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Introduction: Mucinous adenocarcinomas of the appendix are defined as epithelial neoplasms often causing cystic dilation of the appendix due to accumulation of gelatinous material. Pseudomyxoma peritonei is an extremely rare complication of appendiceal mucinous adenocarcinomas with an estimated incidence rate of one to 2 people per million per year. Here-in we present a unique case of enterocutaneous fistula formation secondary to percutaneous biopsy of an enlarging omental mass in the setting of pseudomyxoma peritonei. Case Description/Methods: A 50-year-old male with a past medical history of metastatic appendiceal mucinous adenocarcinoma presented to the ED with abdominal pain, nausea, and vomiting. The patient had previously undergone 2 debulking surgeries over the past 2 years prior to admission and has since been on FOLFOX therapy. Due to the COVID pandemic, the patient did not follow-up in the 2 years period from previous admission. A CT scan was now notable for a new enlarging omental mass despite the recent debulking surgery. Given the enlarging mass, a decision was made to pursue a percutaneous biopsy of the mass due to concern for potential new malignancy. Two weeks after the biopsy, the patient presented to our facility due to worsening erythema and drainage from the biopsy site. The patient met SIRS criteria, thus broad-spectrum antibiotics were initiated. A CT of the abdomen and pelvis with oral and IV contrast was obtained, which demonstrated a 9 cm abscess or continuation of intra-abdominal multilocular cystic lesion/ pseudomyxoma peritonei. The surgical team was consulted. Patient had 100 cc of purulent and mucinous drainage expressed from biopsy site. The patient was then placed for transfer to a hospital capable of advanced surgical management for evaluation and potential resection of fistula formation. The patient had a successful reductive surgery and intraoperative chemotherapy (Figure). Discussion(s): Given the rarity of pseudomyxoma peritonei, appropriate management is not always straightforward. A literature review yielded no previous reports of enterocutaneous fistula as a complication of percutaneous drainage in the setting of pseudomyxoma peritonei. We recommend that percutaneous drainage not be sought in individuals with this diagnosis due to potential for fistula formation.
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Introduction: Vaccination plays an important role in all strategic actions against the COVID-19 pandemic. Despite the high safety and efficacy of vaccination, side effects of the vaccines may also occur. The purpose of this study was to evaluate the clinical and sonographic findings and short-term results of cervical and axillary lymphadenopathy after the BNT-162b2 mRNA vaccine. Materials and Methods: The patients who received at least one dose of BNT-162b2 mRNA vaccine between July-September 2021 and were detected to have ipsilateral axillary and cervical lymphadenopathy related closely to the vaccination period, were included in the study. Clinical characteristics, sonographic findings of lymphadenopathies, and short-term results were analyzed retrospectively. Results: A total of 13 patients [six females (46.2%), seven males (53.8%)] were evaluated in the present study. Mean age of the patients was 41.9 years (min-max= 20-56). Median time-lapse between vaccination and presentation to hospital was six days, and seven (53.8%) patients presented with symptoms and findings after the first dose, and six patients (46.2%) after the second dose. Three (23.1%) axillary lymphadenopathies, and 10 (76.9%) cervical lymphadenopathies were detected. Sonographic examination revealed lymphadenopathies predominantly oval morphology (69.2%), asymmetric cortical thickening (61.5%), and hilar-type vascularization (69.2%). Mean time of regression was found 19.2 days (min-max= 10-35). Conclusion: Ipsilateral cervical and axillary lymphadenopathies may occur because of vaccines against COVID-19. The sonographic findings of these lymphadenopathies may not be distinguished clearly from malignant lymph nodes;and for this reason, close clinical and radiological follow-up would be appropriate to elucidate the process.
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Introduction: The management of encapsulated pancreatic necrosis continues to be a challenge at present, in this context a percutaneous and retroperitoneal endoscopic approach is combined, with a satisfactory success rate. This technique arises when percutaneous drainage is insufficient and transgastric endoscopy is not possible due to the characteristics of the collection. We present a case of a retroperitoneal percutaneous-endoscopic approach for debridement of infected pancreatic necrosis. Case: A 60-year-old man with severe acute biliary pancreatitis with infected necrosis. Initial treatment with meropenem, day 30 of hospitalization percutaneous drainage (12 Fr) of septate collection on the left flank. Day 40 of hospitalization, second drainage (20 Fr) on the left flank. Catheter replacement, with progressive caliber increase, up to 20 Fr and 28 Fr. Day 70 of hospitalization endoscopic debridement through partially covered esophageal stent placed in fistulous tract in the left flank. Necrosectomies + washings and control with tomography in 15 days, significant decrease in the size of the collection. The stent is removed and drainage is allowed. Covid +, treated with remdesivir for 5 days, without complications, later hospital discharge. Ambulatory control and removal of the catheter in 15 days. Conclusion(s): The management of walled necrosis is complex, the staging depends on the characteristics of the cavity and the available resources. Endoscopic percutaneous drainage with stent placement is a valid option with a high therapeutic and clinical success rate. Copyright © 2022
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Introduction: The clinical care of patients with acute necrotizing pancreatitis (ANP) is resource-intensive. Patients with ANP often have severe illness which may require intensive care unit (ICU) admission, invasive drainage procedures, and other high-level multidisciplinary care. The Covid-19 pandemic has put an enormous strain on hospitals and ICUs around the world. The resulting impact of the pandemic, on the ability for hospitals to care for patients with ANP has not been studied. We aimed to analyze the outcomes and management of patients admitted with ANP before and during the pandemic using a large population dataset. Methods: TriNetX is a large international research network. This dataset comprises electronic health record (EHR)-derived disparate data from 57 healthcare networks and over 80,000,000 patient lives. We queried the dataset to find two cohorts of patients: those admitted to a hospital with ANP from April 1, 2018-April 1, 2019, and those admitted to a hospital with ANP from April 1, 2020-April 1, 2021. The two cohorts were propensity matched using a 1:1 greedy nearest-neighbor algorithm based on age, sex, race, ethnicity, BMI, alcohol, and tobacco use. The primary outcome was 30-day all cause mortality. Secondary outcomes included rates of ICU admission, mechanical ventilation, antibiotic usage, endoscopic, and percutaneous drainage. Results: The incidences of ANP in the pre-Covid and post-Covid study years were 10.2 per 100,000 and 9.9 per 100,000 persons, respectively. The pre-Covid cohort contained 2,113 patients and the post-Covid cohort contained 2,083 patients. After matching, two cohorts of 1,943 remained (Table 1). In the post-Covid cohort, 29 patients (1.5%) tested positive for SARS-CoV-2 during the 30 days after hospital admission for ANP. Overall, there was no significant difference in the primary outcome of 30-day allcause mortality (4.4% vs 4.9%, p=0.49). Additionally, there were no significant differences in ICU admission, mechanical ventilation, endoscopic or percutaneous drainage, or antibiotic usage between the two groups. Conclusion: The Covid-19 pandemic has resulted in bed and staffing shortages both in ICU and general medical/surgical floors around the world. Despite this, the clinical management, and outcomes of patients with ANP did not significantly change for the worse compared with outcomes from 2018-2019. These data suggest that despite the strain induced by the Covid-19 pandemic, the care of patients with ANP, including those with critical care needs, was not compromised. (Table Presented)
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Spinal epidural abscess (SEA) is a rare and potentially devastating neurologic disease that is commonly treated with neurosurgical decompression and evacuation. We describe the case of an 11-month-old immunocompetent infant who presented with a large multiloculated methicillin-resistant Staphylococcus aureus abscess in the left lung apex with likely mediastinal involvement, extending into the epidural space from C7 down to L2 causing cord compression which was successfully treated with percutaneous placement of an epidural drainage catheter and antibiotic therapy. Although there are rare reports of percutaneous drainage of SEAs, to our knowledge, there are no reports of successful use of percutaneous indwelling catheters resulting in the complete resolution of an SEA. Holo-spinal epidural abscess in an infant is an extremely rare disease with limited literature available regarding the best practice for its treatment. Multiple considerations must be taken into account when weighing the different treatment options ranging from surgical decompression to conservative management with antibiotic therapy. We present a unique case of successful treatment with percutaneous epidural drain placement. This provides a reasonable alternative for management in children for whom surgical decompression carries multiple risks for complications both acutely and delayed.
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Purpose/Background: Historically, diversion was performed prior to resection of complex diverticular disease. This fell out of favor, but with the advent of laparoscopy, we investigated whether fecal diversion as a first step is a safe alternative in select patients who would otherwise undergo a Hartmann's procedure. Hypothesis/Aim: For select patients with acute medically-refractory diverticulitis, diversion without resection controls sepsis and is a safe option. Methods/Interventions: Single institution retrospective chart review of all patients presenting with acute complicated diverticulitis from July 2016- June 2021 was performed. The subset of patients who underwent diverting loop ileostomy or colostomy without initial resection were analyzed for demographics, reason for diversion alone and clinical course. Results/Outcome(s): Nineteen patients who underwent loop diverting ostomy (17 ileostomies, 2 colostomies) were identified. Seventeen of 19 were performed laparoscopically. The average patient age was 52.8 years old (SD 18.1) and 47% were men. Six patients had preoperative abscesses, one of which was amenable to percutaneous drainage. Several patients were initially admitted for another diagnosis and subsequently developed diverticulitis. Comorbidities included cases of severe COVID, recent bone marrow transplantation, and current chemotherapy for lymphoma. The average time from admission to operation was 3.3 days (SD 2.9), and the average postoperative length of stay was 10.1 days (SD 10.7). None of the 19 patients required resection for failure to improve during that hospitalization. Two patients (10.5%) required placement of a percutaneous drain post-operatively. Seventeen patients were discharged home (89.5%) and 2 were discharged to a rehabilitation facility. Six patients required emergency department visits or readmission, most often for dehydration. Since their diversion, 16 patients have subsequently undergone sigmoid resection (84.2%), 15 with primary anastomosis and subsequent diverting ostomy takedown, and one with conversion from loop colostomy to descending colostomy and Hartmann's pouch. Five of the 16 sigmoid resections were performed laparoscopically (31.3%). Limitations: This study is a single institution retrospective review with a small sample size. Conclusions/Discussion: Fecal diversion appears to be a safe initial surgical strategy, providing adequate control of local sepsis in patients who are felt to be poor candidates for sigmoid resection with primary anastomosis and diversion, and allows patients to avoid an initial Hartmann's procedure. All 19 patients were discharged without requiring additional surgery. For patients with severe acute confounding medical comorbidities, initial diversion may allow the patient to recover from their acute process, permit optimization of their health status, and allow an elective sigmoid resection at a more opportune time. (Table Presented).
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Purpose/Background: The management of acute diverticulitis has evolved, adapting a more individualized approach. With a high postoperative mortality rate in patients with COVID-19, adapting a more conservative management could be beneficial for the management of acute complicated diverticulitis. Hypothesis/Aim: This study aims to review the clinical profile, treatment strategies and outcomes of COVID-19 patients with acute complicated colonic diverticulitis at a single tertiary hospital in the Philippines. Methods/Interventions: The study is a descriptive case series on COVID-19 patients who were also diagnosed with acute colonic diverticulitis between May 2020 to August 2021 at a single tertiary institution in the Philippines. The demographics, clinical history, severity of COVID-19, type of intervention, and post-procedural outcomes of the five patients are reported. Whole abdomen CT scan was performed in confirming the presence of colonic diverticulitis. Results/Outcome(s): Five cases of COVID-19 diagnosed concomitantly with acute colonic diverticulitis were included in the study. All five cases underwent an intervention for their diverticular disease. One patient underwent surgical intervention after failure of conservative management. Four patients underwent percutaneous drainage. Two of them were successfully treated with percutaneous drainage while the other two had treatment failure. The first case of treatment failure subsequently underwent surgery with a good postoperative outcome. The second case, however, succumbed to COVID-19 complications. Limitations: There are two limitations of this study. First, this is a mainly a descriptive case series study design;hence, no statistical analyses were performed. Second, the patients included were limited only to COVID-19 with complicated diverticulitis who needs an intervention, either percutaneous or surgical approaches. Conclusions/Discussion: This case series was able to demonstrate that a nonoperative approach can be safely employed in managing acute complicated diverticulitis without jeopardizing the treatment of COVID-19. In the same way, utilizing this conservative method provides an opportunity to optimize the patient if surgery is eventually needed.
Subject(s)
Appendicitis , COVID-19 , Abscess/etiology , Abscess/surgery , Adult , Appendectomy , Appendicitis/complications , Appendicitis/surgery , COVID-19/complications , Drainage , Humans , Prospective StudiesABSTRACT
Introduction: Ingestion of foreign bodies are not uncommon, however enterohepatic migration of fish bones causing liver abscesses remains a rare phenomenon. Case Report: We present the case of a 58-year-old female admitted with 11 days history of fever, rigors, shortness of breath and malaise associated with vomiting and diarrhoea. Her COVID-19 rapid antigen test was negative. She was tender in the left lower quadrant of her abdomen and inflammatory markers were markedly high so initial differential diagnosis included colitis and diverticulitis. Contrast Computed Tomography of the abdomen and pelvis showed an 8.1cm irregular hepatic lesion initially thought to be a multiloculated abscess, malignancy or complex cyst. She was started on broad-spectrum antibiotics, escalated to Intensive Care Unit (ICU) and discussed at the hepato-biliary multi-disciplinary team (MDT) where magnetic resonance images demonstrated a perforated duodenum from a 2.5cm fish bone penetrating from the duodenal wall into the liver parenchyma causing a necrotic abscess. She underwent percutaneous drainage of the hepatic abscess. Endoscopic retrieval was then attempted;however, the fish bone was not visualised. Definitive management followed with laparoscopic removal of the fish bone and primary duodenal repair. Discussion: Identification of the cause of the abscess during MDT discussion enabled prompt source control which was key in managing intra- abdominal sepsis - radiological drainage in the first instance prevented secondary peritonitis from a potentially ruptured abscess and enabled the patient to be de-escalated from ICU. Previous literature suggests endoscopic retrieval however, laparoscopic surgery remains safer for managing complications following removal of sharp foreign bodies.