Neumatocele en paciente pediátrico. ¿Cuándo debemos actuar? / Pneumatocele in a pediatric patient. When should we act?

El neumatocele es una lesión cavitada llena de aire de carácter adquirido que se encuentra en el interior del parénquima pulmonar. Aunque las causas pueden variar, el origen infeccioso bacteriano es lo más frecuente. Los cambios en los serotipos de neumococo y el aumento de las neumonías necrotizantes observado en las últimas décadas hacen de este tipo de lesiones algo cada vez más frecuente. Es importante conocer la evolución esperable, así como también saber qué paciente se beneficia de intervención para evitar secuelas a largo plazo y complicaciones graves. En este artículo se exponen las causas, epidemiología, orientación diagnóstica y una propuesta de manejo para el neumatocele.

A pneumatocele is an air-filled cavitary lesion of acquired nature located within the pulmonary parenchyma. Although causes can vary, bacterial infectious origin is the most common. Changes in pneumococcal serotypes and the increase in necrotizing pneumonia observed in recent decades have made these lesions increasingly frequent. It is important to know the expected evolution and to identify which patients would benefit from intervention to prevent long-term sequelae and severe complications. This article exposes the causes, epidemiology, diagnostic approach, and a management proposal for pneumatocele.

Splenic Abscesses in Endocarditis: A Rare Disease with High Mortality. The Experience of a Heart Institute in Brazil.

INTRODUCTION: Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition. METHODS: Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed. RESULTS: Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%. CONCLUSION: Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.

Minimally invasive step-up approach for the management of postoperative intraabdominal abscess after laparoscopic appendectomy.

BACKGROUND: Postoperative intraabdominal abscess (IAA) is the most feared complication after laparoscopic appendectomy (LA). We aimed to evaluate the management of this complication in a large cohort of patients undergoing LA in order to design a treatment algorithm. METHODS: We included a consecutive series of patients undergoing LA for acute appendicitis from January 2008 to December 2018. The cohort of patients with postoperative IAA was divided into three groups based on the implemented treatments: G1: antibiotics only, G2: CT-guided drainage, and G3: laparoscopic lavage. Characteristics of the fluid collections and outcomes were analyzed in the three groups. RESULTS: A total of 1668 LA were performed; the rate of IAA was 2.2% (36 patients). There were 12 (33%) patients who received antibiotics only (G1), 8 (22%) underwent CT-guided percutaneous drainage (G2), and 16 (45%) underwent laparoscopic lavage (G3). The median size of the abscesses was 2.7 (1.2-4) cm in G1, 6.2 (4.5-8) cm in G2, and 9.6 (8-11.4) cm in G3 (p < 0.04). Patients with two or more fluid collections underwent a laparoscopic lavage in all cases. Treatment failure occurred in 16% (2/12), 12.5% (1/8) and 12.5% (2/16) of the patients in G1, G2, and G3, respectively. None of the patients in the entire cohort required open surgery to resolve the postoperative IAA. CONCLUSIONS: A minimally invasive step-up approach based on the size and number of fluid collections is associated with excellent outcomes. A treatment algorithm for post-appendectomy IAA is proposed.

Percutaneous transhepatic placement of plastic biliary stents: technical description and preliminary results.

PURPOSE: To describe a novel technique of percutaneous transhepatic (PTH) placement of a plastic biliary stent (PBS), report the feasibility and safety of the technique, and present the preliminary results of a pilot study that included 32 patients with symptomatic obstructive jaundice (SOJ) treated with the technique. MATERIALS AND METHODS: This was a prospective, single-arm, single-center, pilot study of a cohort of patients with the diagnosis of benign or malignant obstructive jaundice that underwent PTH placement of a PBS to relieve the obstruction. RESULTS: Thirty-two patients were included, 16 men and 16 women (age range, 35-88 years). There were 26 malignant and six benign lesions. Cholangiocarcinoma was the most common tumor (n=13, 40.6%), followed by pancreatic adenocarcinoma (n=6, 18.75%) and metastasis (n=5, 15.6%). A total of 35 PBSs were placed in 32 procedures. The bile duct was accessed and drained to the right side in 18 cases, to the left side in 14 cases, and bilaterally in three cases. Technical success was achieved in 100% and clinical success in 93.7% of cases. Using a modified Bismuth-Cortelle classification system, type I was observed in nine patients, type II in nine patients, type III in six patients, and type IV in eight patients. The mean follow-up was 426.1 days for the total sample, and 349.4 days for patients with malignancy. Two complications were observed: transient hemobilia and cholangitis. CONCLUSION: PTH placement of a PBS in patients with SOJ is feasible, safe, and effective.

Tratamiento con drenaje percutáneo ecoguiado de hematomas vesicouterinos postcesárea complicados. Experiencia en 4 casos / Treatment with ultrasound-guided percutaneous drainage of complicated post-cesarean vesicouterine hematomas. Experience in 4 cases

Resumen ANTECEDENTES: Los hematomas vesicouterinos sobreinfectados son una rara complicación de la histerotomía segmentaria transversa. La acumulación de sangre entre la pared posterior de la vejiga y el segmento uterino facilita la proliferación de microorganismos patógenos. Cuando el tratamiento antibiótico falla deben plantearse técnicas invasivas para su resolución, entre las que destaca el drenaje percutáneo ecoguiado. CASOS CLÍNICOS: Se exponen 4 casos de mujeres que, después de la cesárea, iniciaron con descenso del hematocrito, fiebre (3 casos) y cuadro pseudooclusivo (1 caso). Con base en la ecografía se estableció el diagnóstico de hematoma vesicouterino sobreinfectado. Después de la falla del tratamiento con antibióticos se propuso el drenaje percutáneo ecoguiado. Se observó mejoría clínica en todos los casos de forma significativa. El cultivo del material drenado orientó al tratamiento antibiótico específico. La evolución de las pacientes fue satisfactoria. CONCLUSIONES: El drenaje percutáneo ecoguiado permite evacuar el contenido hemático, obtener suficiente muestra para el cultivo y aportar información del microorganismo patógeno concreto. Además, es una técnica efectiva, menos invasiva que la cirugía y se asocia con escasas complicaciones.

Abstract BACKGROUND: Infected bladder-flap hematomas are a rare complication after a lower uterine segment caesarean section. This blood collection located in the space between the posterior bladder wall and the lower uterine segment allows microorganism proliferation. When the treatment with antibiotics fails, invasive techniques are considered, such as ultrasound percutaneous drainage. CLINICAL CASE: We present 4 cases of women whom, after the performance of a cesarean section, began with a decrease in hemoglobin levels, spiking fevers in 3 cases and pseudo-occlusive symptoms in the other one. With an ultrasound examination, the diagnosis of infected bladder-flap hematomas were achieved. After the failure of the antibiotics treatment, an ultrasound percutaneous drainage was performed. As a result of the evacuation of the collection, the clinical situation improved significantly. Culture of the sample obtained permitted to establish a more effective antibiotic treatment. CONCLUSIONS: Ultrasound percutaneous drainage allows not only the evacuation of the blood collection to obtain a sample for culture, but also provides information about the presence of a specific microorganism. Moreover, it is a highly efficient technique, less invasive than surgery which presents few complications.

Absceso esplénico post traumático / Splenic abscess post-traumatic

RESUMEN Los abscesos esplénicos son afecciones infrecuentes, pero con alta mortalidad atribuida a un diagnóstico tardío debido fundamentalmente a la ausencia de síntomas y signos específicos. Presentamos un paciente con antecedente de trauma 6 meses antes en región toraco abdominal, que ingresó con un síndrome febril prolongado de causa no precisada. Se constató la existencia de dolor a la palpación en región de hipocondrio izquierdo, que por ultrasonido abdominal, informa presencia de una lesión hipo ecogénica en un bazo aumentado de tamaño y en la angio tomografía no se evidencio fuga de contraste Se aplicó antibioticoterapia y drenaje percutáneo bajo tomografía con la cual se logró buena respuesta clínica, con evolución favorable y se evitó su esplenectomía.

ABSTRACT Splenic abscesses are infrequent conditions, but with high mortality attributed to a late diagnosis, mainly due to the absence of specific symptoms and signs. We present a patient with a history of trauma 6 months earlier in the abdominal thorax region, who was admitted with a prolonged febrile syndrome of unknown origin. The existence of palpation pain in the left hypochondrium region was confirmed by abdominal ultrasound, the presence of a hypo-echogenic lesion in an enlarged spleen and in the angio tomography no evidence of contrast leakage. Antibiotic therapy and percutaneous drainage were applied under tomography with good clinical response, with favorable evolution and splenectomy was avoided.

Giant simple biliary cyst infection treated with minimally invasive percutaneous drainage.

We describe a minimally invasive alternative approach in a patient with infected hepatic cyst to stabilize the patient before definitive surgery. A 58-year-old man presented with fever and hypotension after 2 weeks of asthenia, chills, weight loss, slight abdominal pain, and a previous asymptomatic simple hepatic cyst. On ultrasound, a giant heterogeneous hepatic cyst with thick wall was noted. A positron emission tomography-computed tomography scan was indicated and demonstrated high uptake (standardized uptake value = 7.6) in the wall of the cyst, suggestive of infection. He underwent percutaneous drainage guided by the tomography. A 12 Fr drain was positioned inside the collection and 5 L of purulent material was aspirated from the cyst, and at day 12th, surgical resection was performed. Histopatological analysis confirmed a simple biliary cyst. The patient remains asymptomatic on 1-year follow-up. Percutaneous drainage before surgical treatment allowed the definitive approach to be performed with the patient in better clinical conditions.

Current management of spontaneous intra-abdominal abscess in Crohn's disease / Tratamento atual de abscesso intra-abdominal espontâneo na doença de Crohn

ABSTRACT Crohn's disease (CD) is a chronic transmural disease process with approximately 10% of patients developing spontaneous intra-abdominal abscess during the first 5 years after the diagnosis. The symptoms are often nonspecific. The treatment modalities include the use of wide-spectrum antibiotics, imaging-guided percutaneous drainage (PD) and surgical drainage with or without resection. The best initial treatment strategy has not been settled controversial, as there are only retrospective studies with small sample sizes available in the literature. The majority of the patients would eventually need surgery. However a highly selected patient population with small abscess in the absence of fistulas or bowel strictures, especially those naive to immunomodulators or biologics, may respond to medical treatment alone with wide-spectrum antibiotics. The increased use of PD drainage in the last few years has been shown to reduce postoperative morbidities and risk of fecal diversion, allowing for subsequent elective surgery. Varied success rates of PD drainage have been reported in the literature. The initial surgical intervention of CD-related spontaneous abdominal sepsis is mandatory in patients with diffuse peritonitis due to free perforation. Surgery is also indicated in those with failed initial medical treatment and/or PD. This review article was aimed to evaluate the treatment modalities for spontaneous intra-abdominal abscess in CD patients and propose an algorithm for the best management of this complication.

RESUMO A doença de Crohn (DC) é um processo patológico transmural crônico, em que aproximadamente 10% dos pacientes desenvolvem um abscesso intra-abdominal espontâneo durante os primeiros 5 anos após o diagnóstico. Com frequência os sintomas são inespecíficos. As modalidades terapêuticas são o uso de antibióticos de amplo espectro, drenagem percutânea (DP) orientada por imagem, e drenagem cirúrgica com ou sem ressecção. A melhor estratégia terapêutica inicial ainda não ficou estabelecida e há controvérsias, visto que a literatura conta apenas com estudos retrospectivos com pequenas amostras. Em sua maioria, os pacientes acabarão necessitando de cirurgia. Mas uma população altamente selecionada de pacientes, com pequeno abscesso na ausência de fístulas ou constrições intestinais, especialmente aqueles que jamais foram medicados com imunomoduladores ou agentes biológicos, podem responder exclusivamente ao tratamento clínico com antibióticos de amplo espectro. Foi demonstrado que o uso mais frequente da DP nos últimos anos diminui as morbidades pós-operatórias e o risco de desvio fecal, o que possibilita uma subsequente cirurgia eletiva. Na literatura, têm sido relatados percentuais de sucesso variados com a DP. A intervenção cirúrgica inicial para a sepse abdominal espontânea relacionada à DC é obrigatória em pacientes com peritonite difusa, devido à perfuração livre. Também há indicação cirúrgica naqueles pacientes que não conseguiram obter sucesso com o tratamento clínico inicial e/ou DP. Esse artigo de revisão teve por objetivo avaliar as modalidades terapêuticas para o abscesso intra-abdominal espontâneo em pacientes com DC; além disso, propõe um algoritmo para o melhor tratamento dessa complicação.

Puerperal sepsis caused by liver abscess: case report / Sepse puerperal secundária a abscesso hepático: relato de caso

Abstract Introduction: sepsis is a serious public health problem, affecting millions of people in the world each year, with a high mortality rate (one out of four patients) and an increasing incidence. Sepsis is one of the main causes of maternal mortality and an important cause of admission to obstetric intensive care units. Case description: In this study, the authors report the case of a woman having been submitted to cesarean section three days before presenting clinical signs of sepsis and septic shock caused by a liver abscess. The patient had a set of complications secondary to shock, such as thrombocytopenia, coagulopathy, toe ischemia and acute kidney failure. The patient had cholelithiasis and recurrent pain in the right hypochondrium during pregnancy. During hospitalization, the mechanism involved in the development of hepatic abscess was infection of the biliary tract. The patient was treated in an obstetric intensive care unit with antibiotics and drainage of the liver abscess. Progress was favorable and the patient was discharged in good health. Discussion: pyogenic liver abscess during pregnancy and puerperium is a serious condition which represents a diagnostic and therapeutic challenge, with few cases reported. The normally nonspecific clinical and laboratory findings can lead to a late diagnosis, which increases the risk of maternal morbidity and mortality.

Resumo Introdução: a sepse é um problema grave de saúde pública, afetando milhões de pessoas no mundo a cada ano. Apresenta uma alta mortalidade, um em quatro doentes, e vem aumentando sua incidência. É uma das principais causas de mortalidade materna, sendo uma causa importante de admissões emunidades de terapia intensiva obstétrica. Descrição do caso: puérpera, no terceiro dia pós-cesariana, apresentou quadro clinico de sepse e choque séptico secundário a um abscesso hepático piogênico.Evoluiu com complicações secundárias ao choque: plaquetopenia, coagulopatia, isquemia de pododáctilos e insuficiência renal aguda. A paciente era portadora de colelitíase e apresentou repetidas crises álgicas em hipocôndrio direitodurante a gestação.Durante o internamento, ficou definido que a causa do abscesso hepático foi a infecção das vias biliares.Realizou-se tratamento em unidade de terapia intensiva obstétrica, tendo a paciente sido submetida à drenagem do abscesso hepático e antibioticoterapia. A evolução foi satisfatória e a paciente obteve alta em boas condições. Discussão: o abscesso hepático piogênico durante a gravidez e o puerpério é uma condição extremamente grave, com poucos casos relatados, representando um desafio diagnóstico e terapêutico. Como os achados clínicos e laboratoriais são usualmente inespecíficos, um diagnóstico retardado é possível, aumentando os riscos de morbidade e mortalidade materna em casos não tratados precocemente.

Resultados del tratamiento quirúrgico de las colecciones de pus del pulmón / Results of the surgical treatment of lung abscess

Introducción: el diagnóstico y tratamiento de las colecciones de pus del pulmón ha variado a través del tiempo. Objetivo: evaluar los resultados del tratamiento quirúrgico de los enfermos en los que fracasó el tratamiento médico. Métodos: estudio descriptivo observacional de 45 enfermos con colecciones de pus del pulmón en los que se realizó algún procedimiento quirúrgico. Resultados: predominó el sexo masculino, 82,2 por ciento entre la sexta y séptima década de la vida, todos presentaban factores de riesgo. El absceso pulmonar primario fue el más frecuente, seguido por cáncer de pulmón abscedado, las bullas, bronquiectasia y el absceso por tuberculosis, 91,1 por ciento eran ASA II o III y 8,9 por ciento IV. Predominaron los gérmenes gran negativos. El pulmón derecho fue el más afectado. Las intervenciones más realizadas fueron las resecciones con predominio de la lobectomía. El drenaje percutáneo y la pleurostomía, la supuración por TB fue tratada con drenaje y drogas antituberculosas. Las complicaciones más frecuentes fueron: infección respiratoria, arritmias e infecciones del sitio quirúrgico, la morbilidad fue inferior al 25 por ciento y la mortalidad 3,8 por ciento. Conclusiones: la selección individual del procedimiento a utilizar -teniendo en cuenta la causa, el estado físico y los factores de riesgo quirúrgico- permiten obtener resultados satisfactorios(AU)

Introduction: diagnosis and treatment of lung abscess has varied throughout the time. Objective: to evaluate the results of the surgical treatment in patients whose medical treatment failed. Methods: observational and descriptive study of 45 patients with lung abscess, who had undergone some type of surgery. Results: males predominated; 82.2 percent aged 60 to 70 years and all presented with risk factors. Primary lung abscess was the most common, followed by abscessed lung cancer, bullas, bronchiectasis and tuberculosis abscess. In the group, 91.1 percent were classified as ASA II or III and 8.9 percent as ASA IV. Gram-negative germs prevailed. Right lung was the most affected one. The most performed surgeries were resections, mainly lobectomy. Percutaneous drainage and pleurostomy; tuberculosis suppuration was treated with drainage and anti-tuberculosis drugs. The commonest complications were respiratory infections, arrhythmias and surgical site infections. The morbidity rate was below 25 percent and the mortality rate was 3.8 percent. Conclusions: taking into account the cause, the physical condition and the surgical risk factors, the individual selection of the procedure to be used allows achieving satisfactory outcomes(AU)

A New CT-Guided Modified Trocar Technique for Drainage of Difficult Locations Abscesses.

PURPOSE: Computed tomography (CT) is commonly used to guide drainage of deep-seated abdominal fluid collections. However, in some cases, these collections seem to be inaccessible due to surrounding organs or their being in difficult locations. The aim of this study is to describe a modified Trocar technique to drain collections in difficult locations, especially those in the subphrenic space, without passing through intervening organs. MATERIALS AND METHODS: This retrospective case series study describes seven inpatients who underwent CT-guided drainage using a modified Trocar technique for abscesses that are difficult to access percutaneously. All patients provided written informed consent prior to the procedure. After placement of a 12-14F catheter inside the peritoneum, the Trocar stylet was removed so that the tip of the catheter became blunt and flexible to avoid injury to organs and structures in the catheter route, and the catheter was slowly advanced towards the collection using CT guidance and tactile sensation. After reaching the target, the stylet was reintroduced to enter the abscess wall. RESULTS: All procedures were performed using an anterior abdominal wall access with adequate catheter positioning and resulted in clinical status improvement in the days after the drainage. No complications related to the procedure were identified in any of the patients. CONCLUSIONS: The modified Trocar technique for percutaneous CT-guided drainage of abdominal abscesses may be feasible for lesions that are difficult to access with conventional methods.

Percutaneous epidural drainage through a burr hole.

Intracranial extradural collection may cause an increase in intracranial pressure, requiring rapid emergency treatment to reduce morbidity and mortality. We described an alternative CT-guided percutaneous access for extradural collection drainage. We report a case of a patient with previous craniectomy for meningioma ressection who presented to the Emergency Department with symptoms of intracranial hypertension. Brains CT showed a extradural collection with subfalcine herniation. After multidisciplinary discussion a CT-guided percutaneous drainage through previous burr hole was performed. The patient was discharged after 36 hours of admission, without further symptoms. We describe a safe and effective alternative percutaneous access for extradural collection drainage in patients with previous burr hole.

Manejo percutáneo de colecciones abdominales en el hospital distrital de Villa Elisa / Percutaneous treatment of abdominal collections in the district hospital of Villa Elisa

Los abscesos abdominales se definen como colecciones localizadas que presentan pus, gérmenes en el frotis o crecen en el cultivo. Estas adquieren importancia cuando se hacen sintomáticas. En el manejo actual, el drenaje percutáneo es el tratamiento de elección por múltiples ventajas, reservándose el drenaje quirúrgico para ciertos casos. Esto se debe al avance de la tecnología de los métodos auxiliares de diagnóstico por imágenes, especialmente la ecografía.Objetivo: demostrar la factibilidad del manejo percutáneo de colecciones intra-abdominales en un hospital periférico de baja complejidad y con disponibilidad de ecógrafo.Diseño: retrospectivo, longitudinal, observacional, cuantitativo, no aleatorio, con componente analítico.Pacientes y método: pacientes con diagnóstico de colección intra-abdominal de distintas etiologías, internados en el Servicio de Cirugía del Hospital Distrital de Villa Elisa, desde junio de 2014, hasta setiembre de 2015.Resultados: 5 pacientes estudiados, 60% del sexo femenino, el cuadro de presentación fue conformado por dolor abdominal, distensión, plastrón palpable y fiebre. Laboratorialmente, leucocitosis con neutrofilia. En todos se realizó el drenaje de la colección bajo pantalla ecográfica con catéteres multipropósito de 10Fr, con la técnica del trocar. Se obtuvo el éxito en el tratamiento en el 80% de los casos. Conclusión: el manejo de colecciones abdominales es factible en hospitales periféricos de baja complejidad.

Abdominal abscess are defined as localized collections of pus, germs visualizated in a frotis or grow in culture. These become important when they become symptomatic. Actually, percutaneous drainage is the gold standard, reserving the surgery approach for a few special cases. This is due to the advanced of technology, particularly the ultrasound. Objective: to demonstrate the feasibility of percutaneous management of intraabdominal collections in a peripheral low complexity hospital, with ultrasound availability. Design: retrospective, longitudinal, observational, quantitative, no randomized, with analytical component. Patients and methods: patients with diagnosis of intraabdominal collections, admitted in surgery service of the Hospital Distrital of Villa Elisa, from June of 2014 to September of 2015. Results: 5 patients studied, 60% female, with clinical of abdominal pain, distension, palpation of abdominal mass or fever. Laboratorial findings neutrophilic leukocytosis. In all cases, percutaneous drainage was made it under ultrasound view, using 10 Fr multipurpose catheter, using trocar technique. Success was possible in 80% of the cases. Conclusion: the management of abdominal collections is possible in peripheral low complexity hospitals.

Utilidad de la ecografia en manos del cirujano para el drenaje percutáneo de los abscesos abdominales y pélvicos / Utility of ultrasound in the hands of the surgeon in percutaneous drainage of abdominal and pelvic abscess

Antecedentes: los abscesos o colecciones abdominopélvicas sintomáticas se caracterizan por ser una entidad clínico-quirúrgica de origen multifactorial, aunque casi siempre su etología es posoperatoria. Objetivo: describir la aplicabilidad y eficacia del drenaje percutáneo de colecciones abdominales y pelvianas, bajo guía ecográfica, en un servicio de cirugía. Material y métodos: en un período de 9 años se incluyeron todos los pacientes con colecciones ab-dominopelvianas tratados en forma consecutiva con drenaje percutáneo bajo guía ecográfica, en el Hospital Italiano de Bahía Blanca. Resultados: desde junio de 2003 hasta junio de 2012 se trataron 87 pacientes con colecciones abdomi-nopelvianas sintomáticas; en 79 de ellos el tratamiento fue realizado bajo guía ecográfica; 4 pacientes no fueron incluidos en el estudio debido a que el tratamiento se realizó bajo guía tomográfica, y los restantes 4 fueron descartados porque eran pacientes pediátricos. En 51 (64,5%) de ellos, el origen fue posoperatorio. Treinta y ocho (48,1%) pertenecían al sexo femenino. El promedio de edad fue 55 años (rango 18-92). El drenaje se realizó bajo guía ecográfica y radioscópica en 78 pacientes (98,7%) y en uno el abordaje fue ecográfico y laparoscópico. En 15 pacientes (18,9%) se presentaron complicaciones inherentes al procedimiento: 7 pacientes cursaron con febre, 3 refrieron dolor luego de la intervención (abordaje intercostal), en 3 se constataron equivalentes febriles, en una, celulits, y en otra, fistula de colon. De acuerdo con la Clasificación de Dindo-Clavien: 14 puntos Grado I (93,3%) y 1 punto Grado III B (6,7%). No hubo mortalidad asociada al procedimiento; 7 pacientes (8,8%) fallecieron por causas no relacionadas con este. La técnica fue resolutiva en 70 pacientes (88,6%) y satsfactoria en 74 (94%). Conclusiones: el drenaje percutáneo de las colecciones abdominales y pélvicas bajo guía ecográfica en manos del cirujano fue factble y eficaz, lo que la convierte en una técnica segura con baja morbilidad y nula mortalidad.

Background: abscesses or symptomatic abdominal collectons have multifactorial origin, although in more than 65% of the cases, the etology is postoperative. Objective: to describe the applicability and utility of abdominal and pelvic percutaneous drainage guided by ultrasound in a surgical team. Methods: a series of consecutive patents with ultrasound guided percutaneous drainage of abdominal or pelvic collecton performed during in a 9 year period. Results: from June 2003 to June 2012, 87 procedures were performed, 79 of them guided with ultrasound.The etology was postoperative in 51 patents (64.5%). Thirty eight (48.1 %) were female. Average age was 55 (range 18-92). Drainage was performed under ultrasound and radiology guide in 78 patents (98.7%) and by laparoscopic and ultrasound guide in one patent. Fifeen patents (18.9%) presented morbidity related to the procedure: fever in 7 patents, unusual pain in 3 (all with intercostal drainage), chills and sweating in 3, cellulits in one, and a colonic leak in one. All patents were included into of Dindo-Clavien Classificaton of Surgical Complicatons and the results were: Grade I: 14 patents, Grade IIIb: one patent. There was no mortality related to the procedure; seven patents (8.8%) died because of other causes. The overall success rate was 88.6 % (70 cases), and satsfactory in 94% (74 cases). Conclusions: in surgeons hands, ultrasound guided percutaneous drainage of abdominal and pelvic collectons was a feasible, efective and safe procedure with low morbidity.

Tratamiento del absceso hepatico. Experiencia en el hospital nacional de itaugua / Treatment of hepatic abscess. The experience at the national hospital of itaugua

Introducción: La introducción de los antibióticos y el desarrollo de técnicas radiológicas (ecografía y TC) que han mejorado la eficacia diagnóstica y posibilitado el drenaje percutáneo de los abscesos. Se realiza un estudio de los aspectos clínicos, terapéuticos y evolutivos. Las técnicas percutáneas, la aspiración y el catéter drenaje han relegado a un segundo plano al drenaje quirúrgico como principal forma de tratamiento. OBJECTIVO: conocer en profundidad la situación actual de este proceso patológico, estudiando los diferentes aspectos clínicos, terapéuticos y evolutivos en el Hospital Nacional de Itaugua en 3 años. MÉTODOS: Estudio descriptivo – retrospectivo, basado en la revisión de historias clínicas de pacientes con diagnóstico de AH entre Enero 2011 a junio 2014. Resultados: De 58 historias clínicas revisadas. La edad media fue entre los 41-50 años (43,1%), y 55% fueron varones. El diagnóstico principalmente fue ecográfico (97,8%), absceso único (73%), ubicado en lóbulo derecho (77%). Treinta y nueve pacientes (67,2%) fueron operados, diesinueve pacientes (32,7%) recibieron drenaje percutáneo. CONCLUSIÓN: El absceso hepatico es una patología aguda, de mediana edad, frecuente en el sexo masculino, el tratamiento actual es el drenaje percutaneo.

Introduction: The introduction of antibiotics and the development of imaging techniques (ultrasound and CT) have improved the diagnostic efficacy and facilitated percutaneous drainage of abscesses. A study of clinical, therapeutic and evolutionary aspects is performed. Percutaneous techniques, aspiration and drainage catheter been relegated to the background surgical drainage as the main form of treatment. OBJECTIVE: To learn more about the current status of this disease process, studying the different clinical, therapeutic and evolutionary aspects in the National Hospital of Itaugua in three years. METHODS: Descriptive - retrospective, based on review of medical records of patients diagnosed with AH between January 2011 to June 2014. RESULTS: Of 58 clinical histories. The average age was between 41-50 years (43.1%), and 55% were male. The diagnosis was mainly ultrasound (97.8%), single (73%) abscess located in the right lobe (77%) .. Thirty-nine patients (67.2%) underwent surgery, diesinueve patients (32.7%) received percutaneous drainage. CONCLUSION: The liver abscess is an acute disease of middle age, frequent in males, the current treatment is percutaneous drainage.

Neumostomía con sonda de balón en colecciones purulentas del pulmón / Neumostomy with a balloon catheter in supurative lung collections

Introducción: el desarrollo de los antimicrobianos provocó que el drenaje externo dejara de realizarse en pacientes con absceso de pulmón, en quienes la resección pulmonar es la opción ante el fracaso médico. En los últimos años, la neumostomía ha resurgido por la necesidad de asistir a enfermos con un marcado deterioro físico que impide una intervención quirúrgica resectiva. Objetivo: caracterizar a los pacientes con supuración pulmonar tratados quirúrgicamente mediante drenaje percutáneo externo y neumostomía con sonda de balón (método de Monaldi) practicados con anestesia local. Métodos: se realizó un estudio descriptivo longitudinal retrospectivo en el período de 1995 a 2012 en el Hospital Universitario Comandante Manuel Fajardo. El universo estuvo conformado por 8 pacientes a los que se les practicó el método de Monaldi. En todos los casos se utilizaron sondas de goma de balón de 24 unidades F, de tres ramas. Resultados: cuatro pacientes padecían de absceso del pulmón y el resto de bullas enfisematosas voluminosas infectadas. Todos los casos tuvieron resolución de la colección infectada en un período inferior a las 2 semanas, y no hubo complicaciones ni mortalidad quirúrgica. Conclusiones: el drenaje percutáneo con anestesia local utilizando sondas de balón es un instrumento adecuado para el tratamiento de colecciones pulmonares en enfermos con deterioro físico por el cuadro infeccioso. Con él se logra la resolución de la lesión pulmonar, y es efectivo tanto en los abscesos pulmonares como en las bullas enfisematosas infectadas(AU)

Introduction: with the advent of the antibiotic therapy, external drainage ceased to be performed in lung abscess patients for whom the pulmonary resection is the choice. In the last few years, pneumostomy has reemerged due to the need of giving assistance to patients with remarkable physically deterioration that hinders resective surgery. Objectives: to characterize patients with pulmonary suppuration and surgically treated by means of external percutaneous drainage with balloon catheter pneumostomy (Monaldi method) using local anesthesia. Methods: retrospective, descriptive and longitudinal study of eight patients, who underwent Monaldi method-based surgery, conducted from 1995 through 2012 at Manuel Fajardo university hospital. Three branch twenty-four F unit balloon rubber catheters were used in all these cases. Results: out of the eight, four had been diagnosed with lung abscess and the other four had large septic emphysematous sacs. The infected collection was eliminated in all these patients in less than 2 weeks with no complication and no surgical death. Conclusion: The percutaneous drainage with local anesthesia using balloon catheter as an instrument was adequate and useful in the treatment of septic lung collections in patients with very poor physical condition. This method manages to eliminate the pulmonary lesion and is good for both pulmonary abscesses and infected emphysematous sacs(AU)

Abscesso hepático por Klebsiella pneumoniae e suas complicações sistêmicas / Liver abscess by Klebsiella pneumoniae and its systemic complication

Abscesso hepático por Klebsiella pneumoniae é incomum em países ocidentais e tem sido associado a complicações severas, sobretudo em pacientes diabéticos. A manifestação clínico-laboratorial da doença é inespecífica. Endoftalmite é uma rara complicação de septicemia por Klebsiella pneumoniae. Atraso terapêutico pode resultar em perda visual acentuada e irreversível. Relatamos um caso de abscesso hepático por Klebsiella pneumoniae complicado com endoftalmite, embolia pulmonar séptica e endocardite em homem diabético.

Klebsiella pneumoniae liver abscess is unco mmon in western countries and has been associated with severe complications, especially in diabetic patients. The clinical and laboratory manifestations of the disease are nonspecific. Endophthalmitis is a rare complication of septicemia due to Klebsiella pneumoniae. Therapeutic delay can result in severe and irreversible visual loss. We report a case of Klebsiella pneumoniae liver abscess complicated by endophthalmitis, septic pulmonary emboli and endocarditis in diabetic man.

Abscesso hepático por klebsiella pneumoniae e suas complicações sistêmicas / Liver abscess by klebsiella pneumoniae and its systemic complications

Abscesso hepático por Klebsiella pneumoniae é incomum em países ocidentais e tem sido associado a complicações severas, sobretudo em pacientes diabéticos. A manifestação clínico-laboratorial da doença é inespecífica. Endoftalmite é uma rara complicação de septicemia por Klebsiella pneumoniae. Atraso terapêutico pode resultar em perda visual acentuada e irreversível. Relatamos um caso de abscesso hepático por Klebsiella pneumoniae complicado com endoftalmite, embolia pulmonar séptica e endocardite em homem diabético.

Klebsiella pneumoniae liver abscess is unco mmon in western countries and has been associated with severe complications, especially in diabetic patients. The clinical and laboratory manifestations of the disease are nonspecific. Endophthalmitis is a rare complication of septicemia due to Klebsiella pneumoniae. Therapeutic delay can result in severe and irreversible visual loss. We report a case of Klebsiella pneumoniae liver abscess complicated by endophthalmitis, septic pulmonary emboli and endocarditis in diabetic man.

Therapeutic impact of CT-guided percutaneous catheter drainage in treatment of deep tissue abscesses.

Combination therapy of CT-guided percutaneous drainage and antibiotics is the first-line treatment for abscesses. Its effectiveness has been demonstrated. However, the therapeutic impact of this procedure for infection treatment has never been reported. We retrospectively analyzed all 47 patients who received CT-guided percutaneous drainage for infection treatment. Patients' characteristics, pathogens isolated, antibiotics administered, technical and clinical outcomes, complications related to this procedure and therapeutic impacts were investigated. Patients were 26 males and 21 females. The mean age was 63.5 years (±18.7). The diseases targeted were 19 retroperitoneal abscesses, 18 intra-abdominal abscesses, three pelvic abscesses, and seven others. As for technical outcomes, all of the 54 procedures (100%) were successful. As for clinical outcomes, 44 (93.6%) were cured and three patients (6.4%) died. No complications related to this procedure were found in this study. A total of 42 patients (88%) had a change in the management of their infection as a result of CT-guided percutaneous drainage, such as selection and discontinuation of antibiotics. In conclusion, CT-guided percutaneous drainage is a safe and favorable procedure in the treatment of deep tissue abscesses. Therapeutic impact of these procedures helped physicians make a rational decision for antibiotics selection.

Manejo del absceso diverticular / Management of the diverticular abscess

Introducción: el absceso diverticular (AD) es la complicación más común de la diverticulitis. Actualmente no hay consenso en definir su mejor estrategia terapéutica. Objetivos: describir las características clínicas de los pacientes con AD y su evolución según tamaño, ubicación y manejo. Material y Método: estudio descriptivo de pacientes con AD hospitalizados en el Hospital Militar, durante el período 2009-2012. Resultados: se hospitalizaron 22 pacientes con diagnóstico de AD, con edad promedio de 65.2 años, el 63% eran mujeres, y las comorbilidades más frecuentes fueron hipertensión arterial, diabetes mellitus e hipotiroidismo. Todos consultaron por dolor abdominal y se encontraban hemodinámicamente estables al ingreso. 15 casos eran AD pericolónicos: 7 AD = 3 cm con buena respuesta a tratamiento médico; 4 AD de 3-5 cm, en este grupo se instaló drenaje percutáneo (DPC) en 3 pacientes de los cuales 2 requirieron cirugía; 4 AD > 5 cm, sólo en un caso se realizó DPC y ningún paciente requirió cirugía. Siete casos eran AD pélvicos o retroperitoneales: 4 AD de 3-5 cm con respuesta favorable a manejo médico; 3 AD > 5 cm, sólo un caso se manejó con DPC y ninguno requirió cirugía. Se realizó una sigmoidectomía electiva sólo en 5 casos, los 15 pacientes restantes han evolucionado satisfactoriamente durante 15.73 meses de seguimiento. No hay mortalidad en esta serie. Conclusión: es factible el manejo conservador de AD > 5 cm de diámetro. No hay mayor recurrencia de diverticulitis en pacientes con AD, independiente del tamaño, ubicación y manejo inicial.

Background: diverticular Abscess (DA) is the most common complication of diverticulitis. Currently, there is no consensus on defining the best therapeutic strategy against it. Objectives: to describe the clinical characteristics of DA patients and their evolution according to size, location and management. Materials and Methods: descriptive study of DA patients hospitalized in Militar Hospital in the period 2009-2012. Results: 22 patients diagnosed with DA were hospitalized (mean age was 65.2, 63% being women). The most frequent comorbidities were high blood pressure, diabetes mellitus and hipothyroidism. All the patients complained about abdominal pain and were hemodynamically stable when admitted. Fifteen cases were pericolonic DA: 7 DA = 3 cm responding well to medical treatment; 4 DS between 3-5 cm (in this group, percutaneous drainage (PCD) was applied to 3 patients, out of which 2 required surgery); 4 AD > 5 cm (in this group, PD was applied to only one patient and none required surgery). Elective sigmoidectomy was performed in only 5 cases; the other 15 patients have recovered satisfactorily during 15.73 months of follow-up. There is no mortality in this series. Conclusion: conservative management of DA > 5 cm in diameter is feasible. There is no considerable recurrence of diverticulitis in DA patients, despite the size, location and early management.