The subphrenic abscess. Surgical and/or percutaneous drainage

The results indicate that the low risk percutaneous drainage of subphrenic abscesses is only feasible in carefully selected patients. The surgical intervention remains the method of choice for the drainage of subphrenic abscesses in conditions such as multiple and complicated abscesses, unfavourable access to the abscess cavities or other pathological conditions. An early and decisive diagnosis is crucial for effective treatment of subphrenic abscesses either by percutaneous drainage or surgical intervention and antibiotic therapy.     

Other conditions of the lung (abscesses,inhaled foreign bodies,bullous lung disease,hydatid)

Lung abscess remains a common complication of pneumonia and aspiration, particularly in immunosuppressed patients and must be differentiated from a cavitary form of lung cancer. The conservative treatment with antibiotics is still the main therapeutic approach; however, percutaneous drainage may be employed in selected cases. Inhaled foreign bodies require a prompt diagnosis with rigid or a combination of rigid and flexible bronchoscopies to remove the foreign body avoiding complications and the need for a thoracotomy. Bullous lung disease is a common pathology mainly developing as a result of emphysema. Occasionally congenital or acquired lung cysts are diagnosed. Surgical bullectomy is the treatment of choice but external drainage may be indicated in patients with a limited functional reserve. Hydatid lung disease is caused by Echinococcus affecting most commonly the liver and lung. Resection of the cystic lesions may be necessary to eliminate the symptoms and to prevent further complications.     

Ventricle puncture for external CSF drainage and pressure measurement using a modified puncture needle

Summary A modified needle for external ventricular drainage is presented. Contrary to conventional spinal needles with this instrument the sharp guide can be withdrawn after penetration of the dura, thus, no sharp instrument affects the brain, nor remains within the ventricles in cases of continuous drainage. Furthermore, depth of penetration can be determined preoperatively by means of a set screw also facilitating fixation of the needle. To date, we have used this modified needle in 50 patients for short or long term CSF drainage and for CSF pressure measurements. Trephination was performed with a hand or battery-driven drill. Except for an infection in one case we found no serious complications in our patients. In our opinion, ventricle puncture for external drainage and pressure measurement with this device is a simple and safe method and can be performed on the ward under local anaesthesia.     

A Retrospective Study of 75 Cases of Splenic Abscess

Splenic abscess is an uncommon and life-threatening condition. Due to its nonspecific clinical picture, it remains a diagnostic challenge. Multiple radiological modalities are used for the diagnosis. In this retrospective study we analyzed 75 patients treated between 1999 and 2009. The patients were divided into three groups depending on the treatment received. Group I (n = 14) consisted of patients treated with only antibiotics, Group II (n = 19) patients were treated with percutaneous drainage and Group III (n = 42) with splenectomy. We tried to establish epidemiologic and clinical features and therapeutic options in splenic abscess. Our study suggests that percutaneous drainage is a safe and effective alternative to surgery especially in unilocular or bilocular abscesses thus allowing preservation of the spleen. It should be considered as the first line of treatment although splenectomy remains the final definitive procedure if percutaneous drainage fails.     

Cerebrospinal fluid shunting: anesthetic particularities

The symptomatic treatment of hydrocephalus remains cerebrospinal fluid (CSF) drainage to an external reservoir (external CSF drainage) or to an internal cavity mainly the peritoneum or the right atrium via a unidirectional valve (internal CSF drainage) and finally by endoscopic ventriculocisternostomy. Local anaesthesia is adequate for external CSF drainage in adults and children above 10 years while general anaesthesia is required in all other cases. The main problems encountered in these patients are difficult intubation and full stomach associated with increased intracranial pressure. The anaesthetic approach should favour homeostasis. With the exception of ketamine and enflurane, the majority of anaesthetic drugs can be used. Anti-epileptic drug are mandatory. Antibioprophylaxis mainly against staphylococcus is systematic in internal CSF drainage. Rapid emergence from anaesthesia and extubation should be encouraged. Complications (infectious, mechanical and bleeding kinds) are frequent and are often the cause of reinterventions or revisions of the device, exposing the patients to iterative anaesthesia. Furthermore, patients with shunts are at risk of malfunction of the device when exposed to situations like pregnancy, magnetic resonance imaging, or laparoscopy. Under these circumstances, it is recommended to associate the neurosurgical team in the management of these patients and to verify that the shunt is working well before and after the procedure or event.     

Complications of lumbar drainage after thoracoabdominal aortic aneurysm repair.

OBJECTIVES: Paraplegia remains a frequent complication of thoracoabdominal aortic aneurysm (TAAA) repair. Many adjunct therapies have been developed to address this complication. Lumbar drainage is frequently used in an attempt to decrease intrathecal pressure and improve intramedullary perfusion pressure. The effectiveness of this therapy is unclear, and the complications of lumbar drainage used for this indication are unknown. We present a case of intraspinal hematoma with significant neurologic deficit after TAAA repair and review the associated complications of lumbar drains placed for TAAA. METHODS: The charts of all patients undergoing operations for TAAA repair were reviewed. Patients who underwent perioperative placement of a lumbar drain were included regardless of aneurysm type or etiology. Demographics, Crawford grade, and perioperative parameters and complications were reviewed. RESULTS: Sixty-five patients underwent TAAA repair with 62 (95%) receiving a preoperative lumbar drain. There were two (3.2%) intraspinal hemorrhagic complications, including one patient with a poor neurologic outcome. No infections or other complications directly related to drainage were identified. Multivariate logistic regression analysis failed to demonstrate a significant association between lumbar drain complications and perioperative and intraoperative parameters such as blood loss or hypotension, level of drain placement, and Crawford grade. CONCLUSIONS: Lumbar drainage is a frequent adjunct to TAAA repair. However, placement of the drain itself can be associated with significant complications whose aggravating factors may be unidentifiable. Complications resulting from lumbar drainage should be considered in any patient who has postoperative lower extremity neurologic deficits.     

Optimum drainage method in descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is a rare but often fatal disease. Transcervical mediastinal drainage and transthoracic mediastinal drainage are the most commonly employed drainage methods for treating patients with DNM. It remains controversial as to whether transcervical mediastinal drainage alone would be adequate for the treatment of DNM, which is a life-threatening disease. Between 1996 and 2004, 13 patients with DNM were treated at our department. We performed transcervical mediastinal drainage in 6 patients with localized DNM, in whom the infection remained limited to above the level of the carina. A more aggressive approach, that is, transthoracic mediastinal drainage, was employed in the remaining 7 patients who had extensive DNM, with the infection extending below the carina. The overall mortality rate was 8%. All the 6 patients treated by transcervical drainage survived without major postoperative complications. Six out of the 7 patients treated by transthoracic drainage survived, while one died of pneumonia. Our results suggest that transcervical mediastinal drainage may be adequate for treating patients with localized DNM in whom the infection does not extend beyond the carina, while transthoracic mediastinal drainage must be adopted for patients with more extensive disease.     

Splenic abscess: presentation, treatment options, and results

Pyogenic splenic abscess is a rare condition that tends to occur in patients with predisposing factors. The use of splenectomy or computed tomography-guided percutaneous drainage in 10 patients with splenic abscess is presented. In 8 of 10 cases, the diagnosis was based on abdominal computed tomography scan. Seven of 10 patients were treated with splenectomy, and 3 were managed with computed tomography-guided drainage. Abscess cultures included Escherichia coli, Enterobacter, Streptococcus viridans, Staphylococcus aureus, and Bacteroides fragilis. There were two morbidities and one death in the splenectomy group and no complications in those treated with percutaneous drainage. This review suggests a flexible approach in the management of splenic abscess. Although splenectomy remains the traditional treatment for bacterial splenic abscess, CT-guided drainage may be appropriate in carefully selected patients.     

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??The reasonable option of biliary drainage for hepatolithiasis ZHOU Jie??ZHANG Qi-fan??SUN Shi-bo??et al. Department of Hepatobiliary Surgery??Nan Fang Hospital??the Southern Medical University??Guangzhou 510515??China
Corresponding author??ZHOU Jie??E-mail??jacky@smu.edu.cn
Abstract Biliary drainage plays a vital role in surgical management of hepatolithiasis. An improper enteric drainage not only complicate the situation but also create unnecessary problems for subsequent treatment. Hepatolobectomy remains the mainstay of curative treatment for hepatolithiasis. Based on the clearance of stone??a reasonable mode of biliary drainage should be decided according to the function of Oddi sphincter and the degree of expansion of bile duct. The indication of choledochojejunostomy should be strictly limited. T-tube drainage should be used in all patients with normal function of Oddi sphincter. Choledochojejunostomy is only necessary in those with distal biliary stricture or with the loss of function of Oddi sphincter combined with remarkable expansion of bile duct.     

Obesity predisposes to increased drainage following axillary node clearance: a prospective audit

BACKGROUND: Whilst sentinel node biopsy is being evaluated for optimising treatment of the axilla, axillary dissection remains the gold standard. Seroma formation, a common sequel to axillary dissection, has been shown to be associated with an increased incidence of wound infection, delayed healing, and lymphoedema. This study was conducted to evaluate the possible contributory role of obesity in axillary drainage following lymphatic dissection. PATIENTS AND METHODS: This study comprised a prospective review of all patients undergoing axillary dissection in conjunction with mastectomy or wide local excision. The total in-patient axillary drainage and the average daily drainage was correlated with various clinical parameters, including obesity, type of surgery, level of axillary dissection and nodal involvement. The body mass index (BMI) was used as a measure of obesity. RESULTS: During a 6-month period, axillary dissection was performed in 79 women. Nineteen patients were excluded. Patey mastectomy was performed on 33 (55%) and the remaining had breast conservation. The amount or duration of axillary drainage did not correlate with the type of operation, tumour histology, level of axillary dissection or the nodal status. Higher BMI correlated with increased mean daily axillary drainage and total volume drained, whilst in hospital. (Spearman correlation coefficient 0.42; P < 0.01). CONCLUSION: Obesity predisposes to increased axillary drainage following nodal clearance.     

Die Wertigkeit von Wunddrainagen mit und ohne Sog

Even though the discussion for desisting from wound drainage has arisen, this is not reflected in the reality of surgical treatment. In more than 90% of all procedures wound drainage is used. It remains to be proven whether suction drainage actually is superior to gravity drainage in everyday use. In a random study with 200 patients it was proven that suction drainage shows no significant advantage in liquid quantum, haematoma and the frequency of complications. We conclude that the economically favourable gravity drainage can replace the more expensive suction drainage in most cases.     

Stereotactic management of congenital midline cysts

Summary The treatment of congenital midline cysts remains a controversial issue. The Stereotactic management of 27 patients (6 symptomatic cavum septi pellucidi/cavum Vergae, 6 suprasellar cysts, 5 intraventricular cysts, 4 parasagittal cysts, and 6 supracollicular cysts) is reviewed. In 23 patients Stereotactic ventriculo-cystostomy by catheter implantation (internal drainage) led to clinical recovery or improvement accompanied by decreased cyst size. In four patients the internal drainage was not sufficient and was therefore completed as a ventriculo-atrial shunt system. Three minor complications (bleeding, aseptic meningitis, catheter infection) led to no sequelae. The results suggest that Stereotactic internal drainage of these benign lesions is a safe, minimally invasive and efficient procedure.     

肝胆管结石术中胆管引流方式合理选择

肝胆管结石病的处理中,胆管引流至关重要。不恰当的胆道内引流会使病情更趋复杂,并给进一步处理带来不必要的困难。肝叶切除是治疗肝胆管结石的主要手段。在取净结石的前提下,应主要根据Oddi括约肌的功能状态以及胆总管的扩张程度来决定胆管引流方式,胆肠吻合的手术指征须严格控制。对于Oddi括约肌功能正常的病例,均应采用T管引流,无须行胆肠吻合。只有对确认胆总管下端炎性狭窄或Oddi括约肌松弛、合并胆总管高度扩张的病例,才有必要行胆肠吻合。     

Lesions of the segmental and lobar hepatic ducts.

Despite reports to the contrary, unobstructed drainage of 50% of an otherwise normal liver through either the right or left uninfected hepatic duct is adequate to restore normal liver function, even if the obstructed lobe remains in place. An undrained liver lobe, if present, may require no further treatment. As long as it is completely obstructed and uninfected, it will undergo a progressive asymptomatic atrophy. Cholangitis invariably develops behind a partial lobar ductal obstruction, producing jaundice, pruritis, and fever. Unless unobstructed, uninfected biliary flow can be achieved through a segmental or lobar duct, it is better that the duct be completely obstructed and the affected liver parenchyma allowed to atrophy, provided there is normal biliary flow from the residual 50% of liver. This concept is important in the management of injured anomalous segmental or lobar hepatic duct and in the palliative treatment of bile duct carcinoma. Localized intrahepatic infections communicating with abnormal biliary ducts will require hepatic resection of the infected parenchyma and ducts for cure. The abnormality may be saccular dilatation of the intrahepatic ductal system with abscess formation or intrahepatic abscess associated with stenosis of the ductal system from trauma to the duct, to the duct and liver, or to retained intrahepatic stones. Diffusely situated intrahepatic abscesses secondary to ductal abnormalities can be treated with systemic antibiotics, local drainage of a dmoninant abscess, and efforts to improve biliary drainage.     

How soon should drainage tubes be removed after cardiac operations?

Pericardial effusion frequently occurs after cardiac operation. Despite its high incidence, the etiological process of postoperative pericardial effusion remains unclear. Residual blood or thrombus has often been suggested as a possible cause, implying that the occurrence of pericardial effusion could be related to the effectiveness of postoperative thoracic drainage. This possible relationship, however, has never been studied. We found that prolonging the duration of thoracic drainage by 24 hours often increases total chest tube output considerably but does not affect the incidence of postoperative pericardial effusion: approximately 55% of 100 patients in this study were shown by two-dimensional echocardiography to have pericardial effusion on the sixth postoperative day, regardless of the duration of postoperative drainage. Because of this, and because a long period of drainage causes discomfort for the patient, mechanical irritation to the heart and the pericardium, and an increased risk of infection, we recommend removing drains as soon as their efficacy has peaked, preferably on the first postoperative day.     

Eclectic drainage of subphrenic abscesses

In 196 cases of subphrenic abscess from 1964 through 1979, 56% were attributable to gastric, hepatic, and colonic disease or surgery. Posttraumatic abscesses in younger patients became more frequent. Synchronous suprahepatic and subhepatic abscesses or bilateral abscesses accounted for 19%. Streptococci, Escherichia coli, Klebsiella, and Bacteroides species were the most frequently isolated organisms. Although the overall mortality rate was 40%, the surgical mortality rate decreased from 33% initially to 17% recently. The mortality rate of transperitoneal drainage decreased from 41% to 16%. From 1980 through early 1983, a success rate of 84%, with no fatalities, was achieved in percutaneous radiologic drainage of 25 unilocular abscesses. At present, radiologically guided drainage should be considered for unilocular abscesses and some bilocular ones. Although extraperitoneal, extrapleural surgical drainage remains an expeditious form of treatment, it may give way to radiologic drainage. Transperitoneal drainage is preferable for multifocal abscesses and for many abscesses secondary to complications of intraabdominal surgery.     

Jejunal Loop Drainage Versus Direct Pancreatic Duct Drainage After Pancreatic Head Resection

Purpose Perioperative mortality after pancreatic head resection has fallen to below 5% in high-volume centers, but dehiscence of the pancreatojejunostomy remains a major concern. Despite various methods of protection, insufficiency rates still range from 6% to 19%. External drainage of pancreatic juice from the anastomotic site has shown promising results in the last decade. We compared the morbidity and mortality of two widely used drainage systems. Methods The subjects were 143 patients who underwent pancreatic head resection, followed by jejunal loop drainage with the top of the drain being placed between the pancreatojejunostomy and hepaticojejunostomy in 89, and by direct drainage of the pancreatic duct in 54. Results The median age was similar in both groups. Pancreatic fistula developed in 3 (5%) patients with a pancreatic drain and 6 (7%) with a loop drain. Breakdown of the pancreatojejunostomy occurred in 1 (2%) patient with a pancreatic drain and 2 (2%) with a loop drain. The overall perioperative mortality was 0.7%. The surgical and medical complications and postoperative course were similar in the two groups. Conclusion The choice of drainage system did not impact on the number or severity of postoperative complications or survival, indicating that loop drainage is as safe and effective as direct pancreatic duct drainage.     

Pancreatic pseudocysts in chronic pancreatitis. Surgical or interventional drainage?

Pseudocyst formation is a well-known complication of acute and chronic pancreatitis. Many pseudocysts are asymptomatic and may resolve without intervention. For a symptomatic pseudocyst drainage is indicated. Although surgical cystoenterostomy has been the treatment of choice for many years, recently invasive but non-operative treatment methods have challenged surgical drainage as the standard therapy for pancreatic pseudocysts. Both the method as well as the timing of intervention has become a matter of debate. Percutaneous catheter drainage and endoscopic drainage have proven beneficial in the treatment of pseudocysts, although long-term outcome remains to be awaited. Resolution rates after surgical and non-surgical methods are comparable, but clinical and technical aspects may mandate either method. Each patient requires an individual, multidisciplinary approach, thereby obtaining optimal treatment-outcome.     

The iliopsoas abscess: aetiology, therapy, and outcome

Background and aims The treatment strategy for patients with a retroperitonally localised abscess is controversial as it remains open which fluid collections should be drained by open access or by percutaneously inserted drainage.Patients Therefore, the data of 40 consecutively treated patients with an iliopsoas abscess were analysed retrospectively.Results Ten patients suffered from a primary abscess and ten from a post-operative abscess; further, in 20 patients, the aetiology of the abscesses were due to Crohn’s disease, neoplasia, spondylitis or other relevant concomitant diseases. Eight of 40 patients were initially treated by image-guided percutaneous drainage (PD), the other by open access drainage. Six patients died (15%), all of them had been operated; 15 (37.5%) patients had a recurrence of their abscess and needed re-operation. Factors predicting a poor outcome were age, APACHE II score, bi-lateral abscesses and a post-operative or bony cause, but the bacteriological findings did not influence the outcome.Conclusions We suggest an algorithm for treatment of iliopsoas abscesses depending on number and volume of the abscesses.     

Proximal biliary malignancy

Hilar cholangiocarcinoma is a rare malignancy that occurs at the bifurcation of the bile ducts. Complete surgical excision with negative histologic margins remains the only hope for cure or long-term survival. Because of its location and proximity to the vascular inflow of the liver, surgical resection is technically difficult and may require advanced vascular reconstructions to achieve complete excision. Patients who are not candidates for resection should undergo palliative biliary drainage. The role of neoadjuvant therapy and liver transplantation in the management of hilar cholangiocarcinoma remains to be defined in light of the recent promising results.