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The clinical picture of subphrenic abscess taking place against the background of the treatment with modern antibacterial drugs has changed essentially, which requires a complex solution of the problem of the timely abscess diagnosis. The antistaphylococcal plasma and gamma globulin applied together with other methods of intense therapy proved to be the most effective after the dissection of the abscess.
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.
INTRODUCTION: We studied subphrenic inflammatory abscesses and splenic fluid collections after splenectomy for trauma. These complications may appear early or late postoperatively; they are easily demonstrated with CT, which permits accurate spatial assessment of the lesions and appropriate treatment with percutaneous drainage. We investigated the diagnostic accuracy of CT in subphrenic inflammatory conditions after emergency splenectomy for traumatic spleen rupture and found that CT is a precious tool for rapid and easy diagnosis and follow-up of subphrenic abscesses treated with percutaneous drainage. MATERIAL AND METHODS: Thirteen patients with left subphrenic inflammatory abscesses after splenectomy for trauma were examined from 1994 to 1998. They were 9 men and 4 women ranging in age 16-67 years (mean: 32). CT demonstrated abscesses early postoperatively in 9 patients and late postoperatively (mean: 3 months) in 4 patients. Abscesses were diagnosed with CT on admission for an abdominal emergency in 3 cases; one abscess was found at outpatient US performed for persisting left abdominal pain. CT-guided percutaneous drainage was performed in all patients with the Trocar technique. RESULTS: A large inflammatory liquid collection with the typical "liquid pseudospleen" appearance and characterized by tomodensitometric coefficients of corpusculated fluid was seen in 3 cases. Multiple confluent lesions with septa were found in 3 cases. Contrastography of the abscess cavity with the injection of a water-soluble iodinated contrast agent was performed in 2 cases to detect fistulas connecting to the intestinal loops. Subphrenic abscesses had the same CT patterns both early and late postoperatively, with the collection organizing into thick and corpusculated phlogistic material and exhibiting enhanced capsulofibrous differentiation. Air bubbles and water-air levels within the collection were found in 7 cases and considered a pathognomonic sign of inflammatory abscesses. A periabscessual reaction involving intestinal loops and adjacent organs was seen in 4 cases. DISCUSSION AND CONCLUSIONS: Splenectomy causes depressed phagocytosis and decreases serum levels of IgM and antigen response. This calls for careful selection of the patients absolutely requiring splenectomy, such as those with decompensated circulation and multiple parenchymal ruptures or spleen detachment from its stalk. Subphrenic abscesses after splenectomy account for 2.5% of postoperative complications and those after splenectomy for trauma are rarer still, with 1.3%. CT is the imaging method of choice in detecting inflammatory abscesses in the residual splenic cavity and assessing their extent. CT-guided drainage is the first-line treatment, while surgery is reserved to later stages, when drainage fails or other complications occur. Finally, CT permits accurate positioning of the catheter inserted with the Trocar technique and its immediate monitoring, which permits to assess treatment efficacy.
Roentgen findings in subphrenic abscess, in the order of their specificity and clinical value, are subphrenic air-fluid level, elevation and restriction of motion of the diaphragm, pleural reaction with congestion, segmental atelectasis or pneumonitis at the lung base and upper abdominal mass. Less frequently there may be empyema or bronchopleural fistula. Suppression of the infection by antibiotics may protract the course and obscure the clinical findings. Serial x-ray and fluoroscopic studies are recommended when a patient who has had rupture of a viscus or previous abdominal operation does not completely recover or has a persistent lowgrade fever.
Laparoscopic surgery has proven to be a very useful technique. Subphrenic abscess, although a rare entity, occurs in the majority of the cases in association with gastroduodenal and biliary disease, appendicitis, or following abdominal surgery. We present the case of a 45-year-old male with a right subphrenic abscess that was successfully treated by laparoscopy. Laparoscopic drainage of subphrenic abscess should be considered as an alternative modern option when dealing with this problem.
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.
Two hundred and fifty-six patients have, during the past 5 years, been examined by combined liver, spleen, and lung radionuclide imaging. The reason for this investigation was to identify or rule out subphrenic abscess, which is a rare but feared complication of abdominal surgery. Primary subphrenic abscess may also be seen, and in such cases the diagnosis is extremely difficult. Subphrenic abscess was demonstrated by radionuclide imaging in 17 patients, and all of these were later confirmed by surgery. In this study there was one false-positive and one false-negative result. During this period other pathological conditions involving lung and liver and with symptoms similar to subphrenic abscess have also been demonstrated by this technique, such as lung embolism and liver abscess.
Percutaneous drainage is now the preferred initial treatment of subphrenic abscess. The result is best for simple, unilocular abscesses but less so for complex ones. Failure of drainage can lead to high morbidity and mortality. We describe a case in which a large multiloculated subphrenic abscess was successfully drained laparoscopically without contaminating the general peritoneal cavity.
Between 1969 and 1982 11 primary (without previous surgery) and 38 secondary (postoperative) subphrenic abscesses were treated out of total 20800 operations. The patients had on an average more than 4 risk factors. Causes contributing to the formation of secondary abscesses were a difficult operation in 42%, deficiencies in surgical technique in 26%, operative contamination in 21% and peritonitis in 13% of the cases. Clear problems in the primary operation were found in 23 of 38 patients and in 6 of 7 patients who died with a later secondary abscess. It seems probable that subphrenic abscesses are more likely to develop in high risk patients after a difficult and/or contaminated operation.
A 39-year-old woman presented with abdominal pain after tubal sterilization. CT showed a subphrenic abscess with fatty inclusions owing to laceration or rupture of a mature ovarian teratoma. Although subphrenic abscess is a well recognized post-operative complication, and ovarian teratomas are frequent, a teratomatous inclusion within a subphrenic abscess is a unique finding.
OBJECTIVE: To assess the results of twelfth rib resection as a direct posterior surgical approach to subphrenic abscesses in case of failure of percutaneous drainage, abandonment of percutaneous drainage in view of a too high risk of perforation of adjacent organs, or contamination of the pleural space, or an inaccessible abdomen. DESIGN: Retrospective study. SETTING: University hospital, The Netherlands. PATIENTS: 17 patients who required rib resection for subphrenic abscesses that developed after infected necrotising pancreatitis, splenectomy, or anastomotic disruption. INTERVENTIONS: 18 rib resections. MAIN OUTCOME MEASURES: Outcome and morbidity. RESULTS: Twelfth rib resection was successfully in 13 of 17 patients. Four patients died from multiple organ failure despite subsequent (re) laparotomies for additional surgical drainage. CONCLUSION: Twelfth rib resection can be useful for the treatment of subphrenic abscesses in selected patients.
OBJECTIVE: To assess the role of 12th rib resection in the treatment of postoperative, subphrenic abscesses. DESIGN: Consecutive case series. SETTING: University hospital, level I trauma center. PATIENTS: Operative logs for a 13-year period were reviewed for all patients undergoing 12th rib resection for drainage of a postoperative subphrenic abscess. Each individual medical record was reviewed for demographic data, primary diagnosis, computed tomographic scan findings, and clinical status (temperature, white blood cell count, and Acute, Physiologic, Age, and Chronic Health Evaluation II score) at the time of rib resection. MAIN OUTCOME MEASURES: Operative results, microbiological data, complications, and outcomes. RESULTS: Twenty-six patients underwent 27 rib resections for a secondary left subphrenic (23) or a right subhepatic (4) abscess. All patients had undergone at least 1 prior laparotomy (average, 1.5; range, 1-4). Sixteen patients had traumatic injuries, and 7 had complicated pancreatitis. Twelve patients had undergone prior failed attempts at percutaneous drainage before rib resection. Fourteen patients underwent operative drainage without attempted percutaneous drainage, mainly for peripancreatic (7) or multiloculated (3) abscesses. There were 3 postoperative complications (3/27 [11%]): a gastrocutaneous fistula, a gastrocolic-cutaneous fistula requiring laparotomy and temporary colostomy, and fasciitis in the resection site. Four (15%) of the 26 patients died: 3 died of progressive multiple system organ failure, and 1 died of an unrelated injury. The remaining 20 (77%) of the patients were discharged from the hospital with healing wounds and no further episodes of intra-abdominal infection. CONCLUSIONS: Twelfth rib resection is an effective alternative therapy for secondary subphrenic abscesses. The nature of the incision allows for open, dependent drainage; avoids subsequent laparotomy; and effectively controls intra-abdominal infections. Twelfth rib resection remains a useful tool in the treatment of subphrenic abscess and may be the preferred approach when other attempts at abscess drainage have failed.
The article reports on 37 patients subjected to sonographic examination because of the clinically suspected diagnosis of a "subphrenic abscess". In 7 of these patients, the diagnosis "subphrenic abscess" was arrived at via sonographic examination, and was confirmed in 6 cases by surgery and in one case by postmortem examination. The importance of ultrasound diagnosis for early identification of the subphrenic abscess is discussed and the high rate of accuracy is underlined. The author emphasises that even discreet x-ray film symptoms should prompt immediate ultrasonic examination.
An echo-poor band of fat is seen between the anterior surface of the left lobe of the liver and the anterior abdominal wall in 25% of patients undergoing an abdominal scan. A similar appearance can be seen in an anterior subphrenic abscess. Normally, with respiration the liver can be seen to slide deeply to this fat band. If the band is due to subphrenic abscess, there is a differential movement due to fixation of the anterior part of the liver. This feature was seen in 4 patients proven to have subphrenic abscesses. This real-time sign is helpful in differentiating if the band is due to fat or to subphrenic abscess.
Diagnosis of a left subphrenic abscess after splenectomy is often difficult. C.T. scanning was used to establish the diagnosis in 5 patients with subphrenic abscesses. The examination is simple and gives valid results. Needle aspirations, controlled by scanning, can confirm the diagnosis or be used for drainage of the abscess.
The authors present case of 60 years old male with subphrenic abscess. The patient had been threefold open abdomen, and cause of subphrenic abscess remain unknown. The authors think, that best treatment are: transperitoneal lavage drainage and antibiotic therapy.
A case of left-sided subphrenic abscess, secondary to perforation of a carcinoma of stomach, is described. The patient presented with a palpable spleen which was shown to be normal in size but displaced by the subphrenic collection. The importance of correct interpretation of this physical sign is discussed.