Special stent for draining the abdominal abscess respectively from colon and duodenum: A case report

Abstract

BACKGROUND

Postoperative abdominal infections are an important and heterogeneous health challenge. Many samll abdominal abscesses are resolved with antibiotics, but larger or symptomatic abscesses may require procedural management.

CASE SUMMARY

A 65-year-old male patient who suffered operation for the left hepatocellular carcinoma eight months ago, came to our hospital with recurrent abdominal pain, vomit, and fever for one month. Abdominal computed tomography showed that a big low-density dumbbell-shaped mass among the liver and intestine. Colonoscopy showed a submucosal mass with a fistula at colon of liver region. Gastroscopy showed a big rupture on the submucosal mass at the descending duodenum and a fistula at the duodenal bulb. Under colonoscopy, the brown liquid and pus were drained from the mass with “special stent device”. Under gastroscopy, we closed the rupture of the mass with a loop and six clips for purse stitching at the descending duodenum, and the same method as colonoscopy was used to drain the brown liquid and pus from the mass. The symptom of abdominal pain, vomit and fever were relieved after the treatment.

CONCLUSION

The special stent device could be effectively for draining the abdominal abscess respectively from colon and duodenum.

Key Words: Abdominal abscess, Stent, Draining, Gastroscopy, Colonoscopy, Case report

Core Tip: Postoperative abdominal infections are an important and heterogeneous health challenge. Many samll abdominal abscesses are resolved with antibiotics, but larger or symptomatic abscesses may require procedural management. The special stent device could be effectively for draining the abdominal abscess respectively from colon and duodenum.

INTRODUCTION

Postoperative abdominal infections are an important and heterogeneous health challenge[1]. Many samll abdominal abscesses are resolved with antibiotics, but larger or symptomatic abscesses may require procedural management[2]. We report a case that the special stent device could be effectively for draining the abdominal abscess respectively from colon and duodenum.

CASE PRESENTATION

Chief complaints

A 65-year-old male patient came to our hospital with recurrent abdominal pain, vomit and fever for one month.

History of present illness

The patient was suffered operation for the left hepatocellular carcinoma eight months ago.

History of past illness

The patient was suffered hypertension for ten years.

Personal and family history

All other personal and family medical history was normal.

Physical examination

Diseased liver face, no yellowing of the skin or sclera, clear breath sounds on both lungs auscultation, no dry or wet rales, heart rate of 86 beats/min, regular heart rhythm. About 20 cm surgical scar can be saw on the above of abdomen. Upper abdominal tenderness was found and there was no edema in either lower limb.

Laboratory examinations

The laboratory result showed white blood cell, platelet, alanine aminotransferase, glucose, triglyceride, cholesterol, amylase, lipase and alpha-fetoprotein were in normal range (Table 1). Hemoglobin, total bilirubin, creatinine, C-reactive protein, prothrombin time and dimer were not in normal (Table 1). Hepatitis B surface antigen, hepatitis C antibody, human immunodefciency virus antibody, syphilis antibody, anti-nuclear anti-bodies were all negative.

Table 1 The laboratory result of the patient before treatment.

	Laboratory result	Normal
WBC (109/L)	5.53	(3.4-9.5)
HB (g/L)	91	(115-150)
Platelet (109/L)	148	(125-350)
PT(S)	15.0	(9.7-13.5)
Dimer (mg/L)	6.41	(0.00-0.55)
ALT (μ/L)	27	(9-50)
TB (umol/L)	28.34	(3-20)
Cr (umol/L)	47	(40-80)
AFP (μg/L)	5.55	(0-9)
CRP (mg/L)	171	(0-10)
Triglyceride (mmol/L)	1.65	(0-1.7)
Cholesterol (mmol/L)	3.10	(2.86-5.98)
Amylase (U/L)	131	(35-135)
Lipase (U/L)	170	(0-190)
Glucose (mmol/L)	5.2	3.0-6.1
HbsAg	Negative	Negative
HIV Ab	Positive	Negative
Sp Ab	Negative	Negative
ANA	Negative	Negative
HC Ab	Negative	Negative

WBC: White blood cell; HB: Hemoglobin; PT: Prothrombin time; ALT: Alanine aminotransferase; TB: Total bilirubin; Cr: Creatinine; AFP: Alpha-fetoprotein; CRP: C-reactive protein; HbsAg: Hepatitis B surface antigen; HC Ab: Hepatitis C antibody; HIV-Ab: Human immunodefciency virus antibody; Sp Ab: Syphilis antibody; ANA: Anti-nuclear anti-bodies.

Imaging examinations

Abdominal computed tomography (CT) showed that a big low-density dumbbell-shaped mass among the liver and intestine (Figure 1A). One day after operation, CT showed that the low-density mass was reduced (Figure 1B). The length of special stent was 20cm and connecting with a dental floss coil at the end of stent. The special stent was cut from the front of a nasobiliary duct [I type F7, 2500 mm, 20212140184, XinChang (ShangHai) Co., Ltd, China] which had multihole hook-shaped drainage, and the another rest long-duct was as a pusher (Figure 2). Gastroscopy showed a big rupture (Figure 3A) on the submucosal mass at the descending duodenum and a fistula (Figure 3B) at the duodenal bulb. Colonoscopy showed a submucosal mass with a fistula (Figure 3C) at colon of liver region.

Figure 1 Computed tomography showed the abdominal abscess before and after the drainage. A: Computed tomography (CT) showed that a big low-density dumbbell-shaped mass among the liver and intestine; B: One day after operation, CT showed that the low-density mass was reduced.

Figure 2 The special stent device.

Figure 3 Special stent for draining the abdominal abscess respectively from colon and duodenum under endoscopy. A: Gastroscopy showed a big rupture on the submucosal mass at the descending duodenum; B: Gastroscopy showed a fistula on the submucosal mass at the duodenal bulb; C: Colonoscopy showed a submucosal mass with a fistula at the colon of liver region; D: The stent was placed into the mass through the fistula; E: A nasojejunal nutrient tube was retained to the jejunum; F: The special stent used to drain the mass from the duodenal bulb.

FINAL DIAGNOSIS

Gastroscopy showed a big rupture on the submucosal mass at the descending duodenum and a fistula at the duodenal bulb. Colonoscopy showed a submucosal mass with a fistula at colon of liver region. There was no infection found except the abdominal mass.

TREATMENT

Under colonoscopy, the brown liquid and pus were drained from the mass with “special stent device”. At first, we pushed the zebra wire [AG-5041-354, 4500mm, Anjie (Hangzhou) Co., Ltd, China] into the fistula, and the special stent was pushed into fistula ahout 10cm with the pusher (the rest long-duct), then the duct was fastened to the peripheral mucosa with a clip [ROCC-D-26-195-C, MMAD230208236, Micro-Tech (Nanjing) Co., Ltd, China] and a dental floss coil (Figure 3D). We could see the drainage form the mass through the hole of stent (Video 1). Under gastroscopy, we retained a nasojejunal nutrient tube [II type 8.5F-G, 2600 mm, 20182660136, Xinchang (Shanghai) Co., Ltd, China] to jejunum (Figure 3E) at first, and then we closed the rupture of the mass with a loop [Loop-30, 080301220409, LeAo (Changzhou) Co., Ltd, China] and six clips [ROCC-D-26-195-C, MMAD230208236, Micro-Tech (Nanjing) Co., Ltd, China] for purse stitching at the descending duodenum, and the same method as colonoscopy was used to drain the brown liquid and pus from the mass (Figure 3F).

OUTCOME AND FOLLOW-UP

The patient's symptom of abdominal pain, vomit, and fever were relieved after the treatment. One day after operation, CT showed that the low-density mass was reduced (Figure 1B).

DISCUSSION

Abdominal abscess is usually a consequence of surgery, inflammatory bowel disease, diverticulum abscess or ischaemic colitis. It is a condition with high rates of morbidity and mortality[3,4]. Postoperative intra-abdominal abscess is a postoperative collection of infected fluid within the intrabdominal cavity. It is usually treated by a combination of interventional measures and anti-infective therapy[5]. Exact criteria for drainage of an abscess are not standardized. Surgical intervention in intra-abdominal abscesses is rare and usually follows ineffective interventional treatment[6].

In this case, we used special stent device to drain the fliud of the abdominal abscess respectively from colon and duodenum. Compared to the other treatments, The special stent device had the following advantages: (1) It could draining abdominal infectious fluid respectively from the colon and duodenum; (2) The hook-shape could fasten the head of the stent in the mass; (3) The multihole of the stent could drain the bile and other fluid; and (4) The clip and dental floss coil could fasten the stent to mucosa.

CONCLUSION

The special stent device could be effectively for draining the abdominal abscess respectively from colon and duodenum.