title: Twelfth rib resection. Preferred therapy for subphrenic abscess in selected surgical patients.
abstract: OBJECTIVE
  To assess the role of 12th rib resection in the treatment of postoperative, subphrenic abscesses.
  
  
  METHODS
  Consecutive case series.
  
  
  METHODS
  University hospital, level I trauma center.
  
  
  METHODS
  Operative logs for a 13-year period were reviewed for all patients undergoing 12th rib resection for drainage of a postoperative subphrenic abscess. Each individual medical record was reviewed for demographic data, primary diagnosis, computed tomographic scan findings, and clinical status (temperature, white blood cell count, and Acute, Physiologic, Age, and Chronic Health Evaluation II score) at the time of rib resection.
  
  
  METHODS
  Operative results, microbiological data, complications, 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, and 7 had complicated pancreatitis. Twelve patients had undergone prior failed attempts at percutaneous drainage before rib resection. Fourteen patients underwent operative drainage without attempted percutaneous drainage, mainly for peripancreatic (7) or multiloculated (3) abscesses. There were 3 postoperative complications (3/27 [11%]): a gastrocutaneous fistula, a gastrocolic-cutaneous fistula requiring laparotomy and 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 and no further episodes of intra-abdominal infection.
  
  
  CONCLUSIONS
  Twelfth rib resection is an effective alternative therapy for secondary subphrenic abscesses. The nature of the incision allows for open, dependent drainage; avoids subsequent laparotomy; and effectively controls intra-abdominal infections. Twelfth rib resection remains a useful tool in the treatment of subphrenic abscess and may be the preferred approach when other attempts at abscess drainage have failed.
authors.affiliation: Department of Surgery, University of Louisville School of Medicine, Ky., USA. daspai01@ulkyvm.louisville.edu
authors.forename: D A
authors.initials: DA
authors.lastname: Spain
authors.forename: R C
authors.initials: RC
authors.lastname: Martin
authors.forename: E H
authors.initials: EH
authors.lastname: Carrillo
authors.forename: H C
authors.initials: HC
authors.lastname: Polk
mesh_terms: D000328:Adult; D000368:Aged; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery*; D012272:Ribs / Q000601:surgery*; D013369:Subphrenic Abscess / Q000601:surgery*