Subdiaphragmatic Abscess Research Articles

Colopleural fistula caused by aspergillus: an extremely rare complication after lung resection-case report.

A colopleural fistula is a rare condition reported to be caused by Crohn’s disease, a malignant tumor of the gastrointestinal tract, and other clinical conditions. Some studies have noted that a sub-diaphragmatic abscess, usually organized following abdominal surgery, may play some role in the formation of this type of fistula. Therefore, a colopleural fistula is a complication very rarely encountered by thoracic surgeons after lung resection.We experienced an extremely rare case of colopleural fistula following a left lower lobectomy for lung aspergillosis. Here, we report a 71-year-old man with a surgical history of proximal gastrectomy for gastric cancer. He underwent left lower lobectomy of the lung for aspergillosis, and a colopleural fistula occurred on the second operative day as a complication. Aspergillus might be responsible for forming a fistula between the colon and lung via the diaphragm, and lung surgery manifested this rare condition. Although some reports suggest that surgical treatment is mandatory to cure this fistula, an immediate colostomy in our case reduced the internal pressure of the colon, thus enabling spontaneous closure of the fistula with appropriate drainage and antibiotics. The patient was discharged in a good condition.

Surgical Techniques for Diaphragmatic Resection During Cytoreduction in Advanced or Recurrent Ovarian Carcinoma: A Systematic Review and Meta-analysis.

Optimal cytoreduction is one the main factors improving survival outcomes in patients affected by ovarian cancer (OC). It is estimated that approximately 40% of OC patients have gross disease located on the diaphragm. However, no mature data evaluating outcomes of surgical techniques for the management of diaphragmatic carcinosis exist. In the present study, we aimed to estimate surgery-related morbidity of different surgical techniques for diaphragmatic cytoreduction in advanced or recurrent OC. PubMed (MEDLINE), Web of Science, and Clincaltrials.gov databases were searched for records estimating outcomes of diaphragmatic peritoneal stripping (DPS) or diaphragmatic full-thickness resection (DFTR) for OC. The meta-analysis was performed using the Cochrane Review software. For the final analysis, 5 articles were available, including 272 patients. Diaphragmatic peritoneal stripping and DFTR were performed in 197 patients (72%) and 75 patients (28%), respectively. Pooled analysis suggested that the estimated pleural effusion rate was 43% and 51% after DPS and DFTR, respectively. The need for pleural punctures or chest tube placement was 4% and 9% after DPS and DFTR, respectively. The rate of postoperative pneumothorax (4% vs 9%; odds ratio, 0.31; 95% confidence interval, 0.05-2.08) and subdiaphragmatic abscess (3% vs 3%; odds ratio, 0.45; 95% confidence interval, 0.09-2.31) were similar after the execution of DPS and DFTR. Diaphragmatic surgery is a crucial step during cytoreduction for advanced or recurrent OC. Obviously, the choice to perform DPS or DFTR depends on the infiltration of the diaphragmatic muscle or not. Both the procedures are associated with a low pulmonary complication and chest tube placement rates.

Is pneumoperitoneum the terra ignota in ultrasonography?

In most cases, pneumoperitoneum is caused by gastrointestinal perforation, which usually requires surgical treatment. Many authors believe that ultrasound imaging of pneumoperitoneum is at least as effective as conventional radiography, or even that its efficacy is superior. In such a situation, it is imperative to make this modality one of the main tools in the diagnostic arsenal of emergency medicine. This is the main aim of this paper. First, ultrasound anatomy of so-called thoracic-abdominal border is discussed. The equipment requirements emphasize that the diagnostic process can be conducted with the simplest portable US scanner, even without the Doppler mode. The technique of a US examination, the aim of which is to detect, free air in the peritoneal cavity is also simple and conducted with the patients lying down, either in the supine or lateral position. A convex transducer with the frequency of 3.5–5 MHz is applied above the lower intercostal spaces on the right and left side, to the epigastric region below the xiphoid process and in various sites of the abdominal wall. The most effective examination, however, is conducted in the left lateral position via the right intercostal spaces. The differential diagnosis on the right side under the diaphragm should include the presence of a subdiaphragmatic abscess with gas and a hepatic abscess with a similar content as well as transposition of the colon in between the diaphragm and the liver (Chilaiditi syndrome). It seems that the inclusion of a US examination to the E-FAST method in order to detect free gas in the peritoneal cavity is justified since it is a sign of gastrointestinal perforation in numerous cases, and is clinically as relevant as the presence of free fluid.

Spleen-preserving D2-lymphodissection in gastric cancer surgery

Oncological advisability of spleen removal during surgical treatment of gastric cancer is arguable at present time. It is presented technique of spleen-preserving D2-lymphodissection used for gastric body and proximal part cancer which was applied in 155 patients. Control group included 197 patients who underwent gastrectomy with splenectomy. Spleen-preserving D2-lymphodissection increased duration of surgery but decreased frequency of subdiaphragmatic abscess and pancreatic fistulas and duration of hospital stay. 5-years survival (Kaplan-Meier) was 59% in main group, in control group - 55% (p>0.05). We consider that spleen-preserving D2-lymphodissection is radical and safe surgical method for locally advanced cancer of gastric body and proximal part.

Abdominal Abscess Caused by Mycobacterium llatzerense

Mycobacterium llatzerense was cultured from a subdiaphragmatic abscess. To our knowledge, this is the first report of isolation of this rapidly growing mycobacterium from a human. Growth characteristics and antimicrobial susceptibilities different from those previously reported for environmental isolates were observed.

Application of damage control surgery in the treatment of severe liver trauma patients

Objective To investigate the clinical application and nursing effect of damage control surgery （ DCS ） in treating patients with severe liver trauma .Methods A retrospective study was used to investigate 83 patients with severe liver trauma （ grade Ⅳ, and Ⅴ） from January 2008 to December 2012 associated with the lethal triad of coagulopathy , hypothermia , and acidosis treated by DCS .Nursing intervention included fluid resuscitation , care of lethal triad and postoperative complications .And the control group was 31 patients with liver trauma of grade Ⅳand Ⅴwho had be treated without DCS .Results The mortality rate was 25.3%and 51.6% in the DCS group and the control group , and the difference was statistically significant （χ2 =7.13, P<0.01）.The main cause of death was coagulopathy .The incidence of abdominal compartment syndrome was respectively 6.0% and 19.4% in the DCS group and the control group , the incidence of subdiaphragmatic abscess was 7.2%and 22.6%, and the differences were statistically significant （χ2 =4.60, 5.27, respectively;P<0.05）.Conclusions DCS for patients with severe liver trauma can obviously increase their survival rate .The point of nursing intervention was limited fluid resuscitation before the surgery , correction of coagulopathy , hypothermia and acidosis during ICU as well as prevention and management of postoperative complications after the surgery . Key words: Damage control; Liver trauma; Coagulopathy; Nursing intervention

Zrosty wewnątrzbrzuszne w ultrasonografii. Część II: Morfologia zmian

Despite their frequent appearance, intra-abdominal adhesions are rarely the subject of clinical studies and academic discussions. For many years the operators have been trying to reduce such unfavourable consequences of interventions in the abdominal structures. The aim of this article is to present the possibilities of intra-abdominal adhesion diagnostics by means of ultrasound imaging based on authors’ own experience and information included in pertinent literature. The anatomy and examination technique of the abdominal wall were discussed in Part I of the article. In order to evaluate intraperitoneal adhesions, one should use a convex transducer with the frequency of 3.5–6 MHz. The article provides numerous examples of US images presenting intra-abdominal adhesions, particularly those which appeared after surgical procedures. The significance of determining their localisation and extensiveness prior to a planned surgical treatment is emphasized. Four types of morphological changes in the ultrasound caused by intra-abdominal adhesions are distinguished and described: visceroperitoneal adhesions, intraperitoneal adhesions, adhesive obstructions as well as adhesions between the liver and abdominal wall with a special form of such changes, i.e. hepatic pseudotumour. Its ultrasound features are as follows:The lesion is localised below the scar in the abdominal wall after their incision.The lesion is localised in the abdominal part of the liver segments III, IV and V.With the US beam focus precisely set, the lack of fascia – peritoneum complex may be noticed. An uneven liver outline or its ventral displacement appears.A hepatic adhesion-related pseudotumour usually has indistinct margins, especially the posterior one, and, gradually, from top to bottom, loses its hypoechogenic nature.In a respiration test, this liver fragment does not present the sliding movement – a neoplastic tumour rarely shows such an effect. The immobility of the liver is a permanent symptom of subdiaphragmatic abscess which needs to be included in the differentiation process.In case of doubts, the suspicious liver area may be examined without the consideration of the scar in the abdominal wall. In the differentiation of visceroperitoneal adhesions, firstly, one needs to exclude the peritoneum infiltration in the course of inflammation and neoplastic spreading, which may be very difficult in patients who have undergone a surgery. Pseudomyxoma peritonei constitutes a source of errors much more rarely.

P-068 Gyneco-obstetrical bleeding in a cohort of female patients with factor XI deficiency. A report from French Canada

terms of pregnancy with threatened abortion. 1st pregnancy (2010) was complicated with repeated bleedings from esophagal and gastric varicose veins. At 20 weeks the patient was undergone urgent surgery (gastrotomy, phleborrhaphy of esophagal and gastric varicose veins). The diagnosis that was made was extrahepatic portal hypertension of thrombotic origin. Esophagal and gastric varicose veins bleeding Splenomegaly. Operation was complicated (subdiaphragmatic abscess with burst in the abdominal cavity, peritonitis, sepsis). At 24 weeks spontaneous abortion happened. The patient was urgently transferred to one of the Moscow clinics where she was reoperated and discharged in a satisfactory condition. On laboratory examination we detected HCV antibodies, Factor V Leiden mutation (+−) and polymorphisms of PAI-1 4G/5G, pro-inflammatory cytokines (IL-6, IL-1β, C-reactive protein). Homocystein level was normal.The antiphospholipid syndrome was excluded. At the moment of the address the patient received Sulodeksid, synthetic progesterone, folic acid. We took into account the medical history of the patient and the confirmed thrombophilic condition and corrected the treatment. We prescribed LMWH, natural micronized progesterone, vitamins, compression stockings. The pregnancy course was uncomplicated.At 39 weeks the patient had normal vaginal delivery, uncomplicated. We recommended to check the child for factor V Leiden mutation. In the postnatal period the treatment with LMWH was continued. Conclusion: The splanchnic vein thromboses are challenging. The clinical picture is various, and if the thrombophilic condition is undiagnosed the patient would remain in the risk group for postnatal portal hypertension.

765 - Results of Surgery of Gastric Lymphomas Complicated with Bleeding, Stenosis and Perforation

ABSTRACT Background Our purpose is to study results of surgery of patients with primary non-Hodgkin's lymphomas complicated with bleeding, stenosis and perforation. Materials and methods 66 patients with primary non-Hodgkin's lymphomas were treated in our centre between 1984 and 2009 because of bleeding – 49, stenosis – 11, gastric perforation – 6. Group under study included 28 females and 38 males, mean age was 49. Bleedings from benign gastric ulcers and gastric perforations outside of tumor lesions' zones were excluded from the study. The histological types: diffuse large B cell lymphoma – 50 patients (76%), MALT-lymphoma – 12 (18,5%), Burkitt's lymphoma – 4 (6%). Localization of the lesions: overall – 29 patients (44%), antrum – 22 (33%), stomach's body – 9 (15%), proximal part – 6 (9%). 26 patients (39%) had stage I, 19 (29%) – II, 21 (31,5%) – IV. 45 patients (68%) had complications before chemotherapy, 8 (12%) – during the course, 13 (20%) – after. Patients after chemotherapy had gastric perforation more frequent (in 20% of cases) than chemo-naive patients (4,3%, p = 0,063). Gastrectomy was performed for 47 patients (71%), subtotal gastrectomy – 12 (19%). Results 43 (65,1%) patients had radical operations, 14 (21,2%) had palliative gastrectomy or gastric resection, 4 (6%) had bypass operations and 5 (7,5%) had only explorative laparotomy. Overall postoperative mortality was 11%. 35% patients had postoperative complications. The most frequent complications were subdiaphragmatic abscess (5,2%), postoperative wound infection (5,2%) and pneumonia (5,2%). Overall 3-, 10- and 10-year survival rate in the group under study was 75%, 65% and 40%, respectively; median survival was 100 months. Patients after radical operations had higher three- and five-year survival rates than patients after palliative gastrectomies and resections (82% and 73% vs. 51% and 44%), however ten-year survival rates in both groups were practically the same. Summary Complications of gastric lymphomas can occur at any stage of the disease. Aggressive surgical approach allows to ablate affected organ and remove the source of fatal complications for 86% of patients. Due to postoperative chemotherapy, more than half of patients survive 5 years after surgery. Disclosure All authors have declared no conflicts of interest.

Chilaiditi Syndrome in an HIV Positive Patient with History of Gastritis

Purpose: In this report, we present the case of a patient with the rare Chilaiditi syndrome, manifesting as episodic abdominal pain that worsened while fasting. Definitive diagnosis of Chilaiditi syndrome requires evidence of the interposition of large or small bowel between the liver and right hemidiaphragm (Chilaiditi sign). Chilaiditi sign is often an incidental roentgen finding in asymptomatic patients. It can be mistaken for pneumoperitoneum, resulting in unnecessary surgery. It can also be mistaken for subdiaphragmatic abscess. Recurrent abdominal pain, distention, vomiting, anorexia, and constipation are typical symptoms of Chilaiditi syndrome. Chilaiditi syndrome more commonly affects males (4:1 male to female ratio), the elderly, and the mentally retarded. Obesity is also a predisposing factor. Case: In the following case, we describe a 55 year old HIV positive gentleman (last absolute CD4 count of 504) with history of gastritis, heavy nonsteroidal anti-inflammatory drug use, hypertension, and anemia presenting with two years of intermittent, crampy epigastric pain that would occur whenever he was fasting. Previous diagnoses included H. pylori-related gastritis and dyspepsia. Symptoms were not associated with fever, chills, weight loss, nausea, or vomiting. However, he has had constipation in the past. Episodes of pain would last two to three hours and resolve spontaneously with no obvious alleviating factors. His daily dose of proton pump inhibitor, esomeprazole, has given him only partial relief. PA and lateral radiographs of the chest showed minimal pleural thickening, and in the right upper quadrant, a loop of transverse colon compatible with Chilaiditi syndrome (Figure 1). There was no acute airspace disease or pulmonary edema identified. This patient has been managed conservatively, and continues to be monitored and evaluated for the possibility of other exacerbating conditions, including peptic ulcer disease.Figure 1: Posterior-anterior chest radiograph revealing hepatodiaphragmatic interposition of the transverse colon (Chilaiditi sign).

High-Dose Ciprofloxacin for Serious Gram-Negative Infection in an Obese, Critically III Patient Receiving Continuous Venovenous Hemodiafiltration

To describe the pharmacokinetic profile and clinical outcome associated with high-dose ciprofloxacin therapy in a patient with the triad of extreme obesity, multiple organ failure, and deep-seated infection. A 45-year-old, class 3 obese (185 kg; body mass index 53.7), critically ill trauma patient receiving continuous venovenous hemodiafiltration (CVVHDF) was treated with ciprofloxacin 800 mg intravenously every 12 hours for presumed Enterobacter aerogenes (ciprofloxacin minimum inhibitory concentration [MIC] ≤1 μg/mL) lumbar spine osteomyelitis. Four sequential plasma ciprofloxacin samples were obtained and analyzed to determine the steady-state pharmacokinetic profile. The observed steady-state maximum (C(max)) and calculated minimum (C(min)) ciprofloxacin plasma concentrations measured on treatment day 8 were 13 μg/mL and 4.8 μg/mL, respectively, corresponding to an estimated half-life, area under the curve (AUC(0-24)), total systemic clearance, and clearance by CVVHDF of 7.6 hours, 192 μg·h/mL, 139 mL/min, and 26 mL/min, respectively. These concentrations produced AUC(0-24)/MIC ratios >125 and plasma C(max)/MIC ratios >10 for MICs ≤1 μg/mL. Intravenous colistin and polymyxin B lumbar wound irrigation were initiated on ciprofloxacin days 12 and 15, respectively, for concomitant multidrug-resistant Acinetobacter baumannii infection. Lumbar tissue cultures on day 24 of ciprofloxacin therapy demonstrated no growth, coinciding with overall improvement of the invasive wound. A week later, the patient developed worsening septic shock and died secondary to an occult subdiaphragmatic abscess. Pharmacodynamic outcome studies suggest that AUC(0-24)/MIC ratios >125 and plasma C(max)/MIC ratios >10 are good predictors of clinical and microbiologic success of ciprofloxacin against gram-negative pathogens. These pharmacodynamic goals were achieved in the plasma with high-dose ciprofloxacin for MICs ≤1 μg/mL. Critically ill obese patients with deep-seated infection involving organisms with MICs >0.5 μg/mL likely require ciprofloxacin dosages greater than traditional daily doses of 400-800 mg during CVVHDF to achieve optimal pharmacodynamic targets.

Pleurobiliary fistula, a rare complication of hepatocellular carcinoma after locoregional chemotherapy: a case report

A rare complication of the compilation of high intrahepatic biliary pressure and the formation of a subdiaphragmatic abscess is that of pleurobiliary fistula. We present a case of 67-year-old male who presented with pleurobiliary fistula following transarterial chemoembolization in a patient with a large hepatocellular carcinoma, as well as the course of the diagnostic procedures and the therapeutics interventions which took place.

Bilateraler Infusothorax und Infusomediastinum nach Punktion der V. subclavia rechts

Complications after the percutaneous insertion of central venous catheters are pneumothoraces, catheter-associated infections and thrombosis. In rare cases, late problems occur as a disruption of the main thoracic duct or vascular erosion. The developing pleural effusion must be analysed for other causes such as congestive heart disease, inflammatory or tumorous disease, pancreatitis, low blood protein, or subdiaphragmatic abscess. The following case report describes a rare catheter complication in a 16-year-old polytraumatised patient. The differentiation to a chylothorax and suitable therapy are described.

A Case of Tuberculosis Presented with Pseudoaneurysm of the Aorta and Acute Respiratory Distress Syndrome

We experienced a case of tuberculosis presented simultaneously with pseudoaneurysm of the aorta and ARDS. A 63-year-old man was admitted with complaints of fever and right upper quadrant abdominal pain for a week. Chest X-ray on admission showed a normal finding. Sub-diaphragmatic abscess on abdomen CT scan was suspected and serosanguinous fluid was aspirated from the abscess pocket. On day 2, he was getting more dyspneic and chest X-ray revealed extensive bilateral infiltration. Aspirated fluid revealed AFB. Later, follow-up abdomen CT scan revealed a leakage of dye from the aneurysmal sac of the descending aorta which was previously diagnosed as sub-diaphragmatic abscess. An aortic stent was placed, covering the opening into the aneurysm. The sputum also showed positive AFB. The patient was successfully weaned from the ventilator, and discharged with anti-tuberculous medication on day 42. Follow-up abdomen CT scan 6 months later showed that the aneurymal sac was completely disappeared. (Tuberc Respir Dis 2008;64:298-302)

Duodeno-pleural fistula: a rare complication of peptic ulcer perforation.

Duodenopleural fistula is a very uncommon complication of peptic ulcer perforation and usually follows empyema after a subdiaphragmatic abscess rupture. We present a rare case of duodenopleural fistula following subdiaphragmatic abscess, which resulted in thoracic empyema after gastric perforation.

Subphrenic abscess and recurring focal lesions due to tuberculosis in a patient with IgA deficiency

Subdiaphragmatic abscess has not yet been reported as a manifestation of tuberculosis. We report an IgA deficient patient with recurrent episodes of unusual extrapulmonary manifestations of tuberculosis including subdiaphragmatic abscesses and metacarpophalangeal osteomyelitis that was improved each time with antituberculosis drugs. There was not any resistance to the drugs used against mycobacterium despite repeated courses of antituberculosis regimens. In such recurrent cases, one should rule out any immunodeficiency states.

Traitement de la super super obésité morbide par gastrectomie longitudinale

INTEREST OF WORK: The longitudinal or "sleeve" gastrectomy was recently introduced into the therapeutic arsenal of the bariatric surgeon. It is a restrictive procedure that reduces stomach capacity by 75%. We present here a preliminary experience with four patients. Four patients with super super obesity (body mass index (BMI)>60 kg/m2) underwent longitudinal or "sleeve" gastrectomy. Their average preoperative weight was 173 kg (range: 147-190 kg) and mean BMI 65 kg/m2 (range: 61-67 kg/m2). The average post-operative follow-up was 6 months (range: 2-12 months). Average weight loss at 6 months was 40 kg (range: 20-60 kg) and average decrease in BMI at 6 months 16.3 kg/m2 (range: 6-23 kg/m2). We noted a postsurgical complication in only one patient (subdiaphragmatic abscess treated with drainage). These preliminary results suggest that the sleeve gastrectomy is associated with few perioperative complications and offers rapidly effective treatment for super super morbid obesity. Long-term results require further investigation.

Hepatic lobectomies in children: experience of a center in the light of changing management of malignant liver tumors

Hepatic resection is the main treatment modality for hepatic tumors in childhood. Advances in diagnostic technique, preoperative preparation, surgical technique, and postoperative management increased the success rate. The aim of this study is to report our experience in hepatic lobectomy, which is relatively rare procedure in childhood. Medical records of 25 patients who underwent hepatic lobectomy between January 1977 and June 2002 were reviewed retrospectively. Age, gender, diagnosis, physical examination findings, results of preoperative laboratory investigations, radiological examination, resectability criteria, preoperative biopsies, chemotherapies, radiotherapies, postoperative pathological results, incisions, operation technique, intraoperative transfusions, drains used, antibiotic prophylaxes, and intraoperative and postoperative complications were evaluated for all patients. Out of 25 patients with hepatic tumor seven patients with hepatoblastoma and four patients with hepatocellular carcinoma were given 5.7 +/- 0.3 cycles of chemotherapy before the operation. Right lobectomy (n = 12), left lobectomy (n = 5), extended left lobectomy (n = 4), and extended right lobectomy (n = 3) and right lobectomy with enucleation of two masses from left lobe (n = 1) were performed. Intraoperative blood transfusion of 30.7+/-6.0 ml/kg body weight was necessary. Pathological examination of resected tumors revealed hepatoblastoma (n=11), mesenchymal hamartoma (n = 5), hepatocellular carcinoma (n = 4), hemangioendothelioma (n=1), malignant mesenchymal tumor (n = 1), hemangioma (n = 1), cyst adenoma (n = 1), and metastasis of cellular mesoblastic nephroma (n = 1). Patients were observed in the intensive care unit for 3.4 +/- 0.3 days. Postoperative complications were sepsis (n = 1), disseminated intravascular coagulation (n = 2), fever (n = 3), jaundice (n = 3), intraabdominal abscess (n = 3), ileus (n = 2), and subdiaphragmatic abscess with pleural effusion (n = 1). Hepatic lobectomy is a major operation, which is feasible yielding curative results in children. Safe hepatic resections with acceptable blood loss can be performed by a technique relying on good anatomic dissection and surgical control.

A case of bronchobiliary fistula associated with subdiaphragmatic abscess after hepatic surgery

A case of bronchobiliary fistula associated with subdiaphragmatic abscess after hepatic surgery

Transphrenic Fistulization of a Subphrenic Abscess to Lung Parenchyma

A 53-year-old woman was admitted with respiratory distress. For several years, she had chronic alcoholic pancreatitis with ductal stones that were treated with a stent and with shockwave lithotripsy. Both treatments were unsuccessful, and the pancreatitis was complicated with an infected pseudocyst. The pancreatic head had to be resected, which was complicated with recurrent subphrenic abscesses. She then was admitted with respiratory distress and initially diagnosed with pneumonia of the right lower lobe. Further investigations showed supradiaphragmatic and subdiaphragmatic air-fluid levels. In both collections Streptococcus milleri was cultured, and subsequently the patient was diagnosed with a fistula connecting the subdiaphragmatic abscess with pulmonary tissue. This was treated with intravenous amoxicillin/clavulanate and drainage of the subdiaphragmatic collection. She did not develop a pulmonary empyema, because multiple adhesions, which were due to recurrent abscesses after pancreatic surgery, prevented breakthrough into the pleural cavity.