right hepatic duct causing upstream dilatation resulting in a partial Mirizzi syndrome (Figure A). The left hepatic duct, CHD, and common bile duct (CBD) were unaffected. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed a large gallbladder neck stone compressing the right hepatic duct, with a normal left hepatic duct, CHD, and CBD (Figure B). Biliary sphincterotomy with basket sweep of the CBD and stent placement was performed. Follow up cholangiogram revealed a decompressed biliary tree. The liver abscess was drained percutaneously, and patient was discharged on intravenous antibiotics. She underwent elective cholecystectomy with right hepaticojejunostomy after 8 weeks. Postoperative imaging showed intact hepaticojejunostomy and no residual abscess. Discussion: This case is unique as patient did not develop classic obstructive jaundice due to intact drainage on the left but developed a liver abscess due to prolonged biliary stasis on the right. The patient required a combined endoscopic, interventional, and surgical approach for therapeutic success. Recognition of Mirizzi syndrome was key to planning therapeutic steps with ERCP followed by abscess drainage prior to surgery to ensure the best possible outcome for the patient.Figure 1.: A: MRCP showing right liver lobe abscess (white arrow). B: ERCP showing gallbladder (black arrow) with stone in gallbladder neck (block arrow) causing compression and upstream intrahepatic dilatation of right intrahepatic duct (white arrow). MRCP (magnetic resonance cholangiopancreatography), ERCP (endoscopic retrograde cholangiopancreatography).

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.

Is routine imaging necessary prior to percutaneous abscess catheter removal?

Routine management after abscess drainage includes CT or fluoroscopic imaging to assess for residual abscess cavity prior to catheter removal. It is unclear whether this practice is necessary in patients without residual infection signs and symptoms. To evaluate safety of abscess catheter removal without follow-up imaging in patients without residual clinical or laboratory signs of infection and catheter output < 10cc/day for 2 consecutive days. In this IRB-approved, HIPAA compliant, retrospective study, consecutive patients that underwent percutaneous CT-guided drainage of a single abdominal or pelvic abscess between 01/2015 and 12/2017 in a single tertiary academic institution with or without follow-up imaging prior to catheter removal were included. In our institution, catheters are routinely removed without imaging if there are no clinical (fever, pain) or laboratory (elevated WBC count) signs of infection and catheter output is < 10cc/day for 2 consecutive days. Patients' and abscess's characteristics, repeat imaging data, and need for re-interventions were obtained through medical records review. Statistical analysis was performed with Fisher's exact test for independent data and Student's t-test for comparison of group means. 310 consecutive patients (age 56 ± 16years, 48% female) were included in the study. In 265/310 (85%) patients, no routine follow-up imaging prior to catheter removal was obtained. In 2/265 (0.8%, 95% CI 0.02-0.27%) patients without routine pre-removal imaging, repeat abscess drainage was required 6 and 15days after catheter removal in patient with perforated appendicitis and after laparoscopic renal cyst decortication, respectively. No patients, 0/45 (0%, 95% CI 0-0.07), that underwent routine imaging without clinical or laboratory signs infection needed to undergo a repeat abscess drainage. There is a low rate (0.8%) of abscess recurrence if percutaneous abscess catheter is removed at the time cessation of drainage without routine imaging in clinically well patient.

A comparative study of laparotomy closure in peritonitis with and without intraabdominal drainage

Background: Purpose of this study was to investigate whether the use of abdominal drainage after laparotomy for peritonitis can prevent or significantly reduce post-operative complications such as intra-peritoneal abscess formation or wound infection.Methods: A prospective randomized study was done of one hundred and one (101) cases who underwent emergency laparotomy at General Hospital Palanpur and Sushrut Surgical Hospital, Palanpur. After completion of operation for peritonitis peritoneal cavity was either drained or not drained. Drained group of cases was termed as group A and non-drained group of cases was termed as group B. Parameters noted in group A were daily drain output, character and culture sensitivity of the fluid. Surgical outcomes in form of hospital stay and postoperative complications like wound infection, wound dehiscence, residual abscess within month of operation were compared between two groups.Results: Significant difference was observed between drained group and non-drained groups in terms of length of hospital stay, wound infection, wound dehiscence, residual abscess and overall postoperative complicationConclusions: From the present study we deduce that prophylactic abdominal drain in each case is unnecessary, as it stops functioning latest by 72 hours if not draining. On the contrary it invites infection from outside. This may delay convalescence. Drain should be kept when leak from suture line is anticipated or when there is lot of necrotic tissue within peritoneal cavity, and kept till it functions; otherwise it should be removed earliest.