Subphrenic Abscess Research Articles

Gastrobronchial Fistula in Sleeve Gastrectomy and Roux-en-Y Gastric Bypass--A Systematic Review.

Gastrobronchial fistula (GBF) is a rare surgical complication after bariatric surgery. We aimed to identify the clinical aspects of GBF and establish diagnostic and treatment strategies. A literature search was conducted in December 2013, in the PubMed electronic database. Eleven studies were selected, comprising a total of 36 patients. Most patients presented with a gastric leak prior to the diagnosis of GBF. Mean period until diagnosis was 7.2months, and main presenting symptoms were productive cough (n = 13) and subphrenic abscess (n = 12). Endoscopic treatment was successful in 18 out of 20 patients, with minimal complication. Surgical treatment was successful in 17 cases with significant complications. GBF can be effectively treated with both endoscopic and surgical approach; however, surgical treatment can be associated with more complication.

Laparoscopic sleeve gastrectomy with duodenal-jejunal bypass for the treatment of type 2 diabetes mellitus

Objective To investigate the clinical effects of laparoscopic sleeve gastrectomy with duodenal-jejunal bypass (LSG+ DJB) for the treatment of type 2 diabetes mellitus. Methods The clinical data of 17 patients with type 2 diabetes mellitus who underwent LSG+ DJB at the Xijing Hospital of the Fourth Military Medical University from March 2013 to February 2014 were retrospectively analyzed. The fasting blood glucose, postprandial 2-hour blood glucose, glycosylated hemoglobin (HbA1c) and body mass index (BMI) in 17 patients before operation were (9.2±0.6)mmol/L, (14.4±2.2)mmol/L, 8.3%±1.2% and (29.4±2.2)kg/m2, respectively. All the patients received LSG+ DJB and were followed up by outpatient examination up to March 2015. The pre- and post-operative 12- month fasting blood glucose, postprandial 2-hour blood glucose, HbA1c and BMI in 17 patients were compared. Measurement data with normal distribution were presented as ±s and analyzed by the t test. Results All the 17 patients received successful laparoscopic LSG+ DJB without conversion to open surgery. The operation time, volume of intraoperative blood loss and recovery time of postoperative gastrointestinal function were (141±53)minutes, 40 mL and 2.5 days. Of 3 patients with postoperative complications, 1 patient with anastomotic leakage at postoperative day 5 received reoperation by laparoscopic Roux-en-Y gastric bypass, 1 patient with digestive tract obstruction at postoperative day 10 released obstruction by reoperation and 1 patient with left subphrenic abscess and leakage at the upper of the stomach at postoperative week 2 was cured by the sympto-matic treatment. The duration of hospital stay was 5.2 days. All the patients were followed up for a median time of 16 months (range, 13-24 months). The postoperative 12-month fasting blood glucose, postprandial 2-hour blood glucose, HbA1c and BMI in 17 patients were (5.5±0.7)mmol/L, (8.8±1.7)mmol/L, 5.1%±0.7% and (24.7±2.3)kg/m2, which were significantly different from preoperative indicators (t=19.96, 10.52, 12.06, 31.99, P<0.05). During the follow-up, no anastomotic ulcer and stenosis, dumping syndrome and severe malnutrition were occurred. Conclusion LSG+ DJB is safe and feasible for the treatment of type 2 diabetes mellitus, with a good short-term hypoglycemic effect. Key words: Diabetes mellitus, type 2; Sleeve gastrectomy; Duodenal jejunal bypass; Laparoscopy

Risk factors and clinical outcomes for spontaneous rupture of pyogenic liver abscess.

To evaluate the risk factors and clinical outcomes in patients with spontaneous rupture of pyogenic liver abscess (PLA). A total of 602 patients diagnosed with PLA between January 2004 and July 2013 were retrospectively analyzed. Among them, 23 patients experienced a spontaneous rupture of liver abscess (SRLA). The prevalence of SRLA was 3.8%. Using multivariate analysis, liver cirrhosis (OR 4.651, P = 0.009), gas-forming abscesses (OR 3.649, P = 0.026), abscess ≥6 cm in diameter (OR 10.989, P = 0.002) and other septic metastases (OR 1.710, P = 0.047) were risk factors for SRLA. Regarding the site of rupture, 20 (87.0%) patients had a localized rupture, specifically, subphrenic abscess in 3 (13.0%), peri-hepatic abscess in 10 (43.5%), localized peritoneal abscess in 3 (13.0%) and empyema in 4 (17.5%); and the other 3 (13%) had peritonitis. Ruptures resulting in peritonitis require urgent surgery, whereas localized ruptures were managed with surgical or percutaneous drainage in addition to appropriate antibiotics. The in-hospital mortality rate of SRLA was 4.3%. Patients with cirrhosis, having abscess ≥6 cm in diameter, gas-forming abscesses and other septic metastases in those with PLA should be monitored closely and may need early intervention for SRLA.

Minimally Invasive Surgery for Small Bowel Obstruction: The Experience of a Tertiary Hospital in the Anglo-Caribbean

Objectives: The aim of this study was to access the feasibility and benefit of minimally invasive surgery for Small Bowel Obstruction in a tertiary hospital in Trinidad and Tobago. Design and Methods: All patients with clinical and radiologically diagnosed small bowel obstruction, who had nil resolution with conservative management at 48 hours, or who had nil passage of oral contrast into the colon at 12 hours, were included in this case series. Exclusion criteria included: anesthesiological contraindication for laparoscopy. The primary endpoints were resolution of obstruction (time to first bowel movement, time to commencement of oral feeds) and length of hospital stay. Secondary endpoints included overall morbidity and operative complications (bleeding, subphrenic or pelvic intraabdominal abscesses, wound infections, respiratory complications), during and after hospitalisation. Results: There were five (5) patients who meet the inclusion criteria for this case series from January 2014 to March 2015. 40% (2/5) of the patients were female. The mean age was 38.4 yrs. Conversion rate was 0%. The enterotomy rate was 20% (1/5). The median duration of postoperative ileus was 5 days. . The median duration of postoperative hospital stay was 5.6 days, mean time to enteral feeds was 1.8 days. Rate of post-operative complications was 20% (1/5). Conclusion: With appropriate patient selection, minimally invasive surgery is a safe alternative to open surgery for SBO, with acceptable morbidity and mortality.

原因不明の横隔膜下膿瘍の1例

症例は70歳の女性．1週間前より継続する左背部痛を主訴に近医を受診し，胸部X線検査で左横隔膜の挙上を指摘され，炎症反応の上昇も認めたため精査加療目的に紹介となった．来院時，血液検査で炎症反応の著明な上昇を認め，画像検査で肝表面のfree airと左横隔膜下に液面形成を伴う空洞性腫瘤を認めた．消化管穿孔の可能性も考慮したが，上部消化管内視鏡検査・下部消化管内視鏡検査ともに穿孔部は確認できず，その他に感染源を疑う所見を認めなかったため，原因不明の横隔膜下膿瘍と診断した．経皮的腹腔内ドレナージを施行，抗生剤を投与し保存的加療を継続した結果，軽快退院となった．横隔膜下膿瘍の原因は消化管穿孔や胆嚢炎，膵炎などが挙げられるが，稀な原因として異所性Meckel憩室や異所性虫垂炎などの報告がある．本症例は原因不明で特発性であると考えられるが，原因検索時には稀な疾患も念頭に置いたうえで診療にあたる必要がある．

Duodenal fistula after gastrectomy: Retrospective study of 13 new cases.

Duodenal stump fistula (DSF) after gastrectomy has a low incidence but a high morbidity and mortality, and is therefore one of the most aggressive and feared complications of this procedure. We retrospectively evaluated all DSF occurred at our hospital after carrying out a gastrectomy for gastric cancer, between January 1997 and December 2014. We analyzed demographic, oncologic, and surgical variables, and the evolution in terms of morbidity, mortality and hospital stay. In the period covered in this study, we performed 666 gastrectomies and observed DSF in 13 patients (1.95%). In 8 of the 13 patients (61.5%) surgery was the treatment of choice and in 5 cases (38.5%) conservative treatment was carried out. Postoperative mortality associated with DSF was 46.2% (6 cases). In the surgical group, 3 patients developed severe sepsis with multiple organ failure, 2 patients presented a major hematemesis which required endoscopic haemostasis, 1 patient had an evisceration and another presented a subphrenic abscess requiring percutaneous drainage. Six patients (75%) died despite surgery, with 3 deaths in the first 24 hours of postoperative care. The 2 patients who survived after the second surgical procedure had a hospital stay of 45 and 84 days respectively. In the conservative treatment group the cure rate was 100% with no significant complications and an average postoperative hospital stay of 39.5 days (range, 26-65 days). FMD is an unusual complication but it is associated with a high morbidity and mortality. In our experience, conservative management has shown better results compared with surgical treatment.

Surgical drain after open or laparoscopic splenectomy: is it needed or contraindicated?

The Authors report their experience with the routine use of surgical drainage in a large series of splenectomies.Benefits and risks related to surgical drains have been always discussed, with some surgeons in favor of them and skeptic others considering not physiological their use. After splenectomy, their use is also largely debated, especially because of susceptibility of operated patients to infections.Two thousand nine cases have been reviewed. Indications for splenectomy, performed either by open or laparoscopic approach, included idiopathic thrombocytopenic purpura in 137 patients (65,4%), splenic lymphoma in 36 (17,2%), hereditary spherocytosis in 15 (7,4%), β-thalassemia in 8 (3,7%), other diseases in 13 (6,1%)."Active" or "passive" drains were placed in 80% and 20% of cases, respectively. Drains were removed 2-3 days after surgery in 90,2%, within 10 days in 4,3%, within 2 months in 0,4% of cases. In 2 cases a post-operative bleeding, detected through the drainage, required re-operation. One patient developed a subphrenic abscess, successfully treated by a percutaneous drainage. One case of pancreatic fistula was observed.In Authors' experience, the use of drains after splenectomy does not affect the risk of subsequent infectious complications, independently on the type of the drainage system used. Early removal of drains in this series might have played an important role in the very low incidence of abdominal infections reported. The use of surgical drains after splenectomy might play an important role to early detect post-operative bleeding, as it happened in 2 cases of this series.

Post traumatic subphrenic abscess: A rare phenomenon

Sub-phrenic abscess is a common phenomenon encountered in surgical practice due to various causes, but very rarely a blunt trauma injury can also cause this, with no obvious infective foci. We report a case of 12 yr old female patient, presented with complain of pain abdomen after sustaining a blunt trauma. Major surgery was avoided using simple method of pig tail catherisation.

Unusual consequences of ‘incomplete’ laparoscopic cholecystectomy

In recent years, laparoscopic cholecystectomy (LC) has become the standard surgical practice for the treatment of cholecystolithiasis. As a recognized technical difficulty, it may be associated with the mechanical injury of the gallbladder and/or spilling some of the gallstones into the abdominal cavity. The actual incidence of the latter complication is ~10%. The removal of lost stones from the abdominal cavity is rather elaborate if not infeasible. There is little information about the behaviour of retained gallstones in the free abdominal cavity. Publications report on subsequent intraperitoneal abscesses and fistulas or on the extreme localization of the impacted gallstones. This paper presents two cases with late complications of the abandoned gallstones or gallbladder. Case 1: A 56-year-old female patient underwent an LC 7 years ago. She was recently admitted with a chronic septic condition and suspected autoimmune disease. Preoperative examinations indicated hepatic abscess. Surgery showed gallstones impacted in the gallbladder bed. Case 2: A 59-year-old male patient underwent an LC a year before his admission. His operation was followed by the development of a septic condition and a subphrenic abscess was identified. During his reoperation, a remnant gallbladder containing bile stones was found and removed. Special attention should be paid to careful revision of residual stones during LC.

A Post-Mortem case of subphrenic and perinephric abscesses in association with acute pancreatitis

<h3>Introduction</h3> The sub-phrenic space is defined as the area below the diaphragm and above the transverse colon. Most sub-phrenic abscesses are secondary to direct contamination of this space after abdominal surgery or trauma. Pancreatitis is a rare cause of subphrenic abscess with only few cases having been reported in the literature. <h3>Case presentation</h3> We present a post-mortem case of a 60-year-old Caucasian man with an extensive history of alcohol use who was found dead by police. Autopsy examination revealed a large sub-phrenic abscess extending to right peri-nephric fat and the right adrenal gland. The shrunken pancreas was covered with pus. Extensive chalky fat necrosis was present in the abdominal cavity. The histological examination of the pancreas showed features of acute suppurative pancreatitis with abscess formation on the background of chronic pancreatitis. Gram stain showed numerous Gram negative cocci which were sub-typed as Klebsiella pneumonia and <i>Strep aglacia</i> in microbiological examination of abdominal swabs. <h3>Conclusion</h3> Sub-phrenic abscess has a high mortality rate of about 30%. Early diagnosis and appropriate imaging are helpful tools to decrease the mortality.

A Case of Peritonitis Caused by a Ruptured Right Subphrenic Abscess

A Case of Peritonitis Caused by a Ruptured Right Subphrenic Abscess

Subphrenic abscess as a complication of hemodialysis catheter-related infection.

We describe an unusual case of subphrenic abscess complicating a central venous catheter infection caused by Pseudomonas aeruginosa in a 59-year-old woman undergoing hemodialysis. The diagnosis was made through computed tomography, and Pseudomonas aeruginosa was isolated from the purulent drainage of the subphrenic abscess, the catheter tip and exit site, and the blood culture samples. A transesophageal echocardiography showed a large tubular thrombus in superior vena cava, extending to the right atrium, but no evidence of endocarditis or other metastatic infectious foci. Catheter removal, percutaneous abscess drainage, anticoagulation, and antibiotics resulted in a favourable outcome.

A Case of Left Subphrenic Abscess Three Years After Surgical Drainage of Anastomotic Leakage Following Sigmoidectomy

A Case of Left Subphrenic Abscess Three Years After Surgical Drainage of Anastomotic Leakage Following Sigmoidectomy

Gemella endocarditis: An aggressive entity

The authors present a rare case of subacute endocarditis caused by Gemella morbillorum. A 72-year-old man, with a history of hypertension, aortic valve disease and upper and lower endoscopy six months previously, was admitted due to fever and abdominal pain. He also complained of long-standing dyspnea on exertion and petechiae on his lower limbs. Imaging scans showed a consolidation in the lower left lung field, a splenic infarct and a left subphrenic abscess. Transthoracic echocardiogram findings were highly suggestive of endocarditis affecting three valves, with destruction of the mitral valve anterior leaflet. G. morbillorum was identified in three blood cultures and was considered the etiologic pathogen. Due to the patient's worsening condition, he underwent cardiac surgery, aiming to control the infection and to resolve the associated mechanical complications. This case highlights the need for a complete and thorough history to arrive at likely diagnostic hypotheses that, together with complementary exams, will lead to correct diagnosis and the prompt institution of appropriate therapy.

Endocardite por Gemella: uma entidade agressiva

The authors present a rare case of subacute endocarditis caused by Gemella morbillorum. A 72-year-old man, with a history of hypertension, aortic valve disease and upper and lower endoscopy six months previously, was admitted due to fever and abdominal pain. He also complained of long-standing dyspnea on exertion and petechiae on his lower limbs. Imaging scans showed a consolidation in the lower left lung field, a splenic infarct and a left subphrenic abscess. Transthoracic echocardiogram findings were highly suggestive of endocarditis affecting three valves, with destruction of the mitral valve anterior leaflet. G. morbillorum was identified in three blood cultures and was considered the etiologic pathogen. Due to the patient's worsening condition, he underwent cardiac surgery, aiming to control the infection and to resolve the associated mechanical complications. This case highlights the need for a complete and thorough history to arrive at likely diagnostic hypotheses that, together with complementary exams, will lead to correct diagnosis and the prompt institution of appropriate therapy.

Perforated duodenal ulcer presenting with a subphrenic abscess revealed by plain abdominal X-ray films and confirmed by multi-detector computed tomography: a case report

IntroductionPeptic ulcer disease is still the major cause of gastrointestinal perforation despite major improvements in both diagnostic and therapeutic strategies. While the diagnosis of a perforated ulcer is straightforward in typical cases, its clinical onset may be subtle because of comorbidities and/or concurrent therapies.Case presentationWe report the case of a 53-year-old Caucasian man with a history of chronic myeloid leukemia on maintenance therapy (100mg/day) with imatinib who was found to have a subphrenic abscess resulting from a perforated duodenal ulcer that had been clinically overlooked. Our patient was febrile (38.5°C) with abdominal tenderness and hypoactive bowel sounds. On the abdominal plain X-ray films, a right subphrenic abscess could be seen. On contrast-enhanced multi-detector computed tomography, a huge air-fluid collection extending from the subphrenic to the subhepatic anterior space was observed. After oral administration of 500cm3 of 3 percent diluted diatrizoate meglumine, an extraluminal leakage of the water-soluble iodinated contrast media could then be appreciated as a result of a perforated duodenal ulcer. During surgery, the abscess was drained and extensive adhesiolysis had to be performed to expose the duodenal bulb where the ulcer was first identified by methylene blue administration and then sutured.ConclusionsWhile subphrenic abscesses are well known complications of perforated gastric or duodenal ulcers, they have nowadays become rare thanks to advances in both diagnostic and therapeutic strategies for peptic ulcer disease. However, when peptic ulcer disease is not clinically suspected, the contribution of imaging may be substantial.

Left-sided Chest Pain and Hemoptysis as Atypical Presentation of Splenic Abscess

Introduction: We report a case of diverticular and splenic abscess in a 51-year-old male presenting with left-sided chest pain and hemoptysis. Case: A 51-year-old Caucasian male with a history of alcoholism and diverticulitis presented to the hospital with complaints of left-sided chest pain and cough for 4-5 days' duration. He had a 1-day history of hemoptysis as well. CT chest (Figure 1) showed a large splenic abscess centered in the splenic parenchyma with subphrenic extension. Also visualized was a left pleural effusion that appeared directly contiguous with the abscess. CT abdomen showed a large pericolonic abscess secondary to diverticulitis. Physical exam showed the patient to be afebrile with stable vital signs, tender left upper quadrant, and coarse breath sounds in left lower lobe. Initial labs were essentially within normal limits.Figure 1Discussion: Splenic abscess is a rare entity with frequency of 0.14-0.7% in autopsy series. It may lead to life-threatening hemorrhage, erosion into hilar vessels, rupture into the peritoneal cavity, leading to diffuse peritonitis. Clinical manifestations may include left upper quadrant abdominal pain, fever, nausea, vomiting, and anorexia. Our patient presented with chief complaint of left-sided chest pain and hemoptysis leading our initial differential towards cardiopulmonary etiology. Diagnosis was made when imaging studies were performed. Therefore this case suggests that clinical presentation for splenic abscess can be nonspecific. Diverse etiologies have been discussed in literature which includes infective endocarditis with systemic embolization. Also, hematogenous spread from infective focus elsewhere in the body such as pancreatitis, diverticulitis, retroperitoneal, and subphrenic abscess. In this case, we suspect splenic abscess resulting from hematogenous spread from antecedent diverticulitis. Our patient initially had percutaneous drainage placed but due to clinical deterioration, splenectomy was performed. Due to narrow therapeutic window and high mortality with delayed treatment, we hope to bring this rare entity to the attention of most clinicians.

Treatment for resistant subphrenic abscess by combined intracavitary doxycycline and cyanoacrylate injection

We report the case of a male patient with resistant subphrenic abscess complicating radiofrequency ablation (RFA) of two left lobe hepatocellular carcinoma (HCCs). The causative organism was multidrug resistant Escherichia coli. Percutaneous pigtail drainage together with IV antibiotics failed to resolve the abscess which persisted for 4months. Intracavitary doxycycline injection causes moderate reduction in the volume of the drained fluid. This was followed by percutaneous cyanoacrylate injection inside the abscess cavity and the fistulous tract which causes complete resolution of the abscess.

Is There a Future for Laparoscopic Gastric Greater Curvature Plication (LGGCP)? A Review of 44 Patients

Laparoscopic gastric greater curvature plication (LGGCP) is a new restrictive weight loss procedure. Between February 2011 and June 2012, 57 patients underwent LGGCP. Thirteen had it associated with a lap band and were excluded from the study. Data was collected through routine follow-up. Demographics, complications, and percentage of excess weight loss (% EWL) were determined. Forty-four patients underwent LGGCP, 40 women and 4 men with a mean age of 40years (range, 18-72), a mean body mass index of 38kg/m(2) (range, 35-46). Comorbidities included 2 diabetes mellitus, 11 hypertension, 8 hyperlipidaemia, and 8 obstructive sleep apnea. The mean operative time was 106min (range, 60-180) and mean duration of hospital stay was 18h (range, 12-168). Operative complications included one subphrenic abscess, one gastrogastric hernia, and one acute respiratory distress syndrome. Thirty patients experienced strong restriction with nausea and vomiting for the first 10days (79.5%). Eleven patients (25.0%) came back with intractable nausea and vomiting, and were hospitalized, or had their hospital stay prolonged. Four patients needed early reversal of gastric plication (9%). There was no postoperative death. The mean postoperative % EWL was 30.6% (n = 40), 57.0% (n = 24), 50.7% (n = 13) at 1, 6, and 12months, respectively. LGGCP yields an acceptable weight loss compared to other restrictive procedures, but with a higher readmission rate for postoperative nausea and vomiting, or even reversal of plication. We advocate more studies to evaluate safety and effectiveness.

Laparoscopic splenectomy and infection

Partial laparoscopic splenectomy is performed commonly in hereditary spherocytosis. Vaccination against capsulated bacteria is essential before undergoing splenectomy. Hand-assisted laparoscopic splenectomy is known to be effective and convenient in the removal of a spleen larger than 20 cm in size. Laparoscopic splenectomy provides less hemorrhage, reduced surgical trauma and pain, shorter duration of hospital stay, and early recovery. Laparoscopic approach was particularly effective in reducing the infectious complication rate compared with the open surgery. Infectious complications of splenectomy were observed to be wound infection, subphrenic abscess, and sometimes pulmonary infection. J Microbiol Infect Dis 2013; 3(1): 1-2