Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_639_Библиотеки_им_академика_М_И_Перельмана.pdf
192 Part II Abdominal Wall
the abdominal wall. e ureteral anastomoses are performed,
and stents are placed (Fig. 9-17E). All aspects of the stoma
construction are the same as those for an ileostomy except that
the appliance must contain a valve to allow emptying since the
volume of urine is high and its weight may tend to pull the
appliance o. is problem is avoided by the patient emptying the appliance frequently and by sleeping attached to a
night drainage system.
Complications of the Urinary Conduit
e most common complication of a urinary conduit is a
leaking appliance because of improper placement or construction of a ush rather than a protruding stoma. Although some
urologists believe that a ush stoma is less susceptible to injury,
most surgeons disagree with this concept and believe that a
spigot conguration is best. Sometimes sutures are placed in
the skin rather than in the dermis during stoma construction.
is leads to a circumferential series of radial scars that preclude maintenance of the seal of the appliance. Because the
stoma euent is thin liquid, the appliance seal must be precise
to avoid injury to the peristomal skin. If there is stasis in the
conduit, an odor will develop and become the cause of great
concern to the patient. Odor, increased mucus production,
ank pain, and fever can indicate a urinary tract infection.
In order to obtain an accurate urine sample for culture, it is
necessary to intubate the stoma rather than sending urine collected from the appliance. It is not unusual to have to revise
and sometimes relocate ush urinary conduit stomas. If this
is done, care must be taken to ensure that the length of the
conduit is adequate. If it is not, it is possible to add a segment
of small intestine so that a proper stoma can be constructed
without having to revise the ureterointestinal anastomoses.
e patient who does not maintain adequate personal
hygiene and acidication of the urine may develop stone formation, with crystal formation around the stoma itself. is
development can be alleviated by acidifying the urine or by
cleaning and soaking the pouch with white vinegar. e use of
Collyseal (Torbot Co.) can also be used to maintain an acidic
environment and thus minimize crystal formation at the stoma.
If the stoma has been constructed within the eld of radiation,
the radiation can break down the skin around the stoma. is
requires relocation of the stoma to a nonirradiated location on
the abdominal wall. Relocation should be done even if the upper
quadrants need to be used. Recent advances have employed the
principles of Kock pouch construction, previously described, to
allow construction of a continent urinary diversion.
INTESTINAL FISTULA
e formation of an intestinal stula is not planned by the
surgeon. erefore, it must be dealt with as it occurs. Applying modern principles of stoma care to maintain the integrity
of the peristomal skin until denitive treatment of the stula
can be carried out should prevent damage to the skin from
primitive means of preventing severe destruction of the skin
and abdominal wall. ese stomal care techniques, coupled
with intravenous nutritional supplementation, should alleviate uncontrolled intestinal drainage from abdominal wounds.
LAPAROSCOPIC CREATION
OF INTESTINAL STOMAS
e most appealing operation early on in the laparoscopic
colorectal surgery experience was creation of a diverting
intestinal stoma. Laparoscopic loop stoma creation does
not require division of the bowel or anastomosis, and the
only incision larger than 5 mm required is at the stoma
site. us, the full benets of the totally laparoscopic
approach can be realized. Surgeons inexperienced in laparoscopic approaches to colorectal disease may nd that
creation of intestinal stomas is a relatively straightforward and rewarding method to begin their laparoscopic
colorectal experience.
Laparoscopic creation of intestinal stomas was reported
in the early 1990s and the technique was quickly adopted
by many surgeons. Several case series demonstrating the
safety and ecacy of the procedure have been reported
in the literature. Although there has not been a prospective, randomized trial of laparoscopic versus open stoma
creation, case-controlled series have demonstrated reduced
duration of postoperative ileus and reduced length of hospital stay with the laparoscopic approach. e benets
of the laparoscopic approach to stoma creation became
immediately obvious to surgeons, and thus, it is unlikely
that a prospective, randomized trial will ever be performed
comparing outcomes of stomas created using laparoscopy
versus laparotomy.
Laparoscopic ileostomy and colostomy creation have
been performed for a plethora of indications, including
obstructing rectal adenocarcinoma, rectal obstruction from
extrarectal malignancies, fecal incontinence, penetrating rectal trauma, sacral pressure ulceration, obstructed defecation,
perineal Crohn’s disease, pelvic fracture, and lumbosacral
burns. Virtually any disease process that is an indication for
fecal diversion is an indication for consideration of the laparoscopic approach. Laparoscopic creation of diverting loop
colostomy is particularly appropriate for patients suering
from symptomatic near-obstructing rectal carcinoma. e
technique allows the surgeon to evaluate the liver and peritoneum for the presence of metastases that may be undetected
on preoperative imaging studies, and institute fecal diversion
without creating adhesions in the abdomen and pelvis that
may increase toxicity of neoadjuvant radiotherapy and make
future proctectomy more dicult. e absence of a laparotomy incision allows patients to recover rapidly, and allows
them to begin neoadjuvant radiotherapy treatments almost
immediately.
Some authors have argued that trephine stoma creation is
an easier, quicker, and less expensive method of stoma creation than the laparoscopic technique. For the thin patient
Chapter 9 Intestinal Stomas 193
with a virgin abdomen who will not benet from abdominal
exploration, the trephine method does oer those advantages.
However, for patients who are obese, those who have had
multiple prior laparotomies, those who would benet from
abdominal exploration, or those who require mobilization of
the intestine from its retroperitoneal attachments, the laparoscopic approach oers signicant advantages.
In order to save time and expense in the operating room,
we have developed an approach to the patient requiring fecal
diversion that combines the advantages of both trephine
and laparoscopic stoma creation. If the patient is thin and
would not necessarily benet from laparoscopic exploration
of the peritoneal cavity, the patient is approached initially
with the intention of creating a trephine stoma, with the
laparoscopic approach held in reserve. e patient is positioned for a laparoscopic procedure, but the laparoscopic
equipment is kept unopened in the operating room. e
stoma incision is made, and if the bowel can be delivered in
correct orientation to the skin level, the stoma is created and
the laparoscopic equipment remains unopened. However, if
trephine creation of the stoma is impossible, a Hasson trocar is placed through the stoma incision and the procedure
proceeds laparoscopically.
Technique of Laparoscopic
Stoma Creation
Patients undergoing diverting colostomy should be placed
in the dorsal lithotomy or split leg position in order to have
access to the anorectum; patients undergoing ileostomy may
be placed in the supine position. e preselected stoma site
is opened, a purse-string suture is placed in the posterior rectus sheath, and a Hasson trocar is placed. A 5 mm trocar is
placed in the contralateral abdomen and the peritoneal cavity
explored. If the bowel to be used for the stoma is suciently
mobile, no other trocars need to be placed. If mobilization is
required, additional 5 mm trocars can be placed to facilitate
the dissection. Mobility is usually adequate when the bowel
will reach to the peritoneal surface at the stoma site, as the
distance to the skin level will decrease when pneumoperitoneum is released. A 5 mm camera is then placed through one
of the 5 mm port sites, and the bowel grasped in the correct
orientation using an instrument placed through the Hasson
trocar at the stoma site. It is occasionally useful to mark the
bowel for orientation of the proximal and distal limbs with
sutures or clips prior to delivery through the stoma site—this
is especially true when creating an ileostomy. e pneumoperitoneum is then released and the posterior rectus sheath
opened over the trocar, allowing the bowel to be delivered
through the stoma opening.
If the bowel is to be divided and an end stoma fashioned,
it is critical that orientation be conrmed. Left-sided colostomy orientation can be conrmed by insuation of air
through a proctoscope, instillation of povidone iodine or dye
through a small opening in the distal limb of the stoma with
conrmation of dye passage to the rectum via a proctoscope,
or passage of a exible sigmoidoscope to the stoma site.
Alternatively, the colon can be divided with a linear-cutting
stapler, the distal end is allowed to retract into the peritoneal
cavity, and direct visualization with a 5 mm laparoscope is
performed to ensure that the distal bowel can be traced in
continuity to the rectum.
e rapidity with which postoperative ileus resolves following laparoscopic creation of intestinal stomas may allow
patients to return home within 1–2 days. is may create
a problem for the patient and the CWOCN, who has little
time to perform in-hospital stoma care training. erefore, it
is imperative that the patient meet with the CWOCN preoperatively, not only for stoma site marking, but for stoma care
teaching as well.
Laparoscopic Stoma Closure
Laparoscopic techniques are most applicable to patients who
have undergone colectomy with construction of a proximal
colostomy. Although laparoscopic adhesiolysis is occasionally a
benecial adjunct to loop stoma closure, this is rarely required,
as most loop stomas can be closed via a peristomal incision.
e most common indication for a laparoscopic approach
to the restoration of intestinal continuity is colostomy takedown and construction of coloproctostomy following sigmoid
colectomy for complicated diverticular disease (“Hartmann
reversal”). is procedure can either be straightforward or
complicated, depending on the number and severity of intraperitoneal adhesions and the degree of pelvic brosis.
Several methods can be used to perform laparoscopic
Hartmann reversal. Some surgeons establish laparoscopic
access initially, perform adhesiolysis, mobilize the colon and
rectum, take down the colostomy and insert the anvil of the
end-to-end stapling device, re-establish pneumoperitoneum,
and perform the anastomosis. A more cost-eective method
is to take down the colostomy initially, perform as much of
the procedure as possible through the colostomy opening,
and then decide whether a laparoscopic technique is feasible.
A substantial amount of adhesiolysis and mobilization can
often be performed through the stoma incision, especially
if there is a parastomal hernia present that has enlarged the
fascial opening. e proximal colon can be prepared for anastomosis and the anvil of a circular stapling device inserted. If
a determination of laparoscopic feasibility can be made prior
to establishing pneumoperitoneum, it avoids the need to
open any laparoscopic instruments or struggle with fruitless
attempts at laparoscopic dissection prior to conversion. However, if it appears that laparoscopic techniques are likely to
be successful, pneumoperitoneum is then established, either
by closure of the fascia around a port or by insertion of a
hand-assist device. e size of the fascial defect will determine which method is more advantageous for the patient and
surgeon. e operation is then completed laparoscopically.
Prior to embarking on a laparoscopic reversal of a Hartmann procedure performed for diverticular disease, the surgeon should consider that it may be necessary to resect retained
194 Part II Abdominal Wall
sigmoid colon and mobilize the splenic exure to allow soft
descending colon to reach easily into the pelvis for a colorectal anastomosis. Preoperative evaluation of the proximal colon
and distal rectal stump with endoscopy and/or contrast enema
will help the surgeon plan the operative procedure and exclude
alternative diagnoses.
It is also possible to perform laparoscopic restoration of
intestinal continuity following total abdominal or subtotal
colectomy and ileostomy. e ileostomy can be taken down,
and an end-to-end anastomosis performed laparoscopically
using a surgical stapling device.
SELECTED READINGS
Arumugam PJ, Bevan L, MacDonald L, et al. A prospective audit of stomas—
analysis of risk factors and complications and their management. Colorectal
Dis. 2003;5:49–52.
Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North
Am. 1950;30:1511.
Burch J. e pre- and postoperative nursing care for patients with a stoma.
Br J Nurs. 2005;14(6):310–318.
Butcher HR Jr, Sugg WL, McAfee CA, et al. Ileal conduit method of ureteral
urinary diversion. Ann Surg. 1962;156:682.
Byers JM, Steinberg JB, Postier RG. Repair of parastomal hernias using
polypropylene mesh. Arch Surg. 1992;127:1246.
Chechile G, Klein EA, Bauer L, Novick AC, Montie JE. Functional equiva-
lence of end and loop ileal conduit stomas. J Urol. 1992;147:582.
Cheung MT. Complications of an abdominal stoma: an analysis of 322 stomas.
Aust N Z J Surg. 1995;65:808–811.
Colwell J, Goldberg MT, Carmel JE. Fecal and Urinary Diversions: Manage-
ment Principles. Mosby Publishing; St. Louis, MO. 2009.
Corman JM, Odenheimer DB. Securing the loop—historic review of the methods
used for creating a loop colostomy. Dis Colon Rectum. 1991;34:1014.
Crile G Jr, Turnbull RB Jr. Mechanism and prevention of ileostomy dysfunction.
Ann Surg. 1954;140:459.
Deol ZK, Shayani V. Laparoscopic parastomal hernia repair. Arch Surg.
2003;138:203–205.
Dinnick T. e origins and evolution of colostomy. Br J Surg. 1934;22:142.
Doughty D. Role of the enterostomal therapy nurse in ostomy patient
rehabilitation. Cancer. 1992;70(Suppl):1390.
Edwards DP, Leppington-Clarke A, et al. Stoma-related complications are
more frequent after transverse colostomy than loop ileostomy: a prospective
randomized clinical trial. Br J Surg. 2001;88:360–363.
Feinberg SM, McLeod RS, Cohen Z. Complications of loop ileostomy. Am J
Surg. 1987;153:102.
Fleshman JW, Cohen Z, McLeod RS, Stern H, Blair J. e ileal reservoir and
ileoanal anastomosis procedure: factors aecting technical and functional
outcome. Dis Colon Rectum. 1988;31:10.
Fleshman JW. Loop ileostomy. Surg Rounds. 1992;Feb:129.
Fucini C, Wol BG, Dozois RR. Bleeding from peristomal varices: perspec-
tives on prevention and treatment. Dis Colon Rectum. 1991;34:1073.
Gottlieb LM, Handelsman JC. Treatment of outow tract problems associated
with continent ileostomy (Kock pouch): report of six cases. Dis Colon Rectum.
1991;34:936.
Grundfest-Broniatowski S, Fazio V. Conservative treatment of bleeding stomal
varices. Arch Surg. 1983;118:981.
Guenaga KF, Lustosa SA, Saad SS, Saconato H, Matos D. Ileostomy or co-
lostomy for temporary decompression of colorectal anastomosis. Cochrane
Database Syst Rev. 2007;(1):CD004647.
Hasegawa H, Radley S, Morton DG, Keighley MR. Stapled versus su-
tured closure of loop ileostomy: a randomized controlled trial. Ann Surg.
2000;231:202–204.
Hampton B. Ostomies and Continent Diversions: Nursing Management. Mosby
Publishing; St. Louis, MO. 1992.
Huser N, Michalski CW, Erkan M. Systematic review and meta-analysis of
the role of defunctioning stoma in low rectal cancer surgery. Ann Surg.
2008;248(1):52–60.
Janes A, Cengiz Y, Israelsson LA. Preventing parastomal hernia with a pros-
thetic mesh. Arch Surg. 2004;139:1356–1358.
Jayaprakash A, Creed T, Stewart L. Should we monitor vitamin B
patients who have had end-ileostomy for inammatory bowel disease? Int J
Colorectal Dis. 2004;19:316–318.
Jeter KF. Perioperative teaching and counseling. Cancer. 1992; 70 (Suppl):1346.
Jeter KF. ese Special Children. A Book for Parents of Children with Colostomies,
Ileostomies, & Urostomies. Palo Alto, CA: Bull; 1982.
Kalady MF, Fields RC Klein S, Nielsen KC, Mantyh, CR, Ludwig, KA. Loop
ileostomy closure at an ambulatory surgery facility: a safe and cost-eective
alternative to routine hospitalization. Dis Colon Rectum. 2003;46:486–490.
Kaveggia FF, ompson JS Taylor RJ. Placement of an ileal loop urinary
diversion back in continuity with the intestinal tract. Surgery. 1991;110:557.
Khoo RE, Cohen MM. Laparoscopic ileostomy and colostomy. Ann Surg.
1995;221:207–208.
Kodner IJ. Colostomy and ileostomy. Clin Symp. 1978;30:1.
Kodner IJ. Colostomy. Indications, techniques for construction, and management
of complications. Semin Colon Rectal Surg. 1991;2:73.
Kodner IJ, Fry RD. Intestinal stomas: their management. In: Veidenheimer
MC, ed. Seminars in Colon & Rectal Surgery. Philadelphia, PA: WB Saunders;
1991:65.
Kodner IJ. Stoma complications. In: Fazio VW, ed. Current erapy in Colon
and Rectal Surgery. Hamilton, Ontario: BC Decker; 1989:420.
Köhler LW, Pemberton JH, Zinsmeister AR, Kelly KA. Quality of life after
proctocolectomy: a comparison of Brooke ileostomy, Kock pouch, and ileal
pouch-anal anastomosis. Gastroenterology. 1991;101:679.
Leblanc KA, Bellanger DE, Whitaker JM, Hausmann MG. Laparoscopic para-
stomal hernia repair. Hernia. 2005;9:140–144.
Leung TT, MacLean AR, Buie WD, Dixon E. Comparison of stapled versus hand-
sewn loop ileostomy closure: a meta-analysis. J Gastrointest Surg. 2008;12(5):
939–944.
Ludwig KA, Milsom JW, Garcia-Ruiz A, Fazio VW. Laparoscopic techniques
for fecal diversion. Dis Colon Rectum. 1996;39:285–288.
MacKeigan JM, Cataldo PA. Intestinal Stomas: Principles, Techniques, and
Management. St. Louis, MO: Quality Medical; 2004.
MacLeod JH. Colostomy irrigation—a transatlantic controversy. Dis Colon
Rectum. 1972;15:357.
Marcello PW, Roberts PL, Schoetz DJ Jr, Coller JA, Murray JJ, Veidenheimer
MC. Obstruction after ileal pouchanal anastomosis: a preventable complica-
tion? Dis Colon Rectum. 1993;36:1105–1111.
McLeod RS, Fazio VW. Quality of life with the continent ileostomy. World J
Surg. 1984;8:90.
McLeod RS, Lavery IC, Leatherman JR. Patient evaluation of the conventional
ileostomy. Dis Colon Rectum. 1985;28:152.
Nightingale JMD, Lennard-Jones JE, Walker ER, Farthing MJ. Oral salt supple-
ments to compensate for jejunostomy losses: comparison of sodium chloride
capsules, glucose electrolyte solution, and glucose polymer electrolyte solution.
Gut. 1992;33:759.
Oliveira L, Reissman P, Nogueras J, Wexner SD. Laparoscopic creation of sto-
mas. Surg Endosc. 1997;11:19–23.
Ortiz H, Sara MJ, Armendariz P, de Miguel M, Marti J, Chocarro C. Does the
frequency of paracolostomy hernias depend on the position of the colostomy
in the abdominal wall? Int J Colorectal Dis. 1994;9:65–67.
Pachler J, Wille-Jorgensen P. Quality of life after rectal resection for cancer,
with or without permanent colostomy. Cochrane Database Syst Rev. 2004;3:
CD004323
Parks SE, Hastings PR. Complications of colostomy closure. Am J Surg.
1985;149:672.
Pata G, D’Hoore A, Fieuws S, Penninckx F. Mortality risk analysis following
routine vs selective defunctioning stoma formation after total mesorectal
excision for rectal cancer. Colorectal Dis. 2009;11(8):797–805.
Pearl RK, Prasad ML, Orsay CP, Abcarian H, Tan AB, Melzl MT. Early local
complications from intestinal stomas. Arch Surg. 1985;120:1145.
Pearl RK, Prasad ML. End-loop stomas: the new generation of intestinal sto-
mas. Contemp Surg. 1985;27:270.
Pemberton JH, Philips SF, Ready RR, Zinsmeister AR, Beahrs OH. Quality of
life after Brooke ileostomy and ileal pouch-anal anastomosis: comparison of
performance status. Ann Surg. 1989;209:620.
Prasad ML, Abcarian H. Pearl RK. End-loop colostomy. Surg Gynecol Obstet
1984; 158:380
Prasad ML, Pearl RK, Orsay CP, Abcarian H. Rodless ileostomy. A modied
loop ileostomy. Dis Colon Rectum. 1984;27:270.
levels in
12
Chapter 9 Intestinal Stomas 195
Price AL, Rubio PA. Laparoscopic colorectal surgery: a challenge for ET
nurses. J Wound Ostomy Continence Nurs. 1994; 21:179–182.
Read TE, Salgado J, Ferraro D, Fortunato R, Caushaj PF. “Peek port”: a novel
approach to avoid conversion in laparoscopic colectomy. Surgical Endoscopy.
2009;23(3):477–481.
Remzi FH, Oncel M, Hull TL, Strong SA, Lavery IC, Fazio VW. Current indica-
tions for blow-hole colostomy:ileostomy procedure. A single center experience.
Int J Colorectal Dis. 2003;18:361–364.
Rieger N, Moore J, Hewett P, Lee S, Stephens J. Parastomal hernia repair.
Colorectal Dis. 2004;6:203–205.
Rolstad BS, Wilson G, Rothenberger DA. Sexual concerns in the patient with
an ileostomy. Dis Colon Rectum. 1983;26:170.
Rombeau JL, Wilk PJ, Turnbull RB Jr, Fazio VW. Total fecal diversion by the tem-
porary skin-level loop transverse colostomy. Dis Colon Rectum. 1978;21:223.
Rondelli F, Reboldi P, Rulli A, Matthews JB. Loop ileostomy versus loop co-
lostomy for fecal diversion after colorectal or coloanal anastomosis: a metaanalysis. Int J Colorectal Dis. 2009;24(5):479–488.
Rubin MS, Schoetz DJ Jr, Matthews B. Parastomal hernia. Is stoma relocation
superior to fascial repair? Arch Surg. 1994;129:413–418.
Saha AK, Tapping CR, Foley GT, et al. Morbidity and mortality after closure of
loop ileostomy. Colorectal Dis. 2009;11(8):866–871.
Sakai Y, Nelson H, Larson D, Maidl L, Young-Fadok T, Ilstrup D. Temporary
transverse colostomy vs loop ileostomy in diversion: a case-matched study.
Arch Surg. 2001;136:338–342.
Salvadalena, G. Incidence of complications of the stoma and peristomal skin
among individuals with colostomy, ileostomy, and urostomy: a systematic
review. J Wound Ostomy Continence Nurs. 2008;35(6):596–607.
Shabbir J, Britton DC. Stoma complications: a literature overview. Colorectal Dis.
2010;12:958.
Shemesh EI, Kodner IJ Statistics from the ostomy registry. Ostomy Quart.
1987;24:70.
Shirley F, Kodner IJ, Fry RD. Loop ileostomy: techniques and indications.
DisColon Rectum. 1984;27:382.
Soliani P, Carbognani P, Piccolo P, Sabbagh R, Cudazzo E. Colostomy plug
devices: a possible new approach to the problem of incontinence. Dis Colon
Rectum. 1992;35:969.
Stephenson ER Jr, Ilahi O, Koltun WA. Stoma creation through the stoma site:
a rapid, safe technique. Dis Colon Rectum. 1997;40:112–115.
Svaninger G, Nordgren S, Palselius IR, Fasth S, Hulten L. Sodium and potas-
sium excretion in patients with ileostomies. Eur J Surg. 1991;157:601.
Swain BT, Ellis CN Jr. Laparoscopy-assisted loop ileostomy: an acceptable
option for temporary fecal diversion after anorectal surgery. Dis Colon
Rectum. 2002;45:705–707.
ompson JS, Williams SM. Technique for revision of continent ileostomy.
Dis Colon Rectum. 1992;35:87.
Turnbull RB Jr, Weakley F, eds. Atlas of Intestinal Stomas. St. Louis, MO: CV
Mosby; 1967.
Unti JA, Abcarian H, Pearl RK, et al. Rodless end-loop stomas: seven-year
experience. Dis Colon Rectum. 1991;34:999.
Wexner SD, Taranow DA, Johansen OB, et al. Loop ileostomy is a safe option
for fecal diversion. Dis Colon Rectum. 1993;36:349.
Wiesner RH, LaRusso NF, Dozois RR, Beaver SJ. Peristomal varices after proc-
tocolectomy in patients with primary sclerosing cholangitis. Gastroenterology.
1986;90:316.
Winslet MC, Drolc Z, Allan A, Keighley MR. Assessment of the defunction-
ing eciency of the loop ileostomy. Dis Colon Rectum. 1991;34:699.
Winslet MC, Poxon V, Youngs DJ, ompson H, Keighley MR. A patho-
physiologic study of diversion proctitis. Surg Gynecol Obstet. 1993;177:57.
Young CJ, Eyers AA, Solomon MJ. Defunctioning of the anorectum: histori-
cal controlled study of laparoscopic vs. open procedures. Dis Colon Rectum.
1998;41: 190–194.
This page intentionally left blank
ABDOMINAL ABSCESS AND ENTERIC FISTULAE
Patrick S. Tawadros • Jory Simpson • Josef E. Fischer
• Ori D. Rotstein
10
ABDOMINAL ABSCESS
De nition and Etiology
Abscesses are well-de ned collections of infected purulent
material that are walled o from the rest of the peritoneal
cavity by in ammatory adhesions, loops of intestine and their
mesentery, the greater omentum, or other abdominal viscera.
Abscesses may occur in the peritoneal cavity, either within or
outside of abdominal viscera (extravisceral), as well as in the
retroperitoneum.
abscesses that usually arise in one of two situations: (1)after resolution of di use peritonitis in which a loculated area of infection persists and evolves into an abscess and (2) after perforation
of a viscus or an anastomotic breakdown that is successfully
walled o by peritoneal defense mechanisms. More than 80%
of intra-abdominal abscesses occur in the postoperative period,
the majority of which occur after pancreaticobiliary or colorectal surgery and are usually related to anastomotic dehiscence.
Occasionally, postsurgical abscesses result from infection of
an intraperitoneal hematoma that develops following surgery.
Less frequently, intra- abdominal abscesses are unassociated
with previous surgery and are usually attributable to spontaneous in ammatory processes associated with a small, localized
perforation, such as in appendicitis, diverticulitis, and Crohn’s
3,
disease.
hematogenous or lymphatic spread of bacteria to the organ.
Retroperitoneal abscesses may be caused by several mechanisms, including perforation of the gastrointestinal (GI) tract
into the retroperitoneum and hematogenous or lymphatic
spread of bacteria to retroperitoneal organs, particularly the
in amed pancreas.
4 Visceral abscesses are most commonly caused by
1
Most relevant to the surgeon are extravisceral
2,
3
Pathophysiology of Abscess Formation
After bacterial contamination of the peritoneal cavity, a
complex series of events is initiated that, under ideal circumstances, e ects complete eradication of invading bacteria.
ethree major defense mechanisms in the peritoneal cavity
are (1) mechanical clearance of bacteria via the diaphragmatic
lymphatics, (2) phagocytosis and destruction of suspended or
adherent bacteria by phagocytic cells, and (3) sequestration
and walling o of bacteria coupled with delayed clearance by
phagocytic cells.
within hours. Egress of bacteria from the peritoneal cavity via
the lymphatics is responsible for the early septic response due
to bacteremia and initiation of the innate immune response
to infection.
e initial peritoneal response to bacterial contamination is characterized by hyperemia, exudation of proteinrich uid into the peritoneal cavity, and a marked in ux
of phagocytic cells. Resident peritoneal macrophages predominate early in the infection, but the rapid in ux of
neutrophils after a 2- to 4-hour delay makes them the predominant phagocytic cell in the peritoneal cavity for the
rst 48–72 hours.
cells plus the in uxing into the peritoneum serves to propagate the initiation of the innate immune response, including
the elaboration of in ammatory cytokines and the procoagulant response. In humans with severe intra-abdominal
infection, peritoneal levels of tumor necrosis factor-alpha
(TNF-α), interleukin (IL)-1, and IL-6 are higher than levels measured simultaneously in plasma.
leagues reported that TNF-α and IL-10 levels are increased
and reach 100- to 1000-fold that is observed in the plasma
following appendiceal perforation. In adult patients, a correlation between the magnitude of the cytokine response
and outcome in infected patients has been demonstrated in
several clinical studies.
and IL-6 have been recorded in patients who later die with
intra-abdominal infection.
neal persist even after systemic in ammatory response has
abated. is suggests that during resolving peritonitis, there
is compartmentalization of the response with local cytokine
elaboration, thereby promoting local resolution of infection. Other cell types are likely important in the initiation
of the local peritoneal response. Peritoneal mast cells and
5
e rst two mechanisms act rapidly, usually
6
e combination of resident peritoneal
7,
8 Haecker and col-
9
Higher levels of circulating TNF-α
7
Interestingly, elevated perito-
197
198 Part II Abdominal Wall
mesothelial lining cells have also been shown to be potent
producers of a range of cytokines and procoagulants. Fibrin
deposition appears to play an important role in this compartmentalization of infection, not only by incorporating
10
large numbers of bacteria within its interstices
but also
by causing loops of intestine to adhere to each other and
the omentum, thereby creating a physical barrier against
dissemination. Fibrin deposition is initiated after the exudation of protein-rich uid containing brinogen into the
peritoneal cavity. e conversion of brinogen to brin
is promoted by the elaboration of tissue factor by both
mesothelial cells and stimulated peritoneal macrophages.
11
In addition, generation of other inammatory mediator
molecules and components of the complement cascade (eg,
C3a and C5a) further promotes the development of local
inammation. e net eect of these responses is the localization of the bacterial infection in the peritoneal cavity,
wherein ultimate resolution can occur. However, a number
of local factors thwart complete resolution and presumably establish the local environment for persistent infection
and hence abscess formation. ese include regional brin
deposition that impedes phagocytic cell migration, factors
that inhibit phagocytic cell function such as hemoglobin,
particulate stool, low pH, and hypoxia. On the microbial side, polymicrobial ora of these infections as well as
the near ubiquitous presence of Bacteroides fragilis and its
unique capsular polysaccharide have been implicated in
persistence of infection and abscess formation. Considered
together, while the process of abscess formation represents
a successful outcome of the peritoneal response to bacterial
contamination of the peritoneal cavity, one is left with a
residual infection that carries with it morbidity and potential mortality and must be actively managed.
Clinical Presentation and Diagnosis
CLINICAL PRESENTATION
Diagnosis of an intra-abdominal abscess is based on clinical
suspicion complemented by radiologic conrmation of
the presence of the abscess. High spiking fevers, chills,
tachycardia, tachypnea, and leukocytosis, associated with
localized abdominal pain, anorexia, and delay in return of
bowel function in the postoperative patient are the classic
signs and symptoms associated with the presence of an intraabdominal abscess. e presence of a well-localized tender
mass on clinical examination is consistent with the presence
of an abscess. However, there may be considerable variability in the clinical appearance of the patient with this infection, ranging from a relatively mild picture where the patient
appears generally well but is “slow to recover” from his surgical procedure to those who manifest evidence of profound
systemic inammation. ere may be no mass palpable on
clinical examination. A number of factors may contribute
to this variability, including patient factors such as age,
immunocompetence, and concurrent use of antimicrobials,
aswellas abscess factors such location and size of the abscess
and how well walled o the abscess is. For example, subphrenic abscesses can present with vague upper quadrant
abdominal pain, referred shoulder pain, and occasionally
hiccoughs but with no localized abdominal tenderness or
palpable mass. By contrast, paracolic abscesses present with
localized tenderness and may manifest as a palpable mass on
abdominal examination. Pelvic abscesses may also cause local
irritation of the urinary bladder causing frequency, or of the
rectum resulting in diarrhea and tenesmus. Retroperitoneal
collections, particularly psoas abscesses, can manifest as leg
and back pain with muscular spasm and exion deformity
of the hip. In reality, with the ready availability of computed
tomography (CT) scanning in most institutions, almost any
deviation from the normal recovery trajectory in the postoperative period will prompt a CT scan and possible early
detection of the abscess.
DIAGNOSTIC TESTS
Imaging provides the denitive evidence of the presence of an
intra-abdominal abscess. Abdominal plain lms can be helpful in identifying air-uid levels in the upright or decubitus
positions, extraluminal gas, or a soft tissue mass displacing the
bowel. In the postoperative patient, however, extraluminal gas
may be present for up to 7 days. Overall, plain radiography
may suggest the presence of an abscess, but other imaging
modalities have essentially replaced plain lms in the evaluation of intra-abdominal abscesses.
CT scanning has emerged as the radiological investigation
of choice in the diagnosis of intra-abdominal abscess.
its ready availability, it has essentially supplanted abdominal
ultrasound (US) as the main diagnostic tool in this setting,
mainly because of its accuracy, but also because its functionality is not impaired in the setting of ileus, wound dressings,
stomas, and the open abdomen. e accuracy of the scan is
improved if contrast is used. IV contrast increases the accuracy of dening the presence of an abscess, while GI tract
contrast helps to distinguish uid-lled bowel loops from an
abscess and in addition may detect the presence of an anastomotic leak. In a retrospective study that compared US and
CT in diagnosing intra-abdominal abscesses, the sensitivity of
US in 123 patients was 82% compared to 97% in 74 patients
by CT, and the overall accuracy of US was found to be 90%
13
versus 96% for CT.
Criteria for identication of an abscess
by CT have been well described and include identication
of an area of low CT attenuation in an extraluminal location
or within the parenchyma of solid abdominal organs. e
density of abscesses usually falls between that of water and
14
solid tissue.
Other radiological signs of an abscess are mass
eect that replaces or displaces normal anatomic structures,
a lucent center that is not enhanced after the intravenous
administration of a contrast medium, enhancing rim around
the lucent center after IV contrast administration, and gas
in the uid collection. One of the major advantages of CT
over US is the ability to detect abscesses in the retroperitoneum and pancreatic area. ere are also some disadvantages
12
With
Chapter 10 Abdominal Abscess and Enteric Fistulae 199
to CTscanning. In the absence of contrast rim enhancement,
gas or visible septations, CT cannot distinguish between sterile and infected uid collections. Occasionally, there may be a
solid-appearing collection that is really an abscess with a high
leukocyte and protein content. Septations and other signs
of loculated abscesses can often be better visualized with US
than CT. Finally, CT scanning is sometimes unable to di erentiate between subphrenic and pulmonic uid, a relatively
15
common situation in abdominal surgery.
In these limited
circumstances, US may be considered as a complement to
CT imaging.
Other modalities include magnetic resonance imaging
(MRI). While MRI can sometimes better delineate the extent
of an abscess, particularly in relation to adjacent soft tissue
structures such as muscles and major blood vessels, it does not
clearly have advantages over CT scanning and its practicality
16
may be limited in the sick surgical patient.
One area where
US and MRI may be relevant is in the investigation of the
17
pregnant patient with abdominal pain.
US is particularly
useful when appendicitis/appendiceal abscess is suspected, and
of radiolabelled compounds in the diagnosis of abdominal
18
abscesses are limited at present.
Management
e basic principles underlying the successful treatment of
intra-abdominal abscesses are threefold:
1. Adequate resuscitation and support
2. Antimicrobial therapy
3. Source control/abscess drainage
ANTIMICROBIAL THERAPY
Considerations regarding antimicrobial use are based on the
microbial ora recovered from the infections. Over the past
decade, there has been increasing appreciation that there is an
evolution of the ora with increasing severity of abdominal
20
infection.
For example, Table 10-1 shows the bacteriology of peritonitis in patients with community-acquired
peritonitis and those with postoperative peritonitis. e
major pathogens in community-acquired intra-abdominal
infections are coliforms (esp. Escherichia coli ) and anaerobes
(esp. B. fragilis ). As illustrated, while both are polymicro-
bial, postoperative peritonitis has a higher incidence of more
resistant microbes. Aside from patients with postoperative
peritonitis, other factors predict this shift in microbiology,
including advanced age, severe physiologic derangement,
immunosuppression, previous use of antibiotics, and residence in a health care institution in hospitals and nursing
homes, etc. Guidelines have been developed recently by the
Surgical Infection Society and the Infectious Diseases Society of America regarding the use of antimicrobial therapy
21
in intra-abdominal infection.
ese authors have riskstrati ed patients into three categories and provided recommendations for empiric antimicrobial regimens according to
category. e three categories are (1) community-acquired
infections of mild to moderate severity; (2) high-risk or
severe community-acquired infections; and (3) health care–
associated infections. Factors that dictate conversion from
mild-to-moderate severity to high severity include severe
physiologic derangement (eg, high Acute Physiology and
Chronic Health Evaluation II [APACHE II] score), advanced
RESUSCITATION AND SUPPORT
In keeping with the variable presentation of patients with
intra-abdominal abscesses, the initial approach to resuscitation and support will vary considerably. Attention to
the ABCs (airway, breathing, circulation) while individualizing the intervention for each patient according to his/
her deviation from normal physiology is appropriate.
Particularly in the postsurgical patient, nutritional support should be considered. When feasible, oral nutrition
should be given in preference to total parenteral nutrition.
Some patients are able to ingest food and/or supplements
by mouth, while others might require an enteral feeding
tube, due to anorexia, precluding adequate ingestion of
nutrients. Systematic review of the literature suggests that
infectious complications and cost are reduced in critically ill
patients receiving enteral nutrition compared to parenteral
19
nutrition.
One can presumably extrapolate to patients
with intra-abdominal infection. When abscess formation
occurs due to an anastomotic leak, there is a sense that this
might preclude use of enteral nutrition. is concern is
likely unfounded, unless there is profound ileus associated
with the infection.
TABLE 10-1: MICROBIOLOGY OF
COMMUNITY-ACQUIRED PERITONITIS
COMPARED TO HEALTH CARE–ASSOCIATED
PERITONITIS
Percent of Isolates of
Strain
Enterococci 5 21
Escherichia coli 36 19
Enterobacter sp 3 12
Bacteroides sp 10 7
Klebsiella sp 7 7
Staphylococcus aureus 1 6
Coagulase-negative staph 1 5
Candida 7 4
Pseudomonas sp 2 6
Streptococci 14 4
Hemolytic strep 3 0
Other 11 9
From Roehrborn A, omas L, Potreck O, et al. e microbiology of
postoperative peritonitis. Clin Infect Dis . 2001;33:1513.
CommunityAcquired
Postoperative
(Health Care–
Associated)
200 Part II Abdominal Wall
TABLE 10-2: RECOMMENDATIONS FOR ANTIMICROBIAL THERAPY
IN THE COMMUNITY-ACQUIRED SETTING
Community-Acquired Infection in Adults
Mild-to-Moderate Severity:
Perforated or Abscessed
Appendicitis and Other
Infections of Mild-toModerate Severity
Regimen
Community-Acquired Infection in
Pediatric Patients
High Risk or Severity: Severe
Physiologic Disturbance, Advanced
Age, or Immunocompromised State
Single agent Ertapenem, meropenem, imipenem-
cilastatin, ticarcillin-clavulanate, and
piperacillin-tazobactam
Combination Ceftriaxone, cefotaxime, cefepime, or
ceftazidime, each in combination with
metronidazole; gentamicin or tobramycin,
each in combination with metronidazole or
clindamycin, and with or without ampicillin
a Because of increasing resistance of Escherichia coli to uoroquinolonoes, local population susceptibility pro les and, if available, isolate susceptibility should be reviewed.
From Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical
Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133, with permission.
age, or immunocompromised state. Table 10-2 shows
the recommended agents according to this strati cation.
ese guidelines are therefore readily applicable to decision
making regarding patients coming into the hospital with
abscesses, including processes such as appendiceal abscess or
peridiverticular abscess. It is noteworthy that while enterococcus is frequently recovered in isolates in these infections,
the evidence demonstrates no additional bene t to treating
this microbe as part of empiric therapy. When possible, switchover to oral agents is appropriate. e duration of antibiotics should be 4–7 days, anticipating resolution of the
clinical signs and symptoms during this period. Should there
be no resolution by this time, reevaluation of the patient for
the presence of persistent infection in the abdomen and elsewhere is appropriate.
Patients who present in the postsurgical period fall into
the category of patients with health care–associated infection.
In these patients, empiric therapy should include agents with
expanded spectra against gram-negative aerobic and facultative
bacilli, including meropenem, imipenem-cilastatin, doripenem,
piperacillin-tazobactam, or ceftazidime or cefepime in combination with metronidazole. Table 10-3 shows the considerations
regarding selection depending on local institutional microbial
isolates. Empiric anti-enterococcal treatment should be given.
Treatment of Candida with uconazole when recovered from
cultures and treatment of methicillin-resistant Staphylococcus
aureus with vancomycin should be followed if the patient is
colonized with the microbe.
Cefoxitin, ertapenem, moxi oxacin,
tigecycline, and ticarcillin-clavulanic
acid
Cefazolin, cefuroxime, ceftriaxone,
cefotaxime, cipro oxacin, or
levo ox acin, each in combination
with metronidazole
a
discussion to abscess drainage, but adequate source control
may also include debridement of necrotic tissue, surgical
repair, resection, and/or exteriorization of the anatomic defect
causing peritoneal contamination.
Over the past two decades, percutaneous drainage of
abscesses has become an established technique and a safe
alternative to surgery. is evolution of care has not been
based on a series of strong randomized trials showing equivalence or superiority of this approach. Rather, observational
studies from a number of centers have shown it to be a safe
e ective alternative to surgical intervention, with equivalent success rates, comparable mortality (10–20%) and
morbidity (~25%).
of percutaneous approaches including avoidance of general
anesthesia, lower costs, and the potential for fewer complications, it has now become the default approach to abscess
management. Prerequisites for catheter drainage include an
anatomically safe route to the abscess, a well-de ned unilocular abscess cavity, concurring surgical and radiologic
evaluation, and surgical backup for technical failure. Multiple abscesses, abscesses with enteric connections as seen
with enterocutaneous stulas, and the need to traverse solid
viscera are not contraindications. Indeed, as the technique
has evolved over several decades, the barriers to accessing
unusually positioned collections have disappeared with the
use of unconventional routes (transgluteal, transvaginal,
transrectal) and the advent of new technologies including
26,
endoscopic US.
27 Even the presence of septations and
Imipenem-cilastatin, meropenem,
doripenem, and piperacillin-tazobactam
Cefepime, ceftazidime, cipro oxacin, or
levo oxacin, each in combination with
metronidazole
23–25
Combined with other advantages
a
22
loculations has not precluded at least an attempt to use per-
28
SOURCE CONTROL
Source control is a term used to include all physical measures
taken to control a focus of infection. Here we focus our
cutaneous drainage.
Percutaneous drainage can be performed with US or CTguidance. CT provides for more precise identi cation of organsand
bowel loops and is more accurate for planning of drainageroute.
15
Chapter 10 Abdominal Abscess and Enteric Fistulae 201
TABLE 10-3: RECOMMENDATIONS FOR ALTERATIONS IN ANTIMICROBIAL THERAPY IN
THE HEALTH CARE–ASSOCIATED SETTING
Regimen
Organisms Seen in
Health Care–associated
Infection at the Local
Institution Carbapenem
<20% Resistant Pseudomonas
aeruginosa, ESBL-producing
Enterobacteriaceae,
Acneobacter, or other MDR
GNB
ESBL-producing
Entorobacteriaceae
P. aeruginosa >20% resistant
to ceftazidime
MRSA Not recommended Not recommended Not recommended Not recommended Recommended
ESBL, extended-spectrum β-1actamase; GNB, gram-negative bacilli: MDR, multidrug resistant; MRSA, methicillin-resistant Staophylococcus aureus.
NOTE . “Recommended” indicates that the listed agent or class is recommended for empiric use, before culture and susceptibility data are available, at institutions that
encounter these isolates from other health care–associated infections. ese may be unit-or hospital-speci c.
a
Imipenem-cilastatin, meropenem, or doripenem
Reproduced from Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the
Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis . 2010;50:133, with permission.
Recommended Recommended Recommemded Not recommended Not recommended
Recommended Recommended Not recommended Recommended Not recommended
Recommended Recommended Not recommended Recommended Not recommended
Piperacillin-
a
Tazobactam
Once the abscess is identi ed, initial diagnostic aspiration should
be sent for Gram’s stain and microbiological culture. e catheter used for drainage should be as small as possible for safety,
yet large enough so that the tubing does not become obstructed.
Most commonly used catheters range in size from 8 to 12F.
With appropriate catheter placement, the abscess cavity typically
decompresses and collapses. Irrigation of the catheter should be
done once daily to ensure tube patency. As catheter drainage
decreases, repeat CT scanning can be performed to evaluate for
residual contents. If drainage increases over time or continues at
a steady rate, the development of an enteric stula must be suspected. is may not have been unexpected when the catheter
was initially placed near a perianastomotic abscess or an abscess
adjacent to some underlying pathological process. Potential
complications of catheter placement include bacteremia, sepsis,
vascular injury, enteric puncture, cutaneous stula, or transpleural catheter placement.
Catheters should be maintained on closed drainage systems. ere does not appear to be bene t to the use of suction
or irrigation of these catheters, although ushing once per
day with saline ensures patency. Patients should respond with
defervesce of symptoms within 48 hours of catheter insertion.
If they do so, a repeat CT scan is done at approximately 5–7
days to ensure shrinkage of the abscess. Criteria for removal
of the drain include (1) clinical resolution of septic parameters, including patient well-being, normal temperature, and
leukocyte count; (2) minimal drainage from the catheter; and
(3) CT evidence of the resolution of the absence.
As noted previously, studies comparing outcomes of surgical and percutaneous drainage of intra-abdominal abscesses
Ceftazidime
or Cefepime,
Each With
Metronidazole Aminoglycoside Vancomycin
demonstrate comparable e cacy. In one study, patients were
matched for age, abscess location, and etiology, and had similar
APACHE II scores. ere were no di erences between percutaneous and surgical drainage in patient morbidity, mortality,
24
or duration of hospital stay.
Furthermore, initial percutaneous drainage of abscesses in the context of diverticular disease
allowed for subsequent de nitive operative resection and primary anastomosis in one rather than two operations. Another
group retrospectively examined postoperative intra-abdominal
abscesses after laparotomy. is study similarly demonstrated
that use of either form of drainage resulted in similar cure rates
25
for postoperative intra- abdominal abscesses.
With clear demonstration of its e cacy when compared
to surgical drainage, percutaneous drainage should be considered the preferred approach in source control of abscesses.
Table 10-4 shows outcome of percutaneous drainage according to underlying pathological processes. In general, one
should predict a successful outcome in patients with a single,
well-de ned abscess with no enteric communication. e
presence of enteric communication per se does not reduce
the likelihood of success as it is de ned by the resolution
of the infection. In a postoperative abscess, following drainage of the infection, the underlying anastomotic defect will
usually close. In other settings, there may be a requirement
for subsequent surgery to manage the underlying disease
process such as diverticular disease or Crohn’s disease. For
example, in one study, approximately 75% of patients with
large peridiverticular abscesses were drained percutaneously
and then they went on to a single-stage sigmoid colectomy.
Other circumstances such as fungal abscesses, infected
28