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Obesity and its related comorbidities is a major health problem worldwide. Sleeve gastrectomy is regarded to be one of the most effective bariatric surgeries with a relatively low risks of complications. Gastrobronchial fistula is an extremely rare and a serious complication after bariatric surgeries, it is associated with major morbidity. A 48-year-old obese lady with a BMI of 40 had underwent laparoscopic sleeve gastrectomy 7 years ago, she developed leak at the 10th postoperative day which was treated with drainage. After 4 years she presented with left subphrenic abscess which was treated with drainage, splenectomy and endoscopic stent. After one year she had repeated chest infections and was coughing-up recently ingested food items. CT-scan showed left subphrenic collection with abnormal fistulous tract between the bronchial tree and the subphrenic cavity. Left thoracotomy was performed, a complex fistula was found between the remnant parts of the gastric fundus, transverse colon and lung. Resection of the fistula was performed, the stomach and colon were closed in 2 layers, resection of the affected segment of lung was performed and the diaphragm was sutured. The BMI was 19 at the last admission. Gastro-colo-bronchial fistula is unreported after sleeve gastrectomy and the management is challenging. Surgeons may follow the same principles of management as in cases of gastrobronchial fistula, but we suggest earlier surgical intervention with the administration of broad spectrum antibiotics. Nutritional deficiencies must be corrected, and such patients must be treated with multidisciplinary team, with an extended duration of follow-up., Highlights • Sleeve gastrectomy is one of the most effective bariatric surgeries with a relatively low complication rates. • Gastro-colo-bronchial fistula is unreported after sleeve gastrectomy and the management is challenging. • Multidisciplinary team is required for the management of such patients.

Introduction Abdominal abscesses are one of the frequent and dangerous postoperative complication. They occur as a result of failure of seams esophagojejunal anastomosis after gastrectomy (17%), perforation of gastric and duodenal ulcers (26.8%), splenectomy (25.4%), failure of biliodigestive anastomoses (23.8%), inadequate drainage of the subphrenic space (22.2%), acute pancreatitis (14%). Left-sided subphrenic abscesses are the most common of them. Case presentation We present a patient with the left-sided subphrenic abscess, formed as a result of insolvency of the esophagojejunal anastomosis after gastrectomy and splenectomy, which underwent percutaneous drainage under the control of ultrasound and X-ray. Sanitation of the abscess cavity and the introduction of fibrin glue into it made it possible to close the fistula and heal the patient. Discussion The described case shows that the rehabilitation of the abscess and the injection of fibrin glue into it, made it possible to avoid surgery, eliminate the abscess and close the connection with the esophagojejunal anastomosis in a short time. Conclusion Percutaneous drainage under the control of ultrasound made it possible to avoid surgery and heal the patient with the left-sided subphrenic abscess in a short time. Fistula treatment with fibrin glue is not only effective, but is also less risky than surgery., Highlights • Abdominal abscesses are frequent and dangerous postoperative complications, and left-sided subphrenic abscesses are the most common of them. • Percutaneous drainage made it possible to avoid surgery and heal the left-sided subphrenic abscess in a short time. • Fistula treatment with fibrin glue is not only effective, but is also less risky than surgery.

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.

Introduction Spillage of gallstones into the peritoneal cavity (dropped gallstones) is more common in laparoscopic compared with open cholecystectomy. Subsequent infectious complications are often delayed, occurring in 0.1% to 2.9% of cases. We present the first reported case of Salmonella enterica subphrenic abscess and empyema complicating dropped gallstones, treated with video-assisted thoracoscopic surgery (VATS), and surgical retrieval. Case report A 67-year-old male with symptomatic cholelithiasis underwent an uncomplicated laparoscopic cholecystectomy. Four years later, he presented with a mass in his right flank, and an abdominal computed tomography (CT) revealed a right flank intramuscular abscess containing gallstones. The abscess was drained surgically with removal of gallstones. He was readmitted 15 months later with right upper quadrant pain, fever, and dyspnea. Chest and abdominal computer tomography (CT) showed a right pleural effusion and a right subphrenic abscess containing a dropped gallstone. The gallstone was localized with a needle using CT guidance. He subsequently underwent a right VATS for decortication. A separate flank incision was made at the site of the needle to drain the subphrenic abscess and retrieve the gallstone. Cultures from his empyema grew S enteritidis. The patient made an uneventful recovery. Discussion During laparoscopic cholecystectomy, efforts should be made to retrieve dropped gallstones as they can cause abscess and empyema, which might necessitate furthermore surgical intervention. The use of VATS has been established as a safe and effective alternative to thoracotomy, including the treatment of empyema. Needle-localization resulted in a successful retrieval of the gallstone in our patient. Culture of the abscess is important, as unusual organisms such as Salmonella could be present. S. enteritidis has not been implicated as a cause of cholecystitis and is rarely associated with abdominal abscesses. We postulate that the organism reached the gallbladder through the bile or bloodstream after gastrointestinal colonization and that its persistence in the gallbladder may have been facilitated by gallstones.

Intrabdominal penetration with intestinal perforation is a relatively uncommon complication after liposuction. Seven cases have been reported in the literature, with a mortality rate > 50%. Here we present a case of a perforated viscus after suction lipoplasty of the abdomen using the tumescent technique. Multiple small-bowel enterotomies were made with the suction cannula. It is our hope that a heightened awareness of this potentially life-threatening complication will promote early and aggressive diagnosis and treatment of liposuction patients who present with gastrointestinal complaints in the early postoperative period.

Ten of 42 patients who underwent liver transplantation were retrospectively found to have enlarging pleural effusions later than 3 days after transplantation. Seven of the 10 patients had subdiaphragmatic pathology, including 4 with hematomas, 1 with a biloma, and 2 with abscesses. One patient with a subphrenic abscess also had an empyema. Patients with a enlarging pleural effusion later than 3 days after transplantation should be evaluated for subdiaphragmatic pathology.

The problems started with an incorrect diagnosis and treatment of an enlarged spleen and lymph nodes. In 1974, French doctors started chemotherapy in secret without a diagnosis. In September 1979, while residing in Cuernavaca, Mexico, the Shah developed fever and jaundice. Mexican physicians diagnosed biliary duct obstruction and arranged for admission to the American British Cowdray Hospital in Mexico City. Then Benjamin Kean, an internist and expert on tropical disease from New York, arrived in Cuernavaca and became the Shah’s physician, prompting Dr Flandrin, his French hematologist, to withdraw from the case upon seeing “a tropical medicine expert managing an oncology case complicated by gallstone biliary obstruction.” Dr Kean convinced US officials that the best medical treatment could be given only in the US, and President Carter admitted the Shah for “humanitarian reasons.” In New York, a CT scan confirmed cholelithiasis and choledocholithiasis. Dr Bjorn Thorbjarnarson performed a cholecystectomy and common bile duct exploration without operative cholangiogram. The patient remained icteric due to retained bile duct stones that were later removed percutaneously by Dr J Buherne, who was flown to New York from British Columbia. Regarding the medical treatment given in New York, the Shah’s wife wrote in her memoirs, “. . . I only discovered much later how clumsily this operation had been carried out. I learned that the fee for the operation had been inordinately high, and was told that an anonymous patient was better cared for than someone known.” In Panama, local surgeons admitted the Shah to Paitilla Hospital and made plans for a splenectomy. Dr Kean asked a famous cardiac surgeon, Dr Michael DeBakey, to operate, but when he arrived at Paitilla, Dr Carlos Garcia, the surgeon in charge, told DeBakey that he could not operate in Panama and DeBakey left the country. The Shah was flown to Egypt, where DeBakey performed the splenectomy. Dr Nour, one of the Egyptian surgeons who witnessed the operation, saw that “the tail of the pancreas was in the specimen.” The Shah developed fever and left pleural effusion, and French and Egyptian doctors diagnosed a subphrenic abscess. DeBakey did not agree with the diagnosis. Dr Flandrin asked for help from a surgeon from Paris, Dr Pierre-Louis Fagniez, who drained a large subphrenic abscess, with 1,500 mL of pus and necrotic pancreatic tissue. Due to a long delay in draining the abscess, the Shah=s condition worsened and he died of pancreatic hemorrhage. The whole affair shows how a medical problem was not handled well because of secrecy and political reasons. When a gallbladder-bile duct obstruction required operation, Dr Kean rejected Mexican facilities and the operation was done in New York. Then a cardiac surgeon went to Panama to perform the splenectomy, without respect for the country=s medical facilities. Again Dr Kean asked DeBakey to do the operation in Egypt, in a place Kean described as a “hygienic disaster area” and “fourth-rate hospital.” This attitude shown by the American physicians to olleagues in France, Mexico, Panama, and Egypt is a sad xample of a case of medical treatment that ended with the hah=s death.

Forty-eight patients were scanned with 111 In-chloride in an attempt to identify the cause of fever. Fifteen true positive scans, 30 true negatives, and 3 false negatives were found. Of the 15 true positives, 7 cases of abdominal or pelvic abscess, and 8 cases of alcoholic hepatitis were detected. The 3 false negatives included: 1) an abscess in the anterior abdominal wall; 2) an abscess in the right upper quadrant at the site of a necrotic gallbladder; and 3) a tuberculous abscesss of the lumbar spine. Examples from the different categories, pitfalls in interpretation and advantages and disadvantages of scanning with 111In-chloride will be presented. These studies indicate that 111In-chloride is a safe, reliable scanning agent for abscesses below the diaphragm especially in patients who cannot undergo adequate bowel preparation.

Of 104 patients evaluated for thoracic sepsis by CT, 22 patients had both CT and clinical evidence of mediastinal infections. The CT findings in these patients were reviewed and compared with a control group of seven postoperative patients following uncomplicated median sternotomy. Based on CT appearance, patients were classified into one of three groups: (a) diffuse soft tissue infiltration with or without gas (i.e., mediastinitis) (10 patients); (b) focal mediastinal abscess (four patients); (c) mediastinal infection associated with empyema or subphrenic abscess (eight patients). Computed tomography proved reliable in distinguishing diffuse mediastinitis from a localized drainable abscess. However, in the absence of mediastinal gas, CT could not differentiate mediastinitis from benign postoperative changes. Computed tomography was helpful in identifying associated empyemas and a variety of other secondary complications. In five of six patients with mediastinal abscess, CT demonstrated communication or contiguity with four empyemas and one subphrenic abscess. Closed chest tube drainage of the empyemas and percutaneous drainage of the subphrenic abscess combined with antibiotic therapy were successful in treating the mediastinal abscess in these five patients. Although overall mortality for mediastinal infection in this series was 27%, there was a 50% mortality for patients with diffuse mediastinitis.

Increased concern over the potential immunologic consequences of splenectomy has prompted surgeons to attempt salvage of traumatized spleens. We report a retrospective study of 172 consecutive patients with documented splenic injury treated over a 2-year period: 107 patients underwent splenectomy; 65 were managed without total splenectomy; 32 were not explored. The overall mortality rate was 27%; the overall complications were 30%, including a 13% incidence of post-splenectomy subphrenic abscess. The incidence of infectious complications after splenectomy was 36%, while the incidence in nonsplenectomized patients was 9%. The Injury Severity Scores (ISS) in the two groups were significantly different (p less than or equal to 0.05). When the group whose spleens were salvaged was compared to an equivalent group matched for ISS, age, and sex, there was no significant difference in sepsis rates (23% vs. 10.7%; 0.10 greater than or equal to p greater than or equal to 0.05). Survival in those with postinjury infectious complications was significantly improved in patients with a remaining spleen (p less than or equal to 0.01). Abdominal computerized tomography was used successfully as a method of following injured and repaired spleens in order to predict return to full activity.

Opportunistic systemic fungal infections are more frequent than generally realized. Increased awareness and a high index of suspicion of fungal super-infection in the presence of sepsis is required to bring about recognition and therapy. The intravenous catheter is an important portal of entry or may act as a foreign body favoring localization of a septic process. In its presence, fungemia must be guarded against. Whenever an intravenous catheter is removed, its tip should be cultured. Removal alone may be a critical item in therapy. In febrile patients, in whom the course of fever is not established, frequent blood cultures with attention directed specifically at fungi should be obtained. Fungi are not easily isolated and identified and only by requesting special attention from the microbiologist can the diagnosis be established in the average institutional laboratory in time to permit appropriate therapy. Since available therapeutic measures are strikingly effective when instituted early, awareness and alertness on the part of the clinician constitute the key to cure.

The technique and results of 29 major hepatic resections using the method of complete vascular isolation and hypothermic perfusion of the liver are reported. The method enables the surgeon to perform otherwise difficult or impossible resections through chilled bloodless hepatic parenchyma. Major intrahepatic vascular structures can thus be recognized and controlled readily under clear vision. Direct neoplastic involvement of, or tumor thrombi in the portal vein, hepatic vein or vena cava, can be successfully dealt with by appropriate surgical measures. The operative mortality was 10.3% for this series which included many tumors previously deemed unresectable. The technical detail and intraoperative physiologic monitoring crucial to success in the use of the method are described. It is hoped that with the widened scope of resectability afforded by this technique, and the use of adjuvant chemotherapy, the currently experienced low cure rates for hepatic cancer can be improved.

One hundred eight patients have undergone major hepatic resection by the senior author during the eight year period April 1970 to April 1978. Primary liver cancer was present in 36; metastatic colorectal cancer in 25, miscellaneous metastatic cancers in 15, hepatoblastoma in 5, gallbladder cancer in 4, and bile duct cancer in 3. Benign tumors, principally giant hemangioma, were resected in 20 additional patients. The 30 day operative mortality rate was 9% overall. Prior to 1975, 41 of the resections were done using the vascular isolation perfusion technique. The operative mortality rate of 17% for this technique is a reflection of early experience and the advanced stage of disease of many patients. The operative mortality for the standard resection has been only 4%. Subphrenic abscess has developed in only 13% of patients during the past three years. Postoperative hospitalization has been shortened, being a median of 13 days. The resectability rate for malignant disease was 33%. Forty-six percent of the resections were performed with curative intent. Fifty-four per cent were palliative, performed in individuals with regional spread or distant metastasis. After curative surgery, three year survival was 88% for individuals with primary liver cancer and 72% with metastatic colorectal cancer. After palliative resection, the rates were 31 and 0%, respectively. The three year survival rate is 46% overall, being 81% for the curative resection group and 18% for the palliative group. Tumor markers proved useful in monitoring patients after hepatic resection.

Staging laparotomy (multiple liver and lymph node biopsies and splenectomy) was performed at the North Carolina Baptist Hospital in 123 patients with Hodgkin's disease. There were no deaths. Wound, pulmonary, intra-abdominal or urinary tract complications developed in 17 patients. Of those complications, one case each of pelvic abscess, subphrenic abscess, small bowel obstruction, staphylococcal peritonitis and subphrenic hematoma required a major intra-abdominal operation. The patients were classified on the basis of histopathology; nodular sclerosis--40, mixed cellularity--44, lymphocyte predominant--24, lymphocyte depleted--13, and undetermined--2. The pathological stage following laparotomy was unchanged from the clinical stage in 62%, reduced in 15%, and advanced in 23%. Subsequent therapy, therefore, was altered in 38% of the patients. Lymphangiography, done in 108 patients, showed lymph node involvement in 46 patients and no involvement in 62 patients. Of those lymphangiographic findings, 79% were confirmed histopathologically, 19% were falsely positive, and 1.8% were falsely negative. There were positive findings of Hodgkin's disease in the spleen in 42% of patients. The staging laparotomy continues to be a valuable tool in the staging and treatment of Hodgkin's disease.

Congenital cystic dilatation of the biliary tree (Caroli's disease) is a rare condition that usually presents with ascending cholangitis. This report demonstrates the difficulty of recognizing other complications of Caroli's disease antemortem. A 35-year-old man developed a subphrenic abscess and malignant transformation of the biliary tree; both were clinically undetected. Episodes of pain, pyrexia, or weight loss should be assessed carefully and the complications of Caroli's disease considered before attributing such symptoms to recurrent cholangitis.

Between January 1, 1984, and June 30, 1987, we performed percutaneous catheter drainage (PCD) of 28 intra-abdominal abscesses in 21 postoperative trauma patients. During this period only three patients had abdominal re-exploration for drainage of abdominal abscess. The PCD patients were predominantly young men who had sustained penetrating abdominal injuries (81% GSW or SW; 19% MVA). Seventeen (81%) patients had multiple abdominal organ injuries with the colon being the most frequently injured (57%). Multiple abscesses were identified in 33% of the patients. All 21 patients had successful treatment of their abscesses by PCD alone. There was one complication (4.8%) from PCD (pneumothorax) and no deaths in this group. Our data suggest that in most cases, PCD can be safe, effective, and definitive treatment for postoperative intra-abdominal abscesses following abdominal trauma. We recommend PCD in all postoperative trauma patients who develop accessible abdominal abscesses before resorting to re-exploration.

From 1971--1975, 107 staging laparotomies for Hodgkin's disease were performed at the University of Wisconsin Hospitals. Forty-one per cent of patients with abnormal abdominal lymphangiograms preoperatively had abdominal nodes which were negative for Hodgkin's. Thirteen per cent of patients with negative preoperative lymphangiograms had positive nodes at staging laparotomy. Twenty-nine per cent were upstaged by laparotomy, i.e. assigned to a less favorable stage (II A to III A), and 11.2% were downstaged. There were no surgical mortalities. Minor surgical complications occurred in 14.9%, and major ones in 3.7%. We conclude that surgical staging for Hodgkin's disease is valuable in making an accurate diagnosis and, hence, in determining the most effective treatment.

A skiing accident had cracked several ribs, collapsed a lung, severely lacerated my liver, and destroyed my right renal artery. I hemorrhaged, went into deep shock, and had one complication after another: acute renal failure, cardiac arrest, hypertension, pulmonary edema, thrombophlebitis, pneumonia, subphrenic abscess, transfusion reactions, massive infection, clotted shunts, azotemia, hyperkalemia, a second pneumothorax, convulsions, digitalis toxicity, and pruritis which was extremely intense. I underwent two laparotomies, two thoracotomies, a tracheostomy, seven shunt revisions, cystoscopy and retrograde pyelography, renal angiograms, two paracenteses, and numerous thoracenteses. There were also a liver scan, spinal taps, electroencephalograms, electrocardiograms, numerous catheterizations, bronchial aspirations, saline lavages, frequent suctioning, over 600 x-rays, and what seemed to be constant laboratory studies. For several weeks, a Levin tube was connected to low Gomco suction and two chest tubes connected

Gallium-67 distribution in normal patients is well known; it is also known that the concentration in some tissues may vary according to an individual physiologic stimulus. In this report, the case of a young woman is presented who was studied 15 days after a cesarean section and showed physiologic and pathologic Ga-67 accumulation.

• Eight cases of hepatic arterial bleeding are reported. Bleeding in five instances was consequent to trauma and was either persistent postoperative (three cases) or delayed with hemobilia (two cases). Bleeding in the other three cases was from rupture of a subcapsular hematoma of the liver, with spontaneous hepatic rupture of pregnancy (two cases) and metastatic melanoma (one case). Angiography demonstrated pseudoaneurysm in six cases, a hepatic artery to portal venous fistula in one case, and a subcapsular hematoma in the final case. Percutaneous angiographic embolization controlled bleeding in seven cases and was not feasible in one case with tortuosity of the celiac axis. Complications included hepatobiliary necrosis in one patient and subphrenic abscess in two patients. Percutaneous angiographic embolization can selectively occlude a branch of the hepatic artery and is effective in the control of hepatic arterial bleeding from a variety of causes. ( Arch Surg 1985;120:1241-1249)

Frank H. Lahey, the descendant of Irish grandparents, was born June 1, 1880, in Haverhill, Massachusetts, the only child of a successful bridge building contracior. He was an outstanding athlete in the schools in Haverhill, and went on to Harvard University for his undergraduate study. In the fall of 1900 he entered Harvard Medical School, and did graduate training at the Boston City Hospital. He had joined the Staffs of Harvard and Tufts Medical Schools when World War I interrupted. He became a major in the Medical Corps and went to France to be Chief of Surgery in an evacuation hospital. Following the war he opened an office and shortly thereafter was joined by a surgeon and an anesthesiologist. It was at this time that he conceived the idea of developing a multiple specialty clinic a practice which had been successful in the mid-west, but not in New England. With the clinic established he developed a Fellowship Program for training surgeons from all over the world. He was a master technician and his surgical interest encompassed a wide range, but he was particularly well known for his operative approaches to the thyroid, the biliary tract, and the gastrointestinal tract. The concept of staged operations was vigorously applied at the Lahey Clinic for many diseases-thyrotoxicosis, esophageal diverticulum, subphrenic abscess, hepatic abscess, pancreatic cancer, diverticular disease, and cancer of the rectum. By staging the operation, Lahey and other surgeons were able to keep operative mortality extremely low.