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Surgery
Published in Seema Khan, Get Through, 2020
‘Pus somewhere, pus nowhere, pus under the diaphragm.’ Be alert when confronted with a patient with a persistent swinging pyrexia of unknown origin, occurring several days postoperatively. There is usually a hidden abscess or, in this case, a subphrenic abscess.
Unexplained Fever Associated with Diseases of the Gastrointestinal Tract
Published in Benedict Isaac, Serge Kernbaum, Michael Burke, Unexplained Fever, 2019
Subphrenic abscess frequently arises as a complication of abdominal surgery, most commonly on the stomach, colon, and biliary tract.79 In other cases the abscess originates from metastatic suppuration or by extension from a diseased neighboring organ into the subdiaphragmatic space. A right-sided subphrenic abscess may be a complication of perforated peptic ulcer, cholecystitis, hepatic abscess, or generalized peritonitis; a left-sided abscess may result from an infected splenic infarct, or pancreatitis; both abscesses may arise from perirenal suppuration. Right-sided subphrenic abscesses are more common.
Upper abdominal cytoreduction for advanced ovarian cancers
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
Scott M. Eisenkop, Christina L. Kushnir, Nick M. Spirtos
Assuming this portion of the procedure is completed and virtually all disease is determined to be resected, diaphragmatic disease should be evaluated and removed. In almost all cases the disease involving the diaphragm can be surgically removed or ablated with the argon beam coagulator if the disease is small volume and not scattered. Cliby et al. (2004) reviewed 41 patients at the Mayo Clinic who underwent diaphragm resection (DR) to achieve optimal cytoreductive surgery in ovarian carcinoma. The majority of diaphragmatic resection (DR) occurred in patients undergoing surgery for recurrent disease (35/41; 85%), and in 13 of these 35 patients, there had been at least one prior recurrence. Lesions were predominately right-sided (80%), but bilateral resection was necessary in two (5%) patients. Pathologic evaluation of resected areas revealed 35 cases (85%) were full-thickness disease. Pleural surface was involved in a minority of cases (10/35). Forty of forty-one women underwent additional procedures for debulking, including splenectomy, liver resection, small bowel resection, and intra-abdominal tumor debulking. At the conclusion of the operations, 33 of 41 (80.1%) had no gross residual disease, 4 of 41 (9.8%) had less than 1 cm of residual disease, 1 of 41 (2.4%) had residual disease of 1 to 2 cm, and 3 of 41 (7.3%) patients had greater than 2 cm of residual disease. Overall, DR allowed for 90% of patients to achieve optimal debulking (no single lesion larger than 1 cm). Ten of the 41 patients had chest tubes placed at the time of surgery. Of the remaining 31 patients, 3 (9.7%) subsequently required a chest tube. Complications that could possibly be attributed to DR were symptomatic pneumothorax requiring chest tube placement (2/41; 4.9%) and the accumulation of pleural effusions contributing to respiratory compromise requiring percutaneous thoracentesis (4/41, 9.8%). One of 41 developed a subphrenic abscess that required percutaneous drainage and antibiotic therapy. One of 41 who underwent left DR as well as splenectomy developed a gastro-pleural fistula late in her hospital course, and eventually died from sepsis. This study was not designed to evaluate diaphragmatic resection and survival, but was designed to address potential complications from DR, and has shown that DR risks are comparable to other debulking procedures.
Chilaiditi syndrome—a clinical conundrum!
Published in Southern African Journal of Anaesthesia and Analgesia, 2018
Supriya Dsouza, Yuvraj Mhaske, Adarsh Kulkarni, Ajit Baviskar
Differential diagnosis includes pneumoperitoneum, subphrenic abscess or diaphragmatic hernia. Finding normal plicae circulares or haustral markings of the colon under the diaphragm can rule out these serious entities. Moreover, changing the position in a patient with Chilaiditi’s sign will not change the position of the radiolucency, unlike in a patient with pneumoperitoneum. Similarly, when using ultrasound, altering the position of a patient with Chilaiditi’s sign will not lead to a change in the location of the gas echo, as opposed to a patient with pneumoperitoneum.5 If chest X-ray or ultrasound is indeterminate, CT scan is recommended to establish an accurate diagnosis, if the patient is clinically stable.