EP.TU.260Retained appendiceal tip and abdominal wall appendicolith - a rare combination of post appendicectomy complications

Appendicitis involving the appendix stump is a recognised post appendicectomy complication but the same involving the appendiceal tip is rare. Similarly, abdominal wall abscess secondary to retained appendicolith is also infrequently encountered. Our case highlights a rare combination of both complications arising separately. An 29 year-old man presented with 3 days of generalised malaise and progressively worsening right iliac fossa pain some ten months after a laparoscopic appendicectomy. This had been complicated by residual right iliac fossa inflammation that was treated conservatively and serial scans demonstrated gradually resolving inflammation. He also had well controlled ulcerative colitis. On examination, he was noted to be pyrexial with a tender fluctuant mass in the right flank. An ultrasound scan demonstrated inflammatory changes in the abdominal wall with no intra-abdominal collections. A diagnostic laparoscopy found an inflamed appendix tip, attached to the residual mesoappendix and embedded in the abdominal wall behind the mid-ascending colon. A completion appendicectomy was performed. The patient recovered well but returned 4 months later with persistent pain and a fluctuant mass over the right iliac fossa. Radiological investigation revealed an abdominal wall collection containing a calcified appendicolith. The collection was refractory to ultrasound guided drainage and an exploration of the abdominal wall allowed extraction of the appendicolith followed by symptomatic relief. This case emphasizes the importance of complete excision of the appendix and extraction of debris, which can be challenging when the appendix lies in a retro-colic position.

956 Retained Appendiceal Tip and Abdominal Wall Appendicolith - A Rare Combination of Post Appendicectomy Complications

Appendicitis involving the appendix stump is a recognised post appendicectomy complication but the same involving the appendiceal tip is rare. Similarly, abdominal wall abscess secondary to retained appendicolith is also infrequently encountered. Our case highlights a rare combination of both complications arising separately. A 29-year-old man presented with 3 days of generalised malaise and progressively worsening right iliac fossa pain some ten months after a laparoscopic appendicectomy. This had been complicated by residual right iliac fossa inflammation that was treated conservatively and serial scans demonstrated gradually resolving inflammation. He also had well controlled ulcerative colitis. On examination, he was noted to be pyrexial with a tender fluctuant mass in the right flank. An ultrasound scan demonstrated inflammatory changes in the abdominal wall with no intra-abdominal collections. A diagnostic laparoscopy found an inflamed appendix tip, attached to the residual mesoappendix and embedded in the abdominal wall behind the mid-ascending colon. A completion appendicectomy was performed. The patient recovered well but returned 4 months later with persistent pain and a fluctuant mass over the right iliac fossa. Radiological investigation revealed an abdominal wall collection containing a calcified appendicolith. The collection was refractory to ultrasound guided drainage and an exploration of the abdominal wall allowed extraction of the appendicolith followed by symptomatic relief. This case emphasizes the importance of complete excision of the appendix and extraction of debris, which can be challenging when the appendix lies in a retro-colic position.

634 Case Report: Large Perforating Ileal Conduit Stone as A Rare Cause of Abdominal Wall Abscess

Introduction Ileal conduits are common following cystectomy for benign or malignant disease of the bladder. They are associated with late complications such as parastomal hernias, strictures, infections and rarely conduit stone formation. We present a previously unreported case of a significant abdominal wall abscess secondary to a very large perforating conduit stone. Case Report A 59-year-old female with an established ileal conduit due to multiple sclerosis presented acutely with abdominal pain, peristomal mass and fever. A CT showed a large (40mm) calcification with a fluid collection adjacent to the conduit in the subcutaneous tissues. Emergency incision and drainage of the abscess revealed a large abscess cavity containing a stone. Conduitoscopy demonstrated a narrow stoma and a perforation between the abscess cavity and the lumen of the conduit suggesting extrusion of the stone through an eroded area in the wall of the conduit. A Foley catheter was inserted to bypass the perforation. The patient recovered well after the procedure with the addition of antibiotics. Subsequent conduitoscopy showed closure of the perforation with these measures. Conclusions Conduit stones are rare but have the potential to perforate the urinary conduit. We believe that the subcutaneous location of the perforation allowed it to go unnoticed and the stone to achieve a significant size before acting as a nidus for infection. A more proximal perforation would likely result in an intraperitoneal urine leak and earlier presentation with an acute abdomen.

Spontaneous rupture of pyonephrosis presenting as anterior abdominal wall abscess: a rare case report

Background A pyonephrosis caused by an obstructing calculus is typically accompanied by fever, loin pain, and other signs of urinary tract infection. Occasionally, severe thinning of the renal parenchyma in pyonephrosis allows direct forniceal rupture into the retroperitoneum and very rarely into the anterior abdominal wall, misconstruing it as an isolated abdominal wall abscess. Case presentation Diabetes-related 55-year-old diabetic male presented with abscess in his periumbilical region extending into right lumbar region. He did not exhibit any urinary symptoms, and contrast enhanced computed tomography [CECT] abdominal and pelvic examinations revealed right pelvic calculus with pyonephrosis. There is a 7.5 mm defect in the lower pole of the right kidney with 171 cc of collection adjacent to the kidney communicating with 150 cc of superficial abdominal wall collection through a 15 mm defect. Incision and drainage of abdominal and retroperitoneal abscesses were done at first. Right DJ stenting was performed. Right lateral decubitus was placed for dependent drainage. Resolution of residual collections was confirmed by subsequent ultrasonography KUB, and drain was then removed. Right DJ stenting done, and patient was discharged. Two months later, DTPA scan done and revealed GFR of 30 ml/min of right kidney. Patient underwent right percutaneous nephrolithotomy. Conclusion The sudden rupture of pyonephrosis is a rare event. Even rarer is the presentation of pyonephrosis as an abscess on the anterior abdominal wall. The correct diagnosis and search for the source of the abscess must be undertaken before intervention. An aggressive and prompt management is needed to prevent further complications from occurring. This case is being presented to add to the literature with regard to abnormal presentations of ruptured pyonephrosis and its management.

Anterior abdominal wall abscess secondary to spontaneous rupture of liver abscess in a resource-limited, rural, surgical setting: A case report

Liver abscess continues to be a major surgical burden in low and mid-low-income countries like India. Spontaneous rupture into the anterior abdominal wall is an uncommon presentation of pyogenic liver abscess. A 53-year-old diabetic lady with a past history of laparoscopic cholecystectomy presented with acute pain in the right upper quadrant. On examination, she had an anterior abdominal wall abscess with tender hepatomegaly. On further evaluation with ultrasonography and plain computed tomography, a diagnosis of liver abscess in the right lobe with rupture into the anterior abdominal wall was made. She was treated successfully in a tribal secondary care hospital with USG guided aspiration followed by surgical drainage under local anesthesia. This case report highlights that a considerable number of patients with liver abscess and its complications can be appropriately managed in resource-limited rural surgical centers. The patient’s clinical presentation, investigations, and management have been discussed with a relevant review of the literature.

Unusual Abdominal Wall Abscess Post-Laparoscopic Cholecystectomy

Cholecystectomy is the most commonly performed operation worldwide nowadays. Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. We present a case of an 81-year-old male with a 3-months’ history of loss of appetite and weight with no associated symptoms. The patient had undergone an LC for symptomatic cholelithiasis 1 year previously, with an uneventful recovery. The clinical examination was essentially normal. A computed tomography (CT) of the abdomen and pelvis showed thickening of the right perihepatic peritoneum measuring 15 × 15 × 3.5 cm, suggestive of chronic granulomatous lesion or atypical mesothelioma. We performed a diagnostic laparoscopy and found the lesion to be an abdominal wall abscess. The abscess cavity was deroofed, the pus was drained and a thorough wash out given. Surprisingly no stones or any foreign body were found in the cavity. Histology of the abscess wall showed non-specific inflammation. We report this case as a post-LC abdominal wall abscess with two peculiar features – (a) no systemic or local symptoms, and (b) no association with spilt gallstones or other foreign bodies like sutures.

Sepsis Due to Port-Site Abscess in Laparoscopic Pelvic Lymphadenectomy: A Case Report

Port-site infection is one of the most frequent complications in gynaecological laparoscopy. We present a rare case of port-site infection complicated by an abdominal wall abscess and sepsis. We conduct a literature review and discuss the difficulties of diagnosis and the management of this clinical situation.

697 An Evaluation of Patient Outcomes Following Percutaneous Cholecystostomy (PC) For Acute Cholecystitis (AC) At Our Health Board Between 2011-2020

Introduction PC is a radiological intervention used in the management of high-risk patients with AC. Method A retrospective study of outcomes following PC, including success rates, complications, AC resolution, readmissions, and subsequent cholecystectomy. Results Our database identified 28 patients (14M:14F), median age 73 (range 40-93). 82% were ASA III/IV. Median follow-up was 2 (range 0-8) years. Imaging suggested AC in 61% and empyema in 39%. 86% were calculous. All procedures were USS-guided with 100% success. AC resolution occurred in 89.3%. Of three unresolved, there was 1 death day-1 post-PC (non-procedure related), 1 index cholecystectomy, 1 chronic complicated cholecystitis. 28.6% developed complications, 2 major (1 late biliary peritonitis and 1 cholecystocutaneous fistula with abdominal wall abscess), 17.9% dislodged drain, 10.7% other. 20 patients had bile cultures (70% positive, mainly gram-negative). 17.9% patients were readmitted with AC, 1 had repeat PC. 21.4% had subsequent ERCP. 32.1% underwent subsequent cholecystectomy, 1 laparoscopic cholecystectomy(LC) index, 4 elective (3 LC, 1 open), 4 emergency (2 LC, 1 LC subtotal, 1 failed open with drain insertion). Conclusions PC is both safe and effective with significant procedural success rates and resolution rates. There are few major complications but significant morbidities, mainly dislodged drains. One-third of patients have subsequent cholecystectomy.