This elevation of the right hemidiaphragm was due to the pus tracking from the hepatorenal space around the lateral and anterior aspect of the liver to sit on top of the liver in a subphrenic position. An ultrasound scan demonstrated this collection of fluid. The abscess cavity could be clearly seen by placing the ultrasound probe between ribs XI and XII. The inferior border of the right lower lobe lies at rib X in the midaxillary line. When the probe is placed between ribs XI and XII the ultrasound waves pass between the intercostal muscles and the parietal pleura laterally on the chest wall, and continue through the parietal pleura overlying the diaphragm into the cavity of the abscess, which lies below the diaphragm.
Drainage was not done by an intercostal route. Instead, using CT guidance and local anesthesia, a subcostal drain was established and 1 liter of pus was removed (eFig. 4.188). It is important to bear in mind that placing a drain through the pleural cavity into the abdominal cavity effectively allows intraabdominal pus to pass into the thoracic cavity, and that this may produce an empyema (pus in the pleural space).
The patient made a slow and uneventful recovery.
A 45-year-old man developed a low-grade rectal carcinoma just above the anorectal margin. He underwent an abdominoperineal resection of the tumor and was left with a left lower abdominal colostomy (see below). Unfortunately, the man’s wife left him for a number of reasons, including lack of sexual desire. He “turned to drink” and over the ensuing years developed cirrhosis. He was brought into the emergency room with severe bleeding from enlarged veins around his colostomy. An emergency transjugular intrahepatic portosystemic shunt was created, which stopped all bleeding (eFigs. 4.189 and 4.190). He is now doing well in a rehabilitation program.
A colostomy was necessary because of the low site of the tumor.
Carcinoma of the colon and rectum usually develops in older patients, but some people do get tumors early in life. Most tumors develop from benign polyps, which undergo malignant change. As the malignancy develops it invades through the wall of the bowel and then metastasizes to local lymphatics. The tumor extends within the wall for a few centimeters above and below its origin. Lymphatic spread is to local and regional lymph nodes and then to the pre-aortic lymph node chain. These drain eventually into the thoracic duct.
When this man was assessed for surgery, the tumor was so close to the anal margin that resection of the sphincters was necessary to be certain that the tumor margins were clear. The bowel cannot be joined to the anus without sphincters because the patient would be fecally incontinent. At surgery the tumor was excised, including the locoregional lymph node chains and the peritumoral fat around the rectum.
The free end of the sigmoid colon was brought through a hole in the anterior abdominal wall. The bowel was then carefully sutured to the anterior abdominal wall to allow placement of a bag to collect the feces. This is a colostomy.
Contrary to their usual immediate negative reaction to having a bag on the anterior abdominal wall, most patients cope extremely well, especially if they have been cured of cancer.
This patient’s pelvic nerves were damaged. The radical pelvic surgical dissection damaged the pelvic parasympathetic nerve supply necessary for erection of the penis. Unfortunately, this was not well explained to the patient, which in some part led to the failure of his relationship. With any radical surgery in the pelvis, the nerves that supply the penis or clitoris may be damaged, so interfering with sexual function.
This patient was bleeding from stomal varices.
As he developed a serious drinking problem, his liver became cirrhotic and this damaged the normal liver architecture. This in turn increased the blood pressure in the portal vein (portal hypertension).