12TH RIB RESECTION - PREFERRED THERAPY FOR SUBPHRENIC ABSCESS IN SELECTED SURGICAL PATIENTS

Objective: To assess the role of 12th rib resection in the treatment o f postoperative, subphrenic abscesses. Design: Consecutive case series . Setting: University hospital, level I trauma center. Patients: Opera tive logs for a 13-year period were reviewed for all patients undergoi ng 12th rib resection for drainage of a postoperative subphrenic absce ss. Each individual medical record was reviewed for demographic data, primary diagnosis, computed tomographic scan findings, and clinical st atus (temperature, white blood cell count, and Acute, Physiologic, Age , and Chronic Health Evaluation II score) at the time of rib resection . Main Outcome Measures: Operative results, microbiological data, comp lications, and outcomes. Results: Twenty-six patients underwent 27 rib resections for a secondary left subphrenic (23) or a right subhepatic (4) abscess. All patients had undergone at least 1 prior laparotomy ( average, 1.5; range, 1-4). Sixteen patients had traumatic injuries, an d 7 had complicated pancreatitis. Twelve patients had undergone prior failed attempts at percutaneous drainage before rib resection. Fourtee n patients underwent operative drainage without attempted percutaneous drainage, mainly for peripancreatic (7) or multiloculated (3) abscess es. There were 3 postoperative complications (3/27 [11%]): a gastrocut aneous fistula, a gastrocolic-cutaneous fistula requiring laparotomy a nd temporary colostomy, and fasciitis in the resection site. Four (15% ) of the 26 patients died: 3 died of progressive multiple system organ failure, and 1 died of an unrelated injury. The remaining 20 (77%) of the patients were discharged from the hospital with healing wounds an d no further episodes of intra-abdominal infection. Conclusions: Twelf th rib resection is an effective alternative therapy for secondary sub phrenic abscesses. The nature of the incision allows for open, depende nt drainage; avoids subsequent laparotomy; and effectively controls in tra-abdominal infections. Twelfth rib resection remains a useful tool in the treatment of subphrenic abscess and may be the preferred approa ch when other attempts at abscess drainage have failed.