Abscess of the brain (2nd report)--special reference to surgical indication of extracapsular excision of brain abscess (author's transl)]

Brain abscess persists as a serious diagnostic problem and critical therapeutic challenge since pre-antibiotic era. After antibiotic agents has been introduced, abscess of the brain seems to be a surgical curable intracranial suppurative disease, although surgical mortality and morbidity due to brain abscess are still distressingly high. Recently, the incidence of brain abscess are gradually increasing. In this present situation, it is necessary to reevaluate the previous method and surgical results of brain abscess. Even with new surgical techniques and antibiotics, the mortality rate and number of neurological deficits remain high, as previously methods, it is most important how to eliminate these problems. It was undertaken to determine the significant factors affecting the clinical management of patients with this serious problem. The general outlines of our neurosurgical treatment are given, with emphasis on our surgical schedule of brain abscess, especially brain abscess in congenital heart disease. In this paper, a review of the current status of the surgical methods, operative mortality and morbidity, diagnostic methods and the therapy of brain abscess has been discussed.     

The results of surgery in amebic liver abscess: experiences in eighty-three patients

Experiences with surgery in 83 patients with amebic liver abscess are presented. The patients' ages ranged from 8 months to 72 years; 85% were men. Symptoms had been present for an average of 4.6 weeks. In 36 (43%) the abscess already was ruptured at the time of admission to the hospital and in an additional eight it ruptured later. Rupture occurred more commonly upward through the diaphragm than downward, and into a serous cavity in 36 patients. Because of the poor general condition and associated illnesses of the patients, surgical procedures were limited to the minimum. Indications for operation were rupture or impending rupture of the abscess, failure of response to medical therapy, and inadequacy of aspiration of left lobe abscess. An additional 27 patients underwent operation because of diagnostic problems or symptoms of an acute abdomen. Two thirds of the patients had one or more complication. The overall mortality rate was 34%. Factors adversely affecting mortality rate were lack of preoperative drug therapy, rupture into a serous cavity, and presence of an associated amebic perforation of the colon.     

Combined approach for otogenic brain abscess

Otogenic intracranial infections usually require both neurosurgical and otolaryngological surgery. This prospective, non-randomized study investigated the value of combining both surgical procedures. Thirteen patients with otogenic intracranial abscess were treated by mastoidectomy and abscess removal through the same incision between 1993 and 2002. Another 12 patients underwent abscess removal or mastoidectomy followed by the other procedure within 7 days. The clinical features of the patients were compared. Four patients died in our series. All four patients had Glasgow Coma Scale (GCS) scores of 7 or less. The preoperative GCS score was the main factor in mortality. One patient had recurrence after the combined approach compared to nine patients with recurrence after separate procedures. The surgical procedure was the main factor affecting the recurrence rate. The combined approach and total capsule excision of the abscess may reduce the risk of recurrence of otogenic intracranial abscess.     

Pancreatic abscess following acute pancreatitis

Without surgical treatment, pancreatic abscess remains a highly lethal complication of acute pancreatitis. Many surgical series have reported mortality rates of 32 to 65 per cent in treated cases. Although pancreatic abscess is a rare condition, it is more common in patients with severe pancreatitis. A retrospective study of 130 patients admitted to our unit with severe acute pancreatitis during the period from 1965 to 1987 revealed 18 cases of pancreatic abscess. All pancreatic abscesses were primary in nature, and no infected pseudocysts were included in the series. Clinical surveillance, repeated laboratory tests, conventional radiology, and especially ultrasonography and CT scan all contributed to the preoperative diagnosis. The applied treatment was surgical debridement of all necrotic tissue and either local or extensive external drainage. In 12 cases this procedure was combined with other surgical interventions. The recorded mortality rate was 16.66 per cent. Factors adversely affecting survival include: 1) severity of precipitating pancreatitis; 2) difficulty in making early and accurate diagnosis of the pancreatic abscess; 3) marked tendency for recurrence of sepsis; and 4) life-threatening associated complications and/or diseases.     

Pyogenic liver abscess: an audit of 10 years' experience and analysis of risk factors.

BACKGROUND/AIMS: Despite continuous improvement in image modalities, availability of potent antibiotics and advancement in the knowledge and treatment of pyogenic liver abscess, mortality remains high. The high mortality rate has underlined the important role of prognostic factors and prompts a number of studies to identify the risk factors. The present study aims to audit our experience in managing patients with pyogenic hepatic abscess during the period of 1989-1999, and to document changes in etiology, bacteriology and outcome, and to identify any risk factor associated with mortality. METHODS: One hundred and thirty-three patients with pyogenic hepatic abscess were studied to determine the demographic characteristics, clinical features, laboratory, bacteriological findings, methods of treatment, final outcome and risk factor analysis. All patients were treated with parenteral antibiotics. One hundred and twelve patients were subjected to ultrasound-guided percutaneous aspiration of the abscess. A percutaneous drainage catheter was inserted after aspiration in all patients. Laparotomy was done in 21 patients. RESULTS: The overall hospital mortality rate was 6% (8/133). Biliary tract disease was the most frequently identified cause. Leukocytosis, hypoalbuminemia and hyperbilirubinemia were common laboratory findings. The most common microorganism cultured was Klebsiella pneumoniae. The most common concomitant disease was diabetes mellitus. On univariate analysis, large abscess, diabetes mellitus and sepsis were significantly associated with hospital mortality. On multivariate logistic regression analysis, the presence of sepsis (p = 0.0031) was found to be an independent risk factor. CONCLUSIONS: In addition to early diagnosis and prompt treatment, making every effort to treat patients with adverse prognostic factors and systemic complications, the hospital mortality rate will be decreased significantly.     

Liver abscess. Review of a 12-year experience

Experience with liver abscess was reviewed to determine whether new trends in treatment have altered clinical outcome. Thirty-one cases of liver abscess were identified from 1973 to 1985. In this group there were ten deaths for a mortality rate of 32 per cent; the primary disease accounted for seven deaths. Significant predictors of liver abscess mortality were multiple abscesses, elevated bilirubin levels, and underlying disease. Percutaneous drainage was effective in three of four patients and should be attempted before operative intervention in selected patients.     

Psoas abscess in patients with an infected aortic aneurysm

BACKGROUND: Psoas abscess is an uncommon disease, and its presenting features are usually nonspecific. Infected aortic aneurysms could be complicated by psoas abscess. METHODS: A retrospective chart review was conducted to examine the incidence, clinical presentations, microbiology, and outcomes of psoas abscess in patients with an infected aortic aneurysm. RESULTS: Between 1996 and 2007, 40 patients (32 men) with an infected infrarenal aortic aneurysm were treated in our hospital. Their median age was 71 years (range, 38 to 88 years). In 38 patients a blood or tissue culture had a positive result. The most common responsible pathogen was Salmonella spp in 29 patients (76%), followed by Staphylococcus aureus in 3 (8%), Escherichia coli in 2 (5%), Klebsiella pneumoniae in 3 (8%), and Mycobacterium tuberculosis in 1 (3%). One patient underwent endovascular repair but died. In-situ graft replacement was done in 32 patients. Persistent or recurrent infection occurred in seven (22%) of 32 operated on patients. The mortality rate was 86%, and the overall aneurysm-related mortality rate of in situ graft replacement was 22% (7/32). In eight (20%) of the 40 patients, aortic infection was complicated by psoas abscess. Infection complicated by psoas abscess was present in seven of 32 operated patients. It was associated with higher incidence of emergency operation, hospital mortality, prosthetic graft infection, and aneurysm-related mortality than infection without abscess. CONCLUSION: Psoas abscess was common in patients with infected infrarenal aortic aneurysm. Salmonella spp was the most common pathogen. Psoas abscess was associated with a high mortality rate, emergency operation, and persistent infection.     

The role of percutaneous transhepatic abscess drainage for liver abscess

To evaluate the efficacy of percutaneous transhepatic abscess drainage (PTAD) as an initial choice of treatment for liver abscess, the medical records of 28 patients with liver abscess were retrospectively analyzed. The patients were predominantly men (23 of 28) with a mean age of 59 years (range, 19–86 years). Their chief complaints were fever (86%), right hypochondralgia (32%), and jaundice (11%). Fifteen of the 28 patients (54%) had hepatobiliary and pancreatic carcinoma, and 31% had postoperative liver abscess. PTAD was performed in 23 patients and surgical drainage in 5. The overall success rate for PTAD was 83%. The success rate for PTAD for patients with multiple abscesses was 83% (5 of 6), compared with a success rate of 82% (14 of 17) for patients with solitary abscess. The prognostic factors for survival were cancer and sepsis and the mortality rate for patients with cancer was 40% (6 of 15) while the mortality rate for patients with sepsis was 56% (5 of 9). As a complication of drainage, 1 patient (4%) in the PTAD group had pleural abscess due to the transpleural puncture. Our findings support the use of PTAD as the primary treatment for liver abscess, as it is safe and effective irrespective of the number of abscesses and the patient's condition. Received for publication on Sept. 7, 1998; accepted on Jan. 22, 1998     

Audit of management of pyogenic liver abscess in a tertiary referral hospital

Aim: To review the management and clinical outcomes of patients with pyogenic liver abscess in Queen Elizabeth Hospital. Methods: This is a retrospective review of the management of patients with a diagnosis of pyogenic liver abscess in Queen Elizabeth Hospital from 2000 to 2004. Results: From 2000 to 2004, 143 patients with a diagnosis of pyogenic liver abscess were managed in Queen Elizabeth Hospital. Procedure‐related complications were 6/143 (4%). The success rate from percutaneous intervention was 122/143 (85%). The overall in‐hospital mortality was 18/143 (13%). Mean hospital stay was 30.1 days and the median was 23 days. Multivariate logistic regression analysis on risk factors for in‐hospital mortality showed high white cell count, large size abscess and prolonged activated prothrombin time as independent risk factors. Conclusion: In the present series, high white cell count, large size abscess and prolonged activated prothrombin time predicted poor outcomes in patients with pyogenic liver abscess.     

不典型症状的儿童脑脓肿临床分析

目的分析症状不典型的儿童脑脓肿的临床特点及其诊治策略。方法回顾性分析46例脑脓肿患儿的临床表现及相关检查资料。结果临床表现有发热31例,呕吐25例,头痛21例;脓肿好发于颞叶,以单发脓肿多见;细菌培养阳性率52.4%;手术治疗24例,保守和手术治疗有效率分别为86.4%和87.5%,总死亡率8.7%。结论儿童脑脓肿的症状隐匿,头颅CT扫描有助于早期确诊,治疗方案应结合病情有所选择。     

肝脓肿溃破77例分析

肝脓肿溃破是肝脓肿的主要并发症。作者总结该院近３０年来收治的肝脓肿溃破７７例，发现其几乎可破向肝周所有邻近脏器。导致肝脓肿溃破的原因包括就诊过晚、误诊、漏诊和处理不力等。提出预防肝脓肿溃破的关键是提高对本病的认识、早期诊断和及时有效的引流。认为经腹引流是最佳途径。大多数患者在肝脓肿溃破后需手术引流，同时经网膜静脉或脐静脉插管滴注有效抗生素。肝脓肿溃破的预后凶险，死亡率高，本组达３５．１％（２７／７７），死亡率与溃破所致的并发症密切相关。     

The clinical presentation of pyogenic liver abscess.

The high mortality rate from pyogenic liver abscess is contributed to by delay in diagnosis. The widespread availability of radio-isotope liver scanning facilitates diagnosis once a hepatic abscess is suspected. This retrospective study identifies diagnostic features present at the time of admission to hospital in 28 patients who were subsequently found to have a hepatic abscess.     

Suppurative pleurisy

In 1928, there were 107 cases with 7 deaths, a mortality of 6.5 per cent. In 1929, 4 deaths occurred in 108 cases, or 3.7 per cent. In 1930, 89 cases were treated and 6 died, the mortality rate being 6.7 per cent. In 1931, the rate was 3.5 per cent, 3 deaths occurring in 86 cases. In 1932, 43 cases were treated without any mortality. In the total group of 433 cases, there were 20 deaths, or a general mortality rate of 4.6 per cent.In the entire group, secondary pelvic abscess developed in 5 patients. All were drained by rectum. During this period, six enterostomies were performed, 2 patients having two enterostomies each. One patient died because the bowel drainage was performed in the presence of an abscess. I would like to call attention to the high autopsy figures. In 20 deaths, 18 post-mortem examinations were obtained.     

细菌性肝脓肿外科处理的临床分析

目的总结细菌性肝脓肿的诊治经验。方法对我院从1992年-2002年十年间所收治的105例细菌性肝脓肿病人进行回顾性分析。本组治疗方法包括：单纯抗生素治疗21例,外科手术引流30例,腹腔镜手术引流6例,经皮穿刺抽吸治疗42例,经皮穿刺置管引流治疗6例。结果本组治愈101例,死亡4例,死亡率3．8％。结论早期诊断和恰当的治疗是提高细菌性肝脓肿疗效的重要因素,超声引导下穿刺抽吸和／或置管引流已成为细菌性肝脓肿的治疗首选,适合于大部分病人。而外科手术引流仅适合于介入治疗失败或脓肿破裂病人。     

Current concepts of percutaneous abscess drainage in postoperative retention

In recent years, percutaneous abscess drainage (PAD) of intraabdominal abscesses has become an important tool with regard to the treatment of intraabdominal sepsis. The aim of this study is to assess the value of PAD in the treatment of postoperative retentions. Between 1995 and 1999, the postoperative course of 3 346 patients undergoing major abdominal surgery was analyzed. Mortality, morbidity, and comparison of different locations of intraabdominal abscesses were assessed. PAD was considered successful when the patient improved clinically within 24 hours, a decrease in the size of the abscess formation was noted, and complete recovery without further surgical intervention occurred. Out of 3 346 operated patients, 174 (5.2%) were diagnosed as having an intraabdominal abscess formation and were treated by PAD. In 63 patients the abscess developed within the upper quadrants, in 66 patients the abscess developed within the lower quadrants, and in the remaining 45 patients the abscess developed within the retroperitoneal cavity or pelvis. The success rate of PAD was 85.6% with a morbidity rate of 4.6%. The least successful location for PAD was the left upper quadrant. Patients with abscess drainage in the right upper and lower quadrant experienced a high success rate. One patient died due to the PAD procedure. Unsuccessful PAD was closely related to an increase in mortality. In the case of intraabdominal abscess formation after visceral surgery, PAD should be the primary procedure. Attention should be paid to abscess formations in the left upper quadrant because there is an increased likelihood of complications caused by PAD.     

Early and late results of aortic root replacement with antibiotic-sterilized aortic homograft

Between November 1972 and November 1986, 108 patients aged 5 to 73 years had complete replacement of the aortic root with an aortic homograft into which the coronary arteries were implanted. The main indications were (1) a tunnel type of aortic obstruction involving a hypoplastic ring, (2) a para-aortic annular abscess, (3) prosthetic valve dysfunction, mainly a previous aortic homograft, and (4) aortic stenosis with a small aortic anulus. Eighty-four patients (78%) had previous aortic valve operations. Concomitant cardiac procedures were done in 34 patients (32%). The 30-day mortality rate was 14% (15 patients). The cumulative follow-up period was 180.3 patient-years. The late mortality rate was 6.1% per patient-year (11 patients). The patients were not given anticoagulants postoperatively, but the entire group has been completely free from thromboembolism. The actuarial 5-year survival rate including operative deaths was 72%. The freedom from valve-related death at 5 years after operation is 86% and freedom from reoperation at 5 years is 96%. The use of homografts for replacement of the aortic valve and root in patients with complex lesions affecting these structures has shown encouraging early and late results, with regard to both survival and valve performance.     

Liver abscess secondary to ingestion of foreign body. A case report

Hepatic abscess is a serious surgical problem with a high mortality rate. The Authors report a case of a liver abscess following the migration of a toothpick from the stomach into the hepatic left lobe. Percutaneous abscess drainage combined with endoscopical removal of the foreign body were the goal treatment. The Authors stress importance of the laparoscopy-guided drainage with placement of intra-hepatic drains.     

Review of pyogenic liver abscess at the Royal Adelaide Hospital 1980-1987

Pyogenic liver abscess is an uncommon condition which carries substantial morbidity and mortality if untreated. A review was undertaken of 31 patients who were admitted to the Royal Adelaide Hospital (RAH) between January 1980 and December 1987 and who were diagnosed as having pyogenic liver abscess. The aims of the study were to review the aetiology, current methods of investigation and treatment of the disease, and to formulate a management plan based on the findings. Hypoalbuminaemia, leukocytosis and elevated alkaline phosphatase were the most common findings. Hyperbilirubinaemia was not a usual feature. Computerised tomography (CT) scanning and ultrasound were the most useful imaging modalities in identification of the abscess. The sensitivity of CT scanning in evaluating the size of abscesses was lower than anticipated and this may lead to a higher than necessary rate of surgical drainage. A case is presented to illustrate this. Most abscesses were secondary and frequently due to extension of infection from biliary structures. Diseases causing diminished resistance to bacterial infection had a significant role in the pathogenesis. The overall mortality rate was 25%. Risk factors increasing mortality included advanced age, multiplicity of abscesses, depressed immune status and the presence of complications due to the abscess. Of patients who survived, four were treated with antibiotics alone, eleven with percutaneous drainage and antibiotics, and eight with surgery and antibiotics. We conclude that patients with hepatic abscesses should be managed initially by CT or ultrasound-guided aspiration. If pus is obtained a percutaneous drain should be inserted into the cavity and systemic antibiotics administered.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of sulfonamides in the treatment of peritonitis of appendiceal origin: A review of 903 cases of acute perforative appendicitis

A study was made of 903 cases of perforative appendicitis at the Los Angeles General Hospital, in order to evaluate the use of sulfonamides in the treatment of peritonitis.During the five-year period 1939 to 1940, the mortality rate for perforated appendicitis decreased from 9.2 to 3.4 per cent.Sulfonamides were used with increasing frequency so that 98 per cent of all the cases during 1942 received some form of chemotherapy. The mortality rate decreased each year as the use of sulfonamides increased.Morbidity as well as mortality was reduced as observed by the yearly decrease in the frequency of postoperative peritoneal abscesses and pneumonitis.Drainage of the peritoneal cavity following appendectomy was used less often, as sulfonamides were used intraperitoneally in nearly all cases. In 1942, one patient out of three had no drain used, either in the peritoneal cavity or abdominal wound.In abscess formation following appendiceal perforation the procedure of choice was incision and drainage only in the completely walled off abscess. In 1942, appendectomy was performed in over three-fourths of the abscess cases without fatality.Clinical observations on a large group of cases apparently confirm the experimental evidence that sulfonamides are an effective form of therapy in the treatment of peritonitis. Their use is of particular value when implanted intraperitoneally during the early stages of peritonitis in perforative appendicitis.     

Epididymo-orchitis and testicular abscess due to Nocardia asteroides complex

Nocardia asteroides complex is a rare human pathogen chiefly affecting immunosuppressed patients. We present the sixth case of epididymo-orchitis attributable to this organism. A 78-year-old man presented to the Mayo Clinic with fever and weight loss after being treated with cyclophosphamide and prednisone for an immune-mediated vasculitis. He was found to have a testicular abscess, and orchiectomy was performed. N. asteroides complex was identified on the wound cultures. Sulfa therapy was begun. In previous case reports, this condition carried a 50% mortality rate. Patients who survive seemed to benefit from aggressive surgical debridement and long-term sulfa therapy.