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We analyzed the serum zinc levels of 37 patients with 40 phlegmon lesions. The mean serum zinc level was 52.1 ± 16.4 μg/dL. The serum zinc level was negatively correlated with the C-reactive protein (CRP) level (r = -0.66) and white blood cell (WBC) count (r = -0.56). It was also positively correlated with the serum levels of albumin, hemoglobin, and hematocrit (r = 0.57, 0.50, and 0.50, respectively). Patients with serum zinc levels of60 μg/dL had higher CRP levels and WBC counts (p 0.005 and p 0.05, respectively) and lower albumin, hemoglobin, and hematocrit levels (p 0.001, p 0.01, and p 0.01, respectively), and were more likely to be hospitalized (p 0.05) than those with serum zinc levels of ≥60 μg/dL. Patients with low serum zinc levels were given zinc tablets. Three of the seven patients who developed recurrent phlegmons did not develop any further lesions after taking zinc tablets for10 months. Of the remaining patients, one only developed a minimal lesion, and another two experienced recurrence twice but did not have any further lesions for 10 and 15 months, respectively. These findings indicate that in patients with phlegmons the serum zinc level is a suitable marker of the severity of infection, and zinc supplementation reduces the risk of further recurrence in patients whose lesions relapse.

Objective To evaluate whether outpatient treatment of periorbital cellulitis with daily administration of intravenous antibiotics and physician evaluation is an effective and safe alternative to admission. Design A retrospective chart review study of paediatric patients treated on an outpatient basis for periorbital cellulitis at a tertiary children's hospital between 2013 and 2015 was performed. Children were assessed day by a paediatrician to monitor for resolution of symptoms or complications. Setting The Montreal Children's hospital, a tertiary care centre. Participants Children diagnosed with an uncomplicated periorbital cellulitis secondary to an acute sinusitis or upper respiratory tract infection. Main outcome measures The number of days of intravenous antibiotics, complications or need for subsequent admission. Complications were defined as formation of an abscess or phlegmon confirmed on computerised tomography scan, worsening or recurrent persistent cellulitis, failure to improve on intravenous antibiotics, and intracranial complications. Results Sixty-six children with a diagnosis of uncomplicated periorbital cellulitis secondary to sinusitis who received intravenous antibiotics via medical day hospital and who fit the inclusion criteria were identified. The mean duration of intravenous antibiotic therapy was 4.1 days. All children received ceftriaxone, with one patient also receiving cefuroxime. Two of 66 patients developed complications; one patient required admission for failure to improve/subperiosteal phlegmon and later underwent functional endoscopic sinus surgery, and one patient developed an eyelid abscess that did not require admission. No patients developed severe neurological or visual deficits. Conclusions Outpatient intravenous therapy with daily reassessment by a physician may be a safe alternative to admission in select cases of periorbital cellulitis without systemic signs of illness.

A four-year-old female brown bear (Ursus arctos) was immobilised via blowpipe targeting the right hind limb to perform a chemical contraception. Few days after anaesthesia, the animal developed lameness and a reduced general condition, and died 1 week after immobilisation when alopecia and swelling of the injection area were observed for the first time. Besides a severe azotaemia, alopecia and reddening of the craniomedial skin, subcutis and skeletal muscles of the entire right hind limb showed a phlegmon, oedema and haemorrhage. Additional widespread haemorrhages were found. Histology revealed a suppurative and necrohaemorrhagic myositis of the affected limb, a suppurative iliofemoral lymphadenitis, blood resorption in the mesenteric lymph nodes and haemorrhage in the adrenal gland cortex. Microbiological investigation revealed high amounts of Escherichia coli, Streptococcus dysgalactiae and Clostridium septicum in skin, musculature, heart, lung, liver and spleen, indicating septicaemia, which led to death due to toxaemic shock.

Introduction Transverse colon resection is one of the most difficult laparoscopic procedures because of anatomic hazards such as variations in the mesenteric vascular anatomy and the complex structure of organs and surrounding membranes. Methods We evaluated the short-term surgical outcomes of laparoscopic transverse colon resection using a creative approach. This approach included preoperative surgical simulation using virtual surgical anatomy by CT, a four-directional approach to the mesentery, and 3-D imaging during laparoscopic surgery. Results A total of 45 consecutive patients who underwent laparoscopic resection for transverse colon cancer from June 2013 to December 2017 were enrolled in this study. All procedures were completed safely, with minor postoperative complications, including two patients with anastomotic stenosis, two with intra-abdominal phlegmon, one with delayed gastric emptying, and one with pneumonia, all treated non-operatively. There were no conversions to open resection. Operation time was 203 min (range, 125-322 min), and the estimated blood loss during surgery was 5 mL (range, 0-370 mL). The mean postoperative hospital stay was 10 days (range, 7-21 days), and no patients required readmission. Conclusion Short-term surgical outcomes after laparoscopic transverse colon resection demonstrated that this creative approach was safe and feasible. The four-directional approach to the meso-transverse attachment combined with preoperative radiological simulation can facilitate laparoscopic transverse colon surgery.

Objectives 1) To analyze clinical outcomes of children stratified by ultrasound into three diagnoses: acute tonsillitis, peritonsillar phlegmon, and abscess; and 2) To compare clinical outcomes and financial impact between children who underwent ultrasound protocol to those who did not. Study Design Retrospective analysis between two cohorts: ultrasound protocol group and control group. Methods Children with peritonsillar abscess (PTA) diagnosed in the emergency department (ED) were enrolled during a 2-year period for transcervical ultrasound evaluation of bilateral tonsillar fossae. Data from a cohort of patients with PTA prior to ultrasound screening were also collected from retrospective chart review. Outcome variables were analyzed using multivariate logistic regression. Results Seventy-eight children (mean 12.3 years) were enrolled in the ultrasound protocol, compared to 101 children (mean 13.6 years) evaluated using traditional methods of examination and/or computed tomography (CT) imaging. Demographics between the two groups were not significantly different. Only one-third of patients presumed to have PTA by ED staff had ultrasound findings consistent with abscess. Overall treatment failure rate was 8%, requiring readmission or surgical intervention for abscess. Length of stay, surgical drainage, and radiation exposure from CT scans were reduced significantly in the ultrasound group (P < 0.006). Differences in readmission rates and mean charges between the two groups did not reach significance. Conclusion Peritonsillar abscess is a common infection in the pediatric population, but diagnosis can be challenging. Transcervical ultrasound is a safe, cost-effective, and accurate modality to help stratify patients into medical and surgical treatment arms. Level of Evidence 3b. Laryngoscope, 2017

Summary Suppurative infections are typically caused by pyogenic bacteria, and are characterised by the formation of purulent exudates (pus). These infections may occur anywhere in the body and are particularly life-threatening when pertaining to the central nervous system (CNS). Suppurative infections of the CNS may be due to trauma, local extension of disease, and haematogenous spread. In horses, suppurative infections are an important cause of morbidity and mortality, but only infrequently involve the CNS. The gross morphology of suppurative inflammation is described as phlegmon, abscess and empyema, with each form having characteristic morphological features that may be identified during advanced imaging of the CNS. In horses with known or suspected suppurative infection of the CNS, imaging may be performed to reduce diagnostic uncertainty, determine prognosis, or to describe the character and extent of the disease to guide case management.

Background Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial. Objectives To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality. Search methods We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials. Selection criteria We included all individual and cluster-randomised controlled trials, irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess. Data collection and analysis Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Main results We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmon Forty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess Forty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD −0.20 days; 95% CI −3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities. Authors' conclusions It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy. Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities, quality of life and the length of hospital stay.

Background The aim of this study was to assess outcomes of medical and surgical treatment of intratonsillar abscess in children. Methods The medical charts of children with intratonsillar abscess were reviewed to obtain information on history and physical examination, imaging, management, and follow-up assessment. Results Eleven children (six male, five female; age range, 4–18 years) were identified. The common complaints included sore throat, fever, and odynophagia. Asymmetric tonsil hypertrophy was present in nine patients and erythema of tonsils in all patients. Peritonsillar fullness was present in three patients. One patient needed emergency intubation due to respiratory compromise. Computed tomography indicated unilateral intratonsillar abscess in nine patients, bilateral intratonsillar abscess in one, and unilateral phlegmon in one. Inflammatory changes were observed in the parapharyngeal space in all patients, retropharyngeal space in one, and pyriform sinus and aryepiglottic folds in two. Antibiotic treatment included clindamycin in seven patients, ampicillin/sulbactam in one, and clindamycin plus ceftriaxone in three. The patients with respiratory compromise underwent surgery prior to antibiotic treatment. Patients with isolated intratonsillar abscess or phlegmon had resolution of their symptoms with i.v. antibiotic treatment. Patients with combination of intratonsillar and peritonsillar abscess required incision and drainage of peritonsillar abscess. Conclusions Clinically stable children with intratonsillar abscess or phlegmon respond to i.v. antibiotic therapy. Surgical drainage can accomplish clinical resolution in the presence of a combination of intra- and peri-tonsillar abscess, airway compromise, or unresponsiveness to medical treatment.

Objectives/Hypothesis: Cervical necrotizing fasciitis (CNF) is challenging to diagnose and associated with high morbidity and mortality. The objective of this study is to evaluate the utility of two laboratory-based diagnostic tools for distinguishing necrotizing from non-necrotizing infection when specifically applied to neck infection. Study Design: Retrospective review. Methods: We reviewed 17 consecutive cases of CNF and 70 cases of non-necrotizing neck infection (cellulitis, phlegmon, abscess) occurring at our institution over a 10.75-year period. Cervical necrotizing fasciitis was confirmed by operative report documentation. Patient demographics, presenting characteristics, and outcomes were recorded. Results: Use of white blood cell count and serum sodium levels to predict cervical necrotizing fasciitis had a sensitivity of 24% (95% confidence interval [CI], 0.078-0.502), specificity of 81% (95% CI, 0.688-0.889), positive predictive value of 23% (95% CI, 0.054-0.401), and negative predictive value of 81% (95% CI, 0.769-0.857). A Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score of ≥ 6 had a sensitivity of 56% (95% CI, 0.227-0.847), specificity of 60% (95% CI, 0.274-0.863), positive predictive value of 25% (95% CI, 0.072-0.433), and negative predictive value of 85% (95% CI, 0.733-0.962). Conclusions: Neither the LRINEC score nor the use of admission white blood cell count and sodium level were useful for distinguishing cervical necrotizing fasciitis from non-necrotizing neck infection.

Aim The role of laparoscopic surgery in the management of patients with diverticular disease is still not universally accepted. The aim of our study was to evaluate the results of laparoscopic surgery for diverticular disease in a centre with a specialist interest in minimally invasive surgery. Method All diverticular resections carried out between 2006 and 2010 were reviewed. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Complicated diverticular disease was defined as diverticulitis with associated abscess, phlegmon, fistula, stricture, obstruction, bleeding or perforation. Results One hundred and two patients (58 men) who had surgery for diverticular disease were identified (median age 59 years, range 49–70 years). Sixty-four patients (64%) had surgery for complicated diverticular disease. The indications were recurrent acute diverticulitis (37%), colovesical fistula (21%), stricture formation (17%) and colonic perforation (16%). Sixty-nine cases (88%) were completed by elective laparoscopy. Postoperative mortality was 0%. For elective cases there was no difference in morbidity rates between patients with complicated and uncomplicated diverticular disease. The overall anastomotic leakage rate was 1% and the wound infection rate 7%. There was a nonsignificant trend to higher conversion to open surgery in the elective group in complicated (11.4%) compared with uncomplicated patients (5.2%) (P = 0.67). Electively, the rate of stoma formation was higher in the complicated (31.6%) than the uncomplicated group (5.2%) (P

Objective Although a few reviews have been conducted, nonoperative management may be the mainstay of therapy for uncomplicated right colonic diverticulitis. With increasing use of radiological evaluation for diverticulitis, the status of the disease is becoming more accessible. In this study, clinical outcomes of nonoperative management for right colonic diverticulitis were assessed according to disease status using radiological evaluation. Method From April 2000 to March 2007, 296 patients were admitted for acute right colonic diverticulitis upon first attack and were treated with nonoperative management. The status of diverticulitis was classified using ultrasonography and/or computed tomography as inflamed diverticulum or phlegmon in 276 patients or pericolic abscess in 20 patients. Uncomplicated diverticulitis was defined as inflamed diverticulum or phlegmon. Length of hospital stay, antibiotic use, failure of initial therapy and the incidence of recurrence after nonoperative management were assessed. Results The mean length of hospital stay and antibiotic use were 6 and 4.7 days respectively. All patients were successfully treated with the initial medical therapy and their hospital stays were uneventful. Of the 276 patients with an uncomplicated diverticulitis, two patients (1%) had a recurrence during follow-up that could be managed nonoperatively. Of the 20 patients with pericolic abscesses, four patients (20%) had a recurrence. One patient underwent laparoscopic ileocolic resection and the other patients were treated nonoperatively. Conclusion Nonoperative management may be the treatment of choice for right colonic diverticulitis with inflamed diverticulum or phlegmon. Diverticulitis with pericolic abscess should be treated with additional care.

Idiopathic primary lymphoedema (‘swollen legs’) and secondary lymphoedema following trauma or infection (e.g. wound oedema or phlegmon/cellulitis) are frequently encountered problems in equine veterinary practice. At present, therapy of these diseases is often based on symptomatic and empirical treatment, using NSAIDs, antibiotics and compression bandages (Fig 1). Less consideration is given to the underlying disturbance of the lymphatic system. In order to understand the susceptibility of horses to lymphoedema better, it must be remembered that the horse is a flight animal, normally in constant movement. Modern methods of keeping horses in box housing, with limited free exercise and concentrated training sessions compromise the lymph system in apparently healthy horses, particularly in the feet (Laue, 1987). Under these conditions, even minor trauma (e.g. skin wounds) can lead to serious oedema. Manual lymph drainage (MLD) is a treatment option applied directly to the lymphatic system. Furthermore, this method does not contravene anti-doping regulations and has no side effects. Although established for decades in human medicine (Foldi et al. 2006), it is only slowly gaining a foothold in veterinary medicine.

Aim: To examine the influence of previous episodes of uncomplicated diverticulitis on the prognosis of patients who subsequently develop complicated diverticulitis. Patients: One hundred and fifty patients with previous episodes of diverticulitis who were admitted to the Mayo Clinic (Rochester, MN, USA) with complicated diverticulitis (perforation, abscess, obstruction, phlegmon, fistula, or bleeding). Design: The retrospective analysis was based on two groups of patients: group A had one or two prior episodes of diverticulitis (n = 118) and group B had more than two prior episodes of diverticulitis (n = 32). Measurement of outcome: The following criteria were used: phlegmon was a symptomatic inflammatory mass separate from and not associated with a purulent fluid collection; pericolic abscess was a collection of purulent material localized near the colon or in the pelvis; obstruction was characterized by obstructive symptoms and a stricture or stenosis diagnosed by radiographic studies or pathological evaluation; fistulas included colovaginal and colovesicular connections; perforation was either a collection of contained air outside the bowel wall or a large amount of free intra-abdominal air; and patients who required a transfusion for a lower gastrointestinal haemorrhage associated with symptoms and signs of diverticulitis were placed in the bleeding category. Results: Perforated diverticulitis occurred more often in patients from group A; because of this, patients in group A underwent more surgical diversions. There were no appreciable differences in operative complications, morbidity or mortality rates. Conclusion: Patients with more than two episodes of uncomplicated diverticulitis are not at increased risk for poor outcomes if they develop complicated diverticulitis.

Summary To evaluate the role of tissue harmonic imaging (THI) in acute pancreatitis, and to compare its findings with conventional grey-scale sonography and contrast-enhanced computed tomography (CECT) scan, we evaluated 25 patients diagnosed with acute pancreatitis on clinical examination and laboratory findings. Conventional grey-scale ultrasound followed by tissue harmonic sonography was done on the same machine followed by a CECT within 12 h of the ultrasound examination. The present study showed that sonograms obtained with THI were of much better quality than those obtained conventionally, especially for the pancreatic tail. The benefits of harmonic imaging were more apparent in obese patients and in others whose body habitus was unfavourable for sonography. In the assessment of pancreatic image quality, grey-scale imaging had an accuracy of 60, 80 and 28% in relation to the head, body and tail, respectively. In comparison, THI had a far higher accuracy of 80, 92 and 60% in relation to the head, body and tail, respectively, with the superiority being most obvious in the pancreatic tail region. There were no cases in which tissue harmonic sonography provided less information than conventional sonography. However, CECT scan remained the best modality in all patients for the evaluation of acute pancreatitis. It showed superior demonstration of all the morphological changes, ranging from minimal pancreatic oedema to extensive fluid collections, necrosis and the haemorrhage that developed in fulminant severe pancreatitis. Our experience thus suggests that THI cannot replace CT scan as the gold standard in the assessment of acute pancreatitis, as it is poor in evaluating the pancreatic tail, cannot clearly distinguish phlegmon from necrosis, and is inferior to CT in the assessment of the complications of acute pancreatitis.

A total of 3081 heifer calves in 122 Swedish dairy herds were monitored from birth to first calving, and all their diseases and treatments were recorded. There were 1268 cases of infectious diseases, of which 335 (26.4 per cent) were treated with antimicrobial drugs. Just over 90 per cent of the treatments were given during the first 210 days of the calves' lives, but only 61.8 per cent of the total quantity of antimicrobial drugs was consumed during this period. The most common diseases from birth until 210 days were respiratory diseases and diarrhoea; treatments for mastitis and interdigital phlegmon (foul in the foot) were more common after 420 days of age. Slightly more than 60 per cent of the treatments were given by the farmers without prior consultation with a veterinary surgeon.

Pancreatitis is a nasty disease. It attacks young and old alike, often occurring without warning signs. Fortunately, most cases are rather mild and resolve spontaneously. However, a subpopulation of patients develops life-threatening disease, spending a month (usually longer) in the hospital with a large part of the stay spent in the intensive care unit (ICU). The disease poses several management problems for the clinician. First, the patients are hypermetabolic, rapidly immobilizing lean tissues in an aggressive catabolic state. Second, infectious complications—both respiratory and intra-abdominal (infected pancreatic tissue, retroperitoneal abscesses, etc)—present a difficult management problem requiring aggressive ICU care, antibiotic (often multiple) therapy, respiratory support, and frequently, surgical debridement. Although enteral access can be safely obtained during laparotomy and successfully used for postoperative enteral nutrition, 1 operative therapy occurs weeks rather than days into the course of the disease process. During the acute preoperative phase, a massive retroperitoneal phlegmon impairs gastric emptying, precluding any form of intragastric nutrition support. The inflamed, edematous duodenum usually makes advancement of a nasojejunal tube technically impossible. Hence, in addition to hemodynamic, respiratory, and other critical care therapies, parenteral nutrition provides the primary method of nutrition support for these patients, often for prolonged periods of time. Even if enteral access is obtained at laparotomy, advancement of jejunostomy feedings is often slow, requiring a very gradual transition from parenteral to enteral therapy.

Purpose We report the gray-scale, color, and power Doppler findings in 3 cases of postpartum ovarian vein thrombophlebitis (PPOVT), an uncommon but potentially lethal disorder. Methods A retrospective review of medical records revealed 3 patients with PPOVT who had pelvic sonography performed during the disease course. Results The sonographic findings of PPOVT included a tubular, hypoechoic mass identified anterior to the psoas muscle in all cases. Perivenous phlegmon formation resulted in hydronephrosis and obstructive periureteritis in 1 case. Inferior vena cava involvement was detected in 2 cases. Decreases in the sizes of the thrombus and the phlegmon were seen on post-treatment studies. Conclusions The long course of the thrombosed ovarian vein and the presence of inferior vena cava thrombus are sonographic signs helpful in distinguishing PPOVT from other inflammatory conditions. Sonography cannot be proposed as a primary tool in the diagnosis of PPOVT because it successfully diagnosed only 1 of our 3 cases. However, sonography may be useful in monitoring the response to anticoagulant therapy. © 1998 John Wiley & Sons, Inc. J Clin Ultrasound26:143–149, 1998.

Background Improvements in surgical techniques, advances in intensive care medicine and progress in the management of peritoneal sepsis have recently favoured colonic resection with primary anastomosis in the treatment of complicated diverticulitis. Methods Some 224 patients with complicated diverticulitis who had undergone surgery in the preceding 22 years were reviewed. Complications present on admission included acute phlegmon without pus formation (92 patients), paracolic abscess and/or localized peritonitis (99), diffuse purulent peritonitis (33), complete obstruction of the sigmoid colon (eight) and paracolic abscess complicated by fistula (27). Results The overall mortality rate was two (1 per cent) of 183 for resection with primary anastomosis, seven of 31 for Hartmann's operation and four of ten for the delayed three-stage procedure. The anastomosis was made by instruments employing the double-stapled technique in 130 patients and hand-sutured in 94. Reversal of Hartmann's operation was undertaken in only 31 per cent compared with 89 per cent for closure of the protective colostomy in patients with primary anastomosis. Conclusion The Hartmann operation may be the most popular at present, but resection with primary anastomosis is the safest procedure for all stages of complicated diverticulitis, and reduces costs. There is no longer any clinical indication for the three-stage operation.

Summary Band erosion is a rare complication of laparoscopic adjustable gastric banding (LAGB) with a reported prevalence varying from 0.3% to 14%. Intraluminal colonic erosion of the connecting tube is very rare, as only isolated cases have been described. Consequently, simultaneous gastric band erosion and connecting tube colonic erosion is an extremely rare event. Herein, we present a case of a woman with morbid obesity, who submitted to LABG 4 years ago. The patient presented with symptoms and signs of right lower quadrant peritonitis. Computed tomography (CT) demonstrated migration of the band into the gastric lumen, inflammation around the intra-abdominal course of the connecting tube and an inflammatory mass surrounding the tube at the right lower quadrant. Laparotomy revealed the eroded band, the eroded transverse colon from the connecting tube, a gastrocolic fistula along the course of the tube and a right lower quadrant phlegmon. The connecting tube was mobilized from the surrounding adherent tissues, the gastric band removed, the stomach and colon walls closed, and the gastrocolic fistula excised. To our knowledge this is the second case of concurrent band erosion and connecting tube colonic erosion along with gastrocolic fistula formation in a patient with morbid obesity treated with LAGB.

Hepatic portal venous gas is a rare condition that may be encountered in bowel necrosis. We report two successfully treated cases of hepatic portal venous gas associated with superior mesenteric artery (SMA) syndrome and ischemic colitis, respectively. In first case, a 28-year-old woman with progressive myoclonic seizures presented with complaints of vomiting and fever. Computed tomography showed a characteristic gas pattern in the liver and marked dilatation of the duodenum proximal to the superior mesenteric artery with a collapsed distal intestine, confirming the diagnosis of SMA syndrome with portal hepatic venous gas. Emergency laparotomy revealed an edematous stomach with phlegmon of the fundus. Fundectomy and gastrojejunostomy were performed. The second case involved a 78-year-old man who was admitted in shock. Colonofberscopy revealed mucosal necrosis and hemorrhage from the dentate line to the sigmoid colon, indicating ischemic colitis. Computed tomography showed hepatic portal venous gas and retroperitoneal emphysema around the rectum. Rectal amputation was performed. Hepatic portal venous gas is considered a serious condition with an overall mortality rate 75%, which actually reflects the outcome of coexisting septicemia. Diagnosis and treatment of the primary disease in the early stage may improve the outcome.

ObjectivesTo describe the presentation and management of pediatric deep neck space infections located at the skull base.MethodsDesign: Retrospective review. Setting: Tertiary children's hospital. The study population comprised pediatric patients admitted to the hospital for management of deep neck space infections between 2000 and 2007. Main Outcome Measure: Resolution of abscess.ResultsOver the study period, 179 patients were admitted for management of deep neck space infections. Of these, 10 (6%) were localized to the skull base by CT scan. 7 of the 10 met radiographic criteria for an abscess; the remaining 3 were designated edema or phlegmon. Patients ranged in age from 2 to 8 years old. The most common presenting symptoms were sore throat (60%), stiff or sore neck (50%), neck or facial swelling (20%), and drooling (20%). Otitis media and Streptococcal pharyngitis were the most common co-morbidities found in 40% of patients. Initial treatment consisted of IV antibiotics in all cases. 70% resolved with ...

ObjectivesTo describe mediastinitis from retropharyngeal abscess in 3 infants.MethodsCase reports of 3 patients.Results3 patients presented in a span of 2 winter months to a tertiary care, pediatric, inner-city hospital. The patients were 8 months, 9 months, and 18 months old. All presented with retropharyngeal phlegmon on CT scan, were started on clindamycin and cefotaxime, and monitored as in-patients for 2–4 days prior to surgery. Interval CT scans revealed progression to retropharyngeal abscess with mediastinal extension. One patient's retropharyngeal abscess was drained trans-orally, one externally, and one required a combined approach. 2 of the 3 patients required video-assisted thoracoscopic debridement of the mediastinitis. 2 cultures grew out methicillin-resistant staphylococcus aureus, while one grew out methicillin-sensitive staphylococcus aureus (all were clindamycin sensitive). The patients' peak white blood cell counts were 18.4, 30.2, and 44.9 thousand. All 3 patients survived and were disc...

The outcome of 78 patients hospitalized with acute diverticulitis was analysed to determine the indications for emergency operation and to examine the safety of sigmoid resection. Forty patients improved on medical therapy, but four relapsed soon after discharge. Forty-two (55%) patients had emergency operations for non-resolution of clinical sepsis (25), persistent symptoms or mass (14) and fistula (three). Operations performed were: sigmoid resection and primary anastomosis (23) with covering colostomy (six). Hartmann's operation (10), drainage with/without colostomy (seven) and right hemicolectomy (two). Findings at operation were: abscess (19), phlegmon (14), generalized peritonitis (six), colovesical fistula (three) and chronic diverticulitis (three). Complications included wound infections (six), respiratory complications (five) and one death. Six patients having drainage of the sigmoid inflammation alone as the first operation required subsequent resection, with prolonged and often complicated hospitalization. Minimal morbidity and shorter hospitalization were achieved when sigmoid resection was performed at the initial procedure.

SUMMARY Although urologists are familiar with the classical pathways of spread of fluid beneath Colles' fascia, it is not commonly appreciated that the periurethral phlegmon, by virtue of its ability to induce vascular thrombosis, ischeemia and necrosis of restraining fascial barriers, may disseminate by routes not expected from anatomical studies alone. Two cases demonstrating posterior extension into the buttocks have been presented and the seriousness of the disease has been emphasised. Recognition of such a complication is of more than academic interest since recovery may be dependent upon drainage of these ancillary areas.