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Intra-abdominal abscesses usually originate from the gastrointestinal tract, with 70% occurring in the postoperative period. The mortality rate can reach 50%. These abscesses most commonly develop in the subphrenic and subhepatic spaces. Treatments include percutaneous drainage or surgical drainage. In this report, we present a minimally invasive video-assisted trans-diaphragmatic drainage (MIVTD) method through a simple incision using a right intercostal approach. This method was successfully performed on a patient who underwent Graham patch repair with laparotomy due to a diagnosis of peptic ulcer perforation and subsequently developed a right subphrenic multiloculated collection after unsuccessful percutaneous drainage. [ABSTRACT FROM AUTHOR]

Introduction: Splenic abscess is a very rare pathology in the pediatric age, and the association with complications such as spontaneous drainage to the pleural cavity is even rarer. There is very little information in the literature regarding the best diagnostic and therapeutic approach. Case presentation: We present the case of an immunocompromised 16-year-old female patient with a splenic abscess that had spontaneous drainage to the left pleural cavity through the diaphragm and presented clinically as recurrent empyema. There was tomographic evidence of a significant pleural effusion on the left side and splenomegaly with a collection in the upper pole that extended to the left hemithorax through a defect in the diaphragm. Patient received successful treatment by laparoscopic splenectomy and transdiaphragmatic drainage of the pleural cavity. There were no complications and no recurrence of pleural effusion or subphrenic abscess on x-ray or ultrasound. At 6-month outpatient follow-up, she presented adequate clinical and radiological evolution. Conclusion: A trans-diaphragmatic pleural drain can be placed under laparoscopic vision in selected cases where a thoracic approach is not a safe option. This minimizes the probability of lung injury and air fistulas in a patient with severe inflammation and previous thoracic surgery.

Despite the development of effective antibiotics, subphrenic abscess continues to be a significant clinical problem. The formation of the subphrenic abscess occurs after intestinal contents and gut bacteria contaminate the abdominal cavity. Here, we report a case of a bilateral subphrenic abscess mimicking a bilateral pleural effusion and the symptoms appeared 1 year after the last abdominal operation. The uniqueness of this case was its late presentation and bilateral distribution, mimicking a bilateral pleural effusion.

Thoracobiliary fistula is a rare presentation of biliary obstruction which is secondary to anastomotic Roux-en-Y cholangiojejunostomy stricture. A 52-year-old man presented with fever, fatigue, and anorexia. He was jaundiced. He had a history of a laparoscopic cholecystectomy complicated by iatrogenic bile duct injury which was corrected by Roux-en-Y cholangiojejunostomy. The CT revealed a subphrenic abscess. Therefore, we established CT-directed percutaneous drainage and antibiotics treatment. Four months later, he presented again with fever, fatigue, and jaundice. He also complained of bilioptysis. Pleurocentesis revealed a deep yellow pleural fluid. Thoracobiliary fistula was suspected. Our patient underwent a right thoracotomy where we drained bile, performed pleural decortication, and excised the damaged portion of the right lower pulmonary lobe. We also inserted a subphrenic drain. The fistula was remained to close spontaneously and the patient had a good postoperative recovery. The obstruction of the bile ducts leads to the retention of bile proximal to the obstruction site, the formation of a liver biloma, and subsequently the abscess formation. By increasing, the abscess gradually erodes the diaphragm. A presence of adhesions between the lower lung lobe and the diaphragm will lead the abscess to erode directly into the lung parenchyma until it reaches the nearest bronchus and a BBF is formed. The presence of bile in the pleural space due to pleurobiliary fistula, or bilioptysis due to bronchobiliary fistula are rare presentations. However, they are serious conditions that may follow bile duct operations. They require early recognition and intervention. • Pleurobiliary fistula is a very rare presentation of common bile duct obstruction. • Thoracobiliary fistula is a serious condition that may follow bile duct operations. • bronchobiliary fistula is usually diagnosed clinically by bilioptysis. • Thoracobiliary fistula treatment is surgical, conservative, or a combination of both. [ABSTRACT FROM AUTHOR]

Background: Phlegmonous gastritis (PG) is a rare and potentially fatal disease characterized by bacterial infection of the gastric wall. However, its clinical features are nonspecific, which may delay its diagnosis and treatment.Case Report: We report a case of a previously healthy 53-year-old woman with localized PG complicated by subphrenic abscess formation who was treated successfully with antibiotics and percutaneous catheter drainage. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early diagnosis and treatment initiation are important to improving outcomes. Emergency physicians should consider PG a differential diagnosis of acute abdomen. [ABSTRACT FROM AUTHOR]

Abstract Background An intra-abdominal abscess can sometimes become serious and difficult to treat. The current standard treatment strategy for intra-abdominal abscess is percutaneous imaging-guided drainage. However, in cases of subphrenic abscess, it is important to avoid passing the drainage route through the thoracic cavity, as this can lead to respiratory complications. The spread of intervention techniques involving endoscopic ultrasonography (EUS) has made it possible to perform drainage via the transmural route. Case presentation We describe two cases of subphrenic abscess that occurred after intra-abdominal surgery. Both were treated successfully by EUS-guided transmural drainage (EUS-TD) without severe complications. Our experience of these cases and a review of the literature suggest that the drainage catheters should be placed both internally and externally together into the abscess cavity. In previous cases there were no adverse events except for one case of mediastinitis and pneumothorax resulting from transesophageal drainage. Therefore, we consider that the transesophageal route should be avoided if possible. Conclusions Although further studies are necessary, our present two cases and a literature review suggest that EUS-TD is feasible and effective for subphrenic abscess, and not inferior to other treatments. We anticipate that this report will be of help to physicians when considering the drainage procedure for this condition. As there have been no comparative studies to date, a prospective study involving a large number of patients will be necessary to determine the therapeutic options for such cases.

• Postoperative subphrenic abscess caused by Clostridium perfringens is rare after hepatic resection. • Clostridium perfringens causes severe sepsis with high mortality rate. • Early antibiotic and surgical treatment for the focus of infection is significantly improve in the survival rate. Subphrenic abscess caused by Clostridium perfringens is rare after hepatic resection. We herein report such a case after hepatic resection for hepatocellular carcinoma following treatment of emphysematous cholecystitis. A 69-years-old man with chronic hepatitis B, was admitted to our hospital for right subcostal pain and loss of appetite. Computed tomography (CT) revealed emphysematous cholecystitis, for which percutaneous transhepatic gallbladder drainage was performed. Clostridium perfringens was identified from the culture of the bile. Imaging studies immediately demonstrated hepatocellular carcinoma with right lobe of the liver, for which the patients underwent hepatic resection and cholecystectomy concomitantly. After operation, the patient developed emphysematous subphrenic abscess on postoperative day 15, for which CT-guided percutaneous drainage was performed. Clostridium perfringens was identified from the culture of the abscess fluid. The patient was given Ciprofloxacin and Clindamycin and made a satisfactory recovery. The patient was discharged on POD 95 and remains well with no evidence of tumor recurrence as of 8 years after resection. We herein reported a subphrenic abscess due to Clostridium perfringens after hepatic resection for hepatocellular carcinoma following emphysematous cholecystitis. [ABSTRACT FROM AUTHOR]

Splenic abscess is a very rare pathology in the pediatric age, and the association with complications such as spontaneous drainage to the pleural cavity is even rarer. There is very little information in the literature regarding the best diagnostic and therapeutic approach. We present the case of an immunocompromised 16-year-old female patient with a splenic abscess that had spontaneous drainage to the left pleural cavity through the diaphragm and presented clinically as recurrent empyema. There was tomographic evidence of a significant pleural effusion on the left side and splenomegaly with a collection in the upper pole that extended to the left hemithorax through a defect in the diaphragm. Patient received successful treatment by laparoscopic splenectomy and transdiaphragmatic drainage of the pleural cavity. There were no complications and no recurrence of pleural effusion or subphrenic abscess on x-ray or ultrasound. At 6-month outpatient follow-up, she presented adequate clinical and radiological evolution. A trans -diaphragmatic pleural drain can be placed under laparoscopic vision in selected cases where a thoracic approach is not a safe option. This minimizes the probability of lung injury and air fistulas in a patient with severe inflammation and previous thoracic surgery. [ABSTRACT FROM AUTHOR]

Drainage of subdiaphragmatic abscesses is difficult due to its anatomical location and it can result in adverse events, including organ damage and the spread of infection. In recent years, endoscopic ultrasonography (EUS) guided drainage for upper abdominal abscesses has become available. We report a case of successful infection control using this procedure for a subdiaphragmatic cyst secondary to perforation of the sigmoid colon after cytoreductive surgery for advanced ovarian cancer. A Japanese woman in her 60s underwent laparotomy for ovarian cancer, and then developed sigmoid colon perforation 6 days after surgery. The emergency reoperation was performed, and a cyst suspected to be an antibiotic-resistant fungal abscess appeared under the left diaphragm in the postoperative period. We adopted an EUS-guided route for diagnostic and therapeutic drainage method, which enabled shrinkage of the cyst and did not concur further adverse events. This procedure was effective as a minimally invasive drainage route for subdiaphragmatic cysts., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Parapneumonic pleural effusions are common in patients with pneumonia. When colonized by pathogenic bacteria or other microorganisms, these effusions can progress to empyema. Additionally, empyema formation may result in extension of the infection into the infradiaphragmatic region, further complicating the clinical scenario. Many subphrenic collections are found to be mesothelial cysts, which are congenital in origin. However, data regarding the potential association between mesothelial diaphragmatic cysts and parapneumonic effusions are limited. We herein describe a toddler with pneumonia complicated by parapneumonic effusion and a lung abscess with a subphrenic collection. After abscess drainage and a full course of antibiotics, imaging revealed clear lung parenchyma with an interval resolution of the effusion and a persistent unchanged subphrenic collection that was confirmed to be mesothelial diaphragmatic cyst. This case highlights the fact that not every subphrenic collection associated with parapneumonic effusion is a communicated collection formed by seeding. Such a collection can instead be an incidental cyst, which is congenital in origin and known as a mesothelial diaphragmatic cyst. A diaphragmatic mesothelial cyst is an uncommon benign congenital cyst that is unrelated to an adjacent parapneumonic effusion. It is usually incidental and can be monitored without invasive intervention., Competing Interests: Declaration of conflicting interestAll authors declare that they have no conflict of interest.

Gastropulmonary fistulas are themselves a very rare clinical entity and very less has been written about them in literature. Most of the cases listed in literature till now show that most of the gastropleural fistulas have been reported after intrathoracic gastric perforation in hiatal hernia, traumatic diaphragmatic hernia with later gastric perforation, perforated malignant gastric ulcer at fundus, extension of subphrenic abscess with gastric perforation, pulmonary resection and gastric bypass operations and only a single case has been documented till now regarding post intercostal chest tube drainage gastropulmonary fistula in tubercular patient. Here we present a first of its kind case where a middle aged female developed gastropulmonary fistula on the left side after multiple pleural aspirations for tubercular pleural effusion. The patient was operated and left lower lobectomy was done with the resection of involved part of stomach and fistulous tract from the left posterolateral thoracotomy.

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

A fístula gastrobrônquica é uma condição rara como complicação decorrente de cirurgia da obesidade. O seu manejo exige a participação ativa de um pneumologista, o qual deve conhecer alguns aspectos dos principais tipos de cirurgia bariátrica. Neste relato, descrevemos dois casos de pacientes que apresentaram abscessos subfrênico e pulmonar recidivantes secundários a fístula no ângulo de His durante 19,5 meses, em média. Após o insucesso das relaparotomias, a cura foi obtida por meio da antibioticoterapia e, principalmente, por meio da estenostomia e da dilatação endoscópica, além do uso de clipes e cola de fibrina na fístula. Estas complicações pulmonares não devem ser tratadas isoladamente sem uma avaliação gastrintestinal pois isso pode resultar em piora do quadro respiratório, dificultando o manejo anestesiológico durante procedimentos endoscópicos.Gastrobronchial fistula is a rare condition as a complication following bariatric surgery. The management of this condition requires the active participation of a pulmonologist, who should be familiar with aspects of the main types of bariatric surgery. Herein, we report the cases of two patients who presented recurrent subphrenic and lung abscess secondary to fistula at the angle of His for an average of 19.5 months. After relaparotomy was unsuccessful, cure was achieved by antibiotic therapy and, more importantly, by stenostomy and endoscopic dilatation, together with the use of clips and fibrin glue in the fistula. These pulmonary complications should not be treated in isolation without a gastrointestinal evaluation since this can result in worsening of the respiratory condition, thus making anesthetic management difficult during endoscopic procedures.

The Italian opera singer Enrico Caruso is considered by many people the most famous opera singer of all time or 'The Matchless Singer' for his unique and suggestive vocal timber. Although a man of humble origins, he managed to rise from poverty, thanks to his extraordinary intelligence and determination. From his debut in 1895 in Naples, until December 24, 1920, the tenor had a brilliant career with many performances and over 500 songs in his repertoire. This intense lifestyle went on until 1919, when the fortune that had always accompanied him began to fade and he entered a fast 'descending parable.' In this study, we analyze Caruso's medical history during his last year of life: Through the study of the newspapers from the period and the statements reported on the tenor's many biographies, we tried to offer a detailed evaluation of the complex pathogenic chain of events that led to his death, impeding him from keeping to alleviate the heart-breaking nostalgia of many emigrants that felt in his singing the warmth of a too distant land. [ABSTRACT FROM AUTHOR]

In the clinic of general surgery SamMI performed 125 surgeries for echinococcosis of the liver subphrenic localizatipn. Thoraco-abdominal access wos used in 31, parallel to the costal arch in 23 and 64 patients with a wide ancient laparotomic access. In the 7 patients with localization of cysts in the segment of the liver, a minidostine developed in our clinic was producted along the lower edge of the xirib along the posterior axillary line. Mostly used 4 types of operations, cyst extirpation (pericystectomy), closed echinococcectomy, semi-closed, echinococctomy, Askerhanov. In the postoperative period, all patients were prescribed albendazole at 12 ml kg of body weight for 28 days of the 35 the corse with an interval of 14 days.After surgical complications were observed in 8 (6.4%). [ABSTRACT FROM AUTHOR]

We describe a case of carbapenemase-harboring Proteus mirabilis together with detection of NDM-5 in Austria accompanied by other bacterial strains with a wide range of beta-lactamases including OXA-181 and VEB-6. Isolates were obtained from a subphrenic abscess from one patient who was previously treated with broad-spectrum antibiotics in Bangladesh. [ABSTRACT FROM AUTHOR]

Purpose: In order to overcome the obstacle that detailed spatial relationships of the omental bursa to its related spaces cannot be displayed clearly by thick-slice sectional anatomical imaging and computed tomography, we designed a new approach to three-dimensional (3D) visualization of the omental bursa. Methods: By Amira software, we employed thin-slice cross-sectional images of the upper abdomen retrieved from second Chinese Visible Human datasets to display the spatial relationships of the omental bursa to its related spaces, especially to the left subphrenic extraperitoneal spaces. Moreover, these spatial relationships were presented on 3D sections reconstructed from second Chinese Visible Human images and computed tomography images. Results: Of importance, the gastric bare area is located among the superior, inferior, and splenic recesses. The appearance of the foramen bursae omenti majoris is the only pathway communicating between the superior and inferior recesses of the omental bursa, and also is the anatomic landmark between the superior and inferior recesses. The splenic recess is surrounded from behind by the splenic bare area and the gastric bare area. Conclusion: As one of the subphrenic spaces, the omental bursa with its related spaces was imaged three-dimensionally using a visualization technique. Familiarity with the anatomic location and spatial relationships of the omental bursa to its related spaces may be beneficial for the differential diagnosis and intervention, improving outcome. [ABSTRACT FROM AUTHOR]

Objectives To study the outcome of different surgical methods of treating subperiosteal abscesses resulting from acute mastoiditis. Methods Medical records for all children from a Swedish retrospective multicentre study, conducted between 1993 and 2007, with acute mastoiditis and subperiosteal abscess, but without predisposing diseases or other complications, were studied. A total of 115 children aged 0–16 years were identified. All patients had received intravenous antibiotics and most had undergone myringotomy. Results Thirty-three children had been treated with only minor interventions such as retroauricular needle aspiration and/or incision, while 67 had undergone mastoidectomy. Fifteen had undergone both needle aspiration and mastoidectomy. The group treated with needle aspiration/incision was compared with those treated with mastoidectomy. One of the few significant differences found between the groups was a longer hospital stay in the group that had undergone mastoidectomy. Conclusions Retroauricular needle aspiration and/or incision combined with intravenous antibiotics and myringotomy was an effective first-line treatment for subperiosteal abscesses resulting from acute mastoiditis. In this retrospective study, no greater risk of further complications was seen in this group compared to the group in which mastoidectomy was performed. [ABSTRACT FROM AUTHOR]

Bronchobiliary fistula (BBF) is a tract between the biliary system and bronchial tree with the presence of bile in the bronchus and the sputum. They are rare but serious complications. In most cases, they are caused by hepatic or subphrenic abscesses, resulting from different conditions. Pulmonary symptoms dominate the clinical picture, and the main manifestations are chronic irritant cough, production of greenish sputum, bronchopneumonia, and dyspnea. The diagnosis of BBF can be confirmed by imaging procedures such as biliary scintigraphy with hepatobiliary iminodiacetic acid, percutaneous transhepatic cholangiography, or endoscopic retrograde cholangiopancreatography. Bronchoscopy can demonstrate the presence of bile in the bronchial tree and may delineate the site of fistula. The treatment strategy for patients with BBF and biliary tract obstruction is the reestablishment of bile drainage, which allows the fistula to heal by reducing intrabiliary pressure. We present two cases of biliary-bronchial fistula, one related to hepatic abscess and the other due to percutaneous transhepatic biliary drainage for common bile duct obstruction secondary to inoperable hilar cholangiocarcinoma. [ABSTRACT FROM AUTHOR]

A patient in her 90s with rheumatoid arthritis was admitted to the hospital. She was brought to the emergency department with a complaint of a fever and diagnosed with a urinary tract infection on admission, and antimicrobial therapy was started. On day 8 of admission, abdominal ultrasonography revealed a right subphrenic abscess due to cholecystitis with perforation. The patient consulted with the Department of Surgery, but drainage was deemed difficult due to the anatomical location of the gallbladder, and conservative treatment with antibiotics was continued. After two months of intravenous antimicrobial therapy, the abscess shrank, and the patient was discharged from the hospital after switching to oral antimicrobial therapy. At a follow-up visit two weeks after discharge, the abscess was confirmed to have disappeared, the oral antimicrobial therapy was discontinued, with no abscess recurrence noted. The principle of treatment for subphrenic abscess is the administration of broad-spectrum antimicrobial agents that cover enterobacteria and anaerobes, and drainage at appropriate times. Indeed, drainage is performed in most of the reported cases of subphrenic abscesses. However, in very elderly patients or those in whom puncture is difficult, conservative treatment while carefully checking imaging findings and other potentially involved factors may be an option.

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

Abdominal pregnancy appears once in 3000 pregnancies. It usually terminates with abortion and urgent surgery. Thanks to ultrasonography and computed tomography the diagnosis is possible before surgery. Most frequently the diagnosis has been established during emergency laparotomy. Gynaecologists are not in agreement wheather removal of placenta is mandatory or not, as it may include removal of parts or entire organs or may be followed with serious bleeding difficult to control. We present a 21-year old woman in whom during an urgent laparotomy performed for abdominal pregnancy placenta inserted in the spleen was left in situ. Postoperatively the patient developed subphrenic abscess which could not be solved without reoperation during which both the placenta and the spleen were removed. Ten years after surgery she is symptom-free.