Treatment of pyogenic hepatic abscesses. Surgical vs percutaneous drainage

A retrospective review of 39 patients with pyogenic hepatic abscess treated from 1977 through 1984 included 23 patients who were surgically treated and 16 who underwent percutaneous drainage. The average age in each group was similar (about 55 years). The most common cause of abscesses in each group was biliary tract disease. Abscesses caused by portal seeding and local extension were more common in the surgical group, 14 of whom required additional surgical procedures at the time of surgical drainage. Of the 16 patients in the percutaneously drained group, seven were seen during the immediate postoperative period. Most of the abscesses occurred in the right lobe of the liver, but single abscesses in the left lobe (30%) and multiple abscesses (57%) were more common in the surgical group. Klebsiella enterobacter and group D streptococcus were most common in the surgically and percutaneously drained groups, respectively. All patients received antibiotics, with a mean length of treatment of 14 days. Mean time to defervescence was about four days in both groups, with a longer hospital stay for the percutaneously drained group (26 vs 46 days). Morbidity was high in both groups (surgical, 48%; percutaneous, 69%). Three of the percutaneously treated patients required surgical drainage because of highly viscous abscess contents. Mortality was 17% in the surgical group and 13% in the percutaneously drained group. Percutaneous drainage with computed tomography probably should be the initial drainage procedure in patients with pyogenic hepatic abscesses in whom no concomitant surgical procedure is planned. Regardless of treatment, the morbidity and mortality remain high.     

Case-report: Peripartum Management of Dual Antiplatelet Therapy and Neuraxial Labor Analgesia After Bare Metal Stent Insertion for Acute Myocardial Infarction

A 31-year-old woman at 32 weeks' gestation presented with an ST segment elevation myocardial infarction with subsequent bare metal stent placement. A multidisciplinary team coordinated the delivery plan, including anticoagulation and delivery mode. Because the patient was at high risk for stent thrombosis, clopidogrel was discontinued after 4 weeks and bridged with eptifibatide for 7 days. Eptifibatide was stopped for induction of labor. Twelve hours after eptifibatide was discontinued, hemostatic function was assessed with thromboelastography before initiating neuraxial analgesia. A successful operative vaginal delivery was performed, followed by an uncomplicated recovery. Clopidogrel was resumed 24 hours postpartum.     

Outcomes of prenatally diagnosed sacrococcygeal teratomas: the results of a Japanese nationwide survey

Background/PurposeFew large multicenter surveys have been performed on sacrococcygeal teratomas (SCTs) describing both the prenatal and postnatal courses. The aim of this study was to review and report on the prenatal surveillance and postnatal outcome of a large cohort of fetuses with SCTs in Japan.MethodsA nationwide retrospective cohort study was conducted on 97 fetuses prenatally diagnosed with SCTs between 2000 and 2009. The prenatal course, perinatal data, and postnatal outcome were reviewed.ResultsEleven pregnancies were terminated before 22 weeks of gestation. Of the 86 remaining fetuses, 3 died in utero, and 83 were delivered. Three infants died before surgery, and 8 infants died after excisional surgery. The overall mortality was 26%, with a mortality excluding terminations of 16%. The gestational age at delivery was younger than 28 weeks in 5, 28 to 31 weeks in 13, 32 to 36 weeks in 27, and 37 weeks or more in 37 cases, with mortality rates of 60%, 38%, 11%, and 0%, respectively. The tumor component was predominantly cystic in 54 and predominantly solid in 32 cases, with mortality rates of 2% and 33%, respectively.ConclusionsThe overall mortality of prenatally diagnosed SCTs excluding terminations was 16%. Early delivery and predominantly solid component tumors were associated with an increased risk of mortality.     

Effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes

Background/Purpose

This study examined the effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes, with adjustment for key confounding variables.

Methods

This retrospective cohort study included all gastroschisis patients treated at a single tertiary children's hospital between 1999 and 2009. Prenatal care, delivery mode (vaginal vs cesarean section before labor vs after labor), patient characteristics, and clinical outcomes were determined by chart review. Time to discontinuation of parenteral nutrition (PN) was the primary outcome of interest. Effects of multidisciplinary prenatal care and delivery mode were evaluated using Cox proportional hazards regression models that included gestational age, birth weight, sex, concomitant intestinal complications, and year of admission.

Results

Of 167 patients included, 46% were delivered vaginally, 69% received multidisciplinary prenatal care, and median time to PN discontinuation was 38 days. On multivariable modeling, gestational age, uncomplicated gastroschisis, and year of admission were significant predictors of early PN independence. Delivery mode and prenatal care had no independent effect on outcomes, although patients receiving multidisciplinary prenatal care were more likely to be born at term (49% vs 27%, P = .01).

Conclusions

Gestational age and intestinal complications are the major determinants of outcome in gastroschisis. Multidisciplinary prenatal care may facilitate term delivery.     

Cesarean section does not improve outcome in gastroschisis

Elective cesarean section (CS) following prenatal diagnosis of gastroschisis has been advocated to decrease morbidity and mortality. To examine this hypothesis, we reviewed the records of 28 consecutive patients with gastroschisis treated between 1975 and 1987. Fourteen infants were delivered vaginally (V) and fourteen by CS, of which seven were elective, five were for fetal distress, and two were for breech presentation. Prenatal diagnosis was made in nine infants in the CS group and none in the vaginal group. The two groups were comparable in gestational age (V = 37.6 weeks, CS = 35.8 weeks, P = .05), birth weight (V = 2,508 g, CS = 2,444 g, P = NS), and five-minute Apgar score (V = 7.8, CS = 6.8, P = NS). Outcome was similar as measured by hospital mortality (V = 0/14, CS = 1/14, P = NS), complications (V = 4/14, CS = 5/14, P = NS), days to enteral feeding (V = 14, CS = 19, P = NS), and days in the hospital (V = 27, CS = 34, P = NS). The only complication related to mode of delivery was preventable; an infant delivered vaginally had avulsion of a short segment of mesentery requiring bowel resection. Infants born by CS were slightly more likely to have primary closure (5/14) than babies delivered vaginally (3/14, P = NS), but this may reflect independent trends in the last 5 years. Elective CS following prenatal diagnosis in seven patients did not improve outcome; primary closure was achieved in only one infant, and three had a complication. Since these data show no significant difference in morbidity and mortality between vaginal and CS delivery, we suggest that CS should not be recommended simply because a prenatal diagnosis of gastroschisis is made.     

Ultrasound-guided percutaneous drainage of 25 abscesses

Twenty-four confirmed well-defined abdominal abscesses and one abscess in the thorax were percutaneously drained in 21 patients. In all, 28 puncture and drainage procedures were performed. Nineteen abscesses were drained without further surgery (76%). The high success rate, combined with minimal complications and low overall mortality (9.5%), indicates that ultrasound-guided percutaneous drainage is probably the method of choice in the treatment of well-defined, unilocular abscesses, avoiding the risk of major surgery.     

Interventional and surgical treatment of pancreatic abscess

Pancreatic abscess is one of the infectious complications of acute pancreatitis. It is a collection principally containing pus, but it may also contain variable amounts of semisolid necrotic debris. Most of these abscesses evolve from the progressive liquefaction of necrotic pancreatic and peripancreatic tissues, but some arise from infection of peripancreatic fluid or collections elsewhere in the peritoneal cavity. Included also are abscesses found after surgical débridement and drainage of pancreatic necrosis. Although open surgical treatment of infected necrosis is the established treatment of choice, percutaneous drainage of abscesses is successful in some circumstances. We used percutaneous catheter drainage in 39 patients during 1987–1995. Only 9 of 29 (31%) attempts at primary therapy were successful; 2 patients died, and 18 required subsequent surgical drainage. On the other hand, 14 of 14 patients with recurrent or residual abscesses after surgical drainage were successfully drained percutaneously. Percutaneous catheter drainage of pancreatic abscesses may be useful for initial stabilization of septic patients, drainage of further abscesses after surgical intervention (especially when access for reoperation will be difficult), associated abscesses remote from the pancreas, and selected unilocular collections at a sufficient interval after necrotizing pancreatitis to have allowed essentially complete liquefaction.     

PERCUTANEOUS CYSTOGASTROSTOMY FOR TREATMENT OF PANCREATIC PSEUDOCYSTS

Cystogastrostomy or cystojejunostomy at open operation has been the usual treatment for symptomatic pancreatic pseudocyst. The aim of this study was to assess prospectively the results of percutaneous cystogastrostomy (PCG) for the treatment of symptomatic pseudocysts. The technique of PCG comprised initially of drainage of the pseudocyst with a 10 Fr percutaneous, transgastric catheter. This initial drainage catheter had two components; the first, between the pseudocyst and the stomach, drained the pseudocyst and the second, between the stomach and exterior, acted as a percutaneous gastrostomy. The initial drain was left in situ for 14 days, at which time it was exchanged percutaneously for the definitive PCG; a double ended Mallecot type catheter that drained between the pseudocyst and the stomach. The latter catheter was left in situ until there was no residual pseudocyst demonstrated on computerized tomography scan and was removed endoscopically. Eleven patients with large (> 6 cm), symptomatic pseudocysts have been treated with PCG. All patients were treated successfully without the need for surgical intervention. The median time to radiological resolution was 24 days. There were four episodes of sepsis, two related to central venous line infections and two related to catheter blockage. Percutaneous cystogastrostomy blockage was managed by either replacing the initial drain or inserting a second catheter. The median follow up after successful treatment was 9 months (range 2–17). There were no symptomatic recurrences and one small (2 cm) asymptomatic recurrent pseudocyst. This preliminary experience with PCG demonstrates the efficacy of this procedure for treating symptomatic pancreatic pseudocysts.     

Sacrococcygeal teratoma: prenatal assessment, fetal intervention, and outcome

Purpose

To understand the natural history and define indications for fetal intervention in sacrococcygeal teratoma (SCT), the authors reviewed all cases of fetal SCT presenting for evaluation.

Methods

Prenatal diagnostic studies including ultrasound scan, magnetic resonance imaging (MRI), echocardiography and pre- and postnatal outcomes were reviewed in 30 cases of SCT that presented between September 1995 and January 2003.

Results

The mean gestational age (GA) at presentation was 23.9 weeks (range, 19 to 38.5) with 3 sets of twins (10%). Overall outcomes included 4 terminations, 5 fetal demises, 7 neonatal deaths, and 14 survivors. Significant obstetric complications occurred in 81% of the 26 continuing pregnancies: polyhydramnios (n = 7), oligohydramnios (n = 4), preterm labor (n = 13), preeclampsia (n = 4), gestational diabetes (n = 1), HELLP syndrome (n = 1), and hyperemesis (n = 1). Fetal intervention included cyst aspiration (n = 6), amnioreduction (n = 3), amnioinfusion (n = 1), and open fetal surgical resection (n = 4). Indications for cyst aspiration and amnioreduction were maternal discomfort, preterm labor, and prevention of tumor rupture at delivery. Although 15 SCTs were solid causing risk for cardiac failure, only 4 fetuses met criteria for fetal debulking based on ultrasonographic and echocardiographic evidence of impending high output failure and favorable anatomy at 21, 23.6, 25, and 26 weeks’ gestation. Intraoperative events included maternal blood transfusion (n = 1), fetal blood transfusion (n = 2), chorioamniotic membrane separation (n = 2), and fetal arrest requiring successful cardiopulmonary resuscitation (CPR) (n = 1). In the fetal resection group, 3 of 4 survived with mean GA at delivery of 29 weeks (range, 27.6 to 31.7 weeks), mean birth weight of 1.3 kg, hospital stay ranging from 16 to 34 weeks, and follow-up ranging from 20 months to 6 years. Postnatal complications in the fetal surgery group included neonatal death (n = 1, secondary to premature closure of ductus arteriosus with cardiac failure), embolic event (n = 1, resulting in unilateral renal agenesis, jejunal atresia), chronic lung disease (n = 1), and tumor recurrence (n = 1).

Conclusions

For fetal SCT, the rapidity at which cardiac compromise can develop and the high incidence of obstetric complications warrant close prenatal surveillance. Amnioreduction, cyst aspiration, and surgical debulking are potentially life-saving interventions.     

Epidural analgesia for term vaginal delivery after balloon valvotomy for mitral stenosis at 24 weeks gestation

A woman presented at 24 weeks gestation with previously undiagnosed mitral stenosis. She did not respond to conservative management and underwent successful percutaneous balloon mitral valvotomy for refractory congestive cardiac failure, with complete resolution of her symptoms. The remainder of her pregnancy was uncomplicated and she delivered a healthy infant at 39 weeks gestation. An epidural block provided analgesia/anesthesia for vaginal delivery and repair of the perineal tear.     

Cervico-Mediastinal Bronchogenic Cyst Occurring in the Prenatal Period: Report of a Case

We experienced a case of cervico-mediastinal bronchogenic cyst in which a cervical cystic mass was detected by prenatal ultrasonography. On prenatal ultrasound, a unilocular, well-defined and hypoechoic mass was detected in the fetal neck. The baby was born by a normal vaginal delivery at 40 weeks of gestation, and had no respiratory distress. Radiological investigations demonstrated a cyst in the cervico-mediastinal region, which displaced the trachea to the left. At the age of 32 days, an elective resection was easily performed through a right inferior collar incision after first aspirating the contents of the cyst. Prenatal sonography showing abnormal findings is effective for identifying cysts in the perinatal period and allows for the timely resection of such cysts before respiratory distress occurs. Received: October 22, 1999 / Accepted: May 30, 2000     

Vaginal delivery after pubovaginal sling surgery

For pregnant women who have had previous successful surgery for genuine stress urinary incontinence, an elective cesarean section is generally recommended. Many of these patients are multiparous and can be expected to have a relatively short and uncomplicated labor. We report a case of vaginal delivery after a pubovaginal sling and urethral diverticulectomy with preservation of continence at 1 year.     

腹腔镜胆囊切除术后胆囊管瘘的诊断和处理

目的　探讨腹腔镜胆囊切除术 (LC)后胆囊管瘘的诊断和处理方法。方法　回顾性分析 3例LC术后胆囊管瘘病例的临床资料。结果　 3例均为女性 ,因慢性结石性胆囊炎行LC。临床表现分别为原有心律失常的加重 ,腹腔引流管引流出胆汁 ,以及脐部穿刺孔溢出胆汁样液。确定诊断的时间分别是术后第 1天、第 2天和第 2 0天。 2例再次行腹腔镜手术 ,套扎关闭开放的胆囊管 ,腹腔冲洗并引流 ;1例行腹腔穿刺置管引流 ,并经内镜乳头切开及置入胆道支架。 3例均获治愈。结论　LC术后胆囊管瘘临床表现多样 ,B超可以发现腹腔积液 ,确定诊断依赖于MRCP和ERCP。微创手术可以安全有效地处理这一并发症。腹腔镜再手术可以有效地关闭开放的胆囊管 ;内镜下引流的方法要有有效的腹腔引流的配合     

Splenic abscess as a complication of percutaneous nephrostomy

We report a case of splenic abscess as a complication of percutaneous nephrostomy tube placement. The patient was a sixty-three-year-old man suffering from a recurrence of transitional cell carcinoma of the bladder after cystectomy and neobladder substitution. Computed tomography of the abdomen identified the abscess, which was drained percutaneously. The patient's condition improved dramatically, and computed tomography showed complete resolution of the abscess two weeks after drainage. Splenic abscess is fatal if untreated and should be considered in a patient in whom sepsis or left lower pulmonary effusion develops after percutaneous manipulation of the kidney.     

Appendiceal abscesses: primary percutaneous drainage and selective interval appendicectomy.

OBJECTIVE: To present our results of non-surgical primary management of appendiceal abscesses using ultrasonic percutaneous drainage under local anaesthesia, and selective interval appendicectomy. DESIGN: Retrospective study. SETTING: University hospital, Sweden. SUBJECTS: 24 patients with appendiceal abscesses 3-12 cm in size. INTERVENTIONS: Primary ultrasonic percutaneous drainage under local anaesthesia, antibiotic treatment, and selective surgical treatment. MAIN OUTCOME MEASURES: Long-term follow-up. RESULTS: All patients had their abscesses drained successfully without complications. One patient continued to have fever, but eventually responded to conservative treatment and in one the bowel was perforated by the drain but again this was treated conservatively. Four abscesses recurred. Seven patients underwent planned interval appendicectomy. Another three patients were also operated on-one for caecal adenocarcinoma, and two for persisting symptoms and enterocutaneous fistulas. CONCLUSIONS: Appendiceal abscesses can be effectively drained percutaneously using ultrasound-guided drainage under local anaesthesia, without complications. Recurrent appendicitis is common, and malignancy is a substantial risk in elderly patients. Modern laparoscopic appendicectomy and early postoperative discharge makes interval appendicectomy a valid treatment option after primary non-surgical management of appendiceal abscesses.     

The Morphological Classification of a Serous Cystic Tumor (SCT) of the Pancreas and Evaluation of the Preoperative Diagnostic Accuracy of Computed Tomography

Background  Although the honeycomb microcystic type is common and typical for a serous cystic tumor (SCT), clinical and radiological features are diverse. Systematic classification of SCT subtypes is not well established. The purpose of this study was to classify the subtypes of SCT and to clarify its clinical and pathological characteristics. Methods  Clinical data from 52 patients with a pathologically confirmed SCT were prospectively collected using a standard data form. According to cyst size and multiplicity, on gross and radiological evaluation, the cysts were classified as microcystic when they were smaller than 2 cm, and macrocystic when larger than 2 cm. The microcystic tumors were subdivided into honeycomb and solid types, while the macrocystic tumors into unilocular and multilocular types based on the number of cysts. Results  There were 22 cases with microcystic SCTs that were subclassified into the honeycomb (n = 21) and solid types (n = 1), while 30 cases were macrocystic type and were subclassified into multilocular (n = 16) and unilocular types (n = 14). There were no differences between four subtypes with regard to gender, tumor location, and size. The preoperative diagnostic accuracy of the unilocular macrocystic SCT was only 35.7%, while that of honeycomb microcystic SCT and multilocular macrocystic SCT were 81% and 87.5%, respectively (P = 0.005). Conclusion  Microcystic SCTs and multilocular macrocystic SCTs can be accurately diagnosed preoperatively; therefore conservative treatment and observation are possible in some cases. However, the unilocular macrocystic SCT is difficult to differentiate from the other pancreatic cystic tumors with malignant potential, therefore resection must be considered. Seung Eun Lee, M.D. and Yujin Kwon, M.D., contributed equally in this work.     

Long-term percutaneous biliary drainage in an infant with hemangioendothelioma

A 5-month-old female infant with jaundice (bilirubin = 11) and dilated intrahepatic and extrahepatic bile ducts was explored. A 3-cm mass in the head of the pancreas and portal region completely obstructed the cystic and common bile ducts. Cholecystectomy was done and biopsy of the tumor and regional nodes revealed hemangioendothelioma with no nodal involvement. After tissue diagnosis was made, the infant's biliary tract was decompressed percutaneously. External drainage was maintained for 22 months until the tumor regressed. This infant is the youngest patient ever reported to undergo percutaneous biliary drainage.     

Management of lymphoceles after kidney transplantation

Post-transplant lymphoceles (LC) may lead to impaired graft function. Treatment modalities include fine-needle aspiration, percutaneous drainage, and surgical internal drainage. Recently, laparoscopic fenestration has been performed with good results, but experience is still limited. Between January 1991 and August 1996, 919 kidney transplantations were performed in 876 patients at our department. There were 745 first, 133 second, 30 third, 9 fourth, and 2 fifth operations. Sixty-three symptomatic LCs were detected in 62 patients (6.8 %) after 39 ± 31 days. In 44 % of the cases, graft function was impaired; in 29 % hydronephrosis was documented and in 6 % infection of the LC. Forty-five of the 62 patients with LC (73 %) had histologically proven rejection. Thirty-five of the 63 LCs were drained percutaneously, 20 LCs were internally drained by open surgery, and 8 LCs were drained by laparoscopy. In 14 of the 47 patients (30 %) with primary percutaneous drainage, LC recurred; infection occurred in 17 %. Twelve of these patients underwent surgery. One surgical redrainage was necessary after open fenestration. No conversion or complication was noted in the laparoscopy group. We conclude that surgery for post-transplant lymphoceles is safe and effective. We favor the laparoscopic technique in selected patients. Received: 17 October 1997 Accepted: 14 January 1998     

Percutaneous drainage treatment of abscess and fluid retention following abdominal surgery

61 patients with abdominal abscesses and fluid collections as a postoperative complication underwent percutaneous drainage. 60 abscesses, 11 haematomas, 3 steril seromas and 3 bile collections were drained. The fluid collections were associated with biliary or enteric fistulae in 16 cases. The percutaneous drainage was successful in 69%, additional surgery was required in 15%. The overall mortality rate was 13%. Reasons for drainage failure were infected clots, phlegmonic abscesses and pancreas involvement of the abscesses.     

An unusual complication after percutaneous drainage of a pancreatic pseudocyst into the stomach

In the period between September 1995 and June 1999, we performed percutaneous drainage into the stomach in 12 patients. There were no complications or pseudocyst recurrences on insertion or after endoscopic removal of the catheter, which was left in site for 1 year on average. After endoscopic removal of the drainage catheter, one of the patients presented with a cystic formation in the stomach wall, which caused stomach emptying disorder. Therefore, the patient had to be reoperated. The cyst wall was incised and a part of the cystic wall sampled for histological examination. The cyst was then drained into the isolated Roux loop of the jejunum. Histological findings of the cystic wall specimen showed the presence of granulation tissue and smooth muscle layers with ganglia cells of myenteric nerve plexus. Despite this complication, we believe that percutaneous endoscopically and ultrasonographically guided drainage of pancreatic pseudocyst into the stomach by means of a double pigtail catheter is a good method that yields encouraging results in sonographically selected cases. The position of the drainage catheter needs to be checked endoscopically, and the catheter should be removed only after 1 year.