UNLABELLED Multiple pyogenic liver abscesses formed after appendectomy and their percutaneous treatment with multiple catheters have been rarely described. We report a case of multiple pyogenic liver abscesses in a critically ill patient, formed after appendectomy and treated successfully by antibiotics and drainage with six catheters that were introduced simultaneously under ultrasound control. Even though this was a case of liver abscess secondary to appendicitis, today very rare in Western countries, but still a serious complication in developing countries, it was successfully resolved by percutaneous drainage, along with antibiotic therapy. CONCLUSION We emphasize the advantages of percutaneous treatment compared with surgery regarding the avoidance of perioperative complications and the risks of general anesthesia.

We read with great interest the editorial article by Meshikhes AWN published in issue 25 of World J Gastroenterol 2011. The article described the advantages of emergency laparoscopic appendectomy compared with interval appendectomy as a new safe treatment modality for the appendiceal mass. The author concluded that the emergency laparoscopic appendectomy was a safe treatment modality for the appendiceal mass, and might prove to be more cost-effective than conservative treatment, with no need for interval appendectomy. However, we would like to highlight certain issues regarding the possibility of percutaneous catheter drainage to successfully treat the appendiceal mass, with no need for appendectomy, too.

Objective: To report an uncommon method of managing pancreatic fistulas and retroperitoneal abscess. Clinical Presentation and Intervention: A 50-year-old man was admitted with fever, abdominal pain, periumbilical fistula and pus in stool. Five months before admission, he underwent urgent necrosectomy (7 days after onset of pain) and subsequently two more surgeries for necrotizing pancreatitis. Ultrasound revealed fluid collection in the retropancreatic space. After evacuation of pus, contrast medium instilled through a catheter showed a retroperitoneal abscess cavity, retroperitoneal-periumbilical and retroperitoneal-sigmoidal fistulas. After percutaneous drainage and iodine irrigation, the abscess collection and fistulas disappeared. Conclusion: In this case, percutaneous drainage was a successful option in the management of pancreatic fistulas and a retroperitoneal abscess.

To The Editor: We commend Chung et al for an interesting original article reporting on the safety, efficacy, and long-term outcome of percutaneous cholecystostomy (PC) as of a definitive treatment for acute acalculous cholecystitis (AAC). They concluded that PC is an effective procedure and a good alternative for patients unfit to undergo immediate surgery because of the existence of severe sepsis or an underlying comorbidity. This is an excellent article with a strong impact on clinical practice. Traditionally, acute cholecystitis is mainly treated by surgical approach 1–3 but, in patients with poor general condition surgical treatment may carry a high risk of complications associated with major morbidity and mortality. Only limited data are available on PC treatment of AAC and little is known about the safety of PC in critically ill patients. Therefore, Chung’s study, which evaluates the feasibility and clinical outcome of PC in patients with AAC is of a high importance. However, AAC comprises <10% of all cases of acute cholecystitis. In over 90% of cases, acute cholecystitis is caused by cholecystolithiasis. Therefore, it is important to answer whether PC should be limited only to AAC. We had several cases of acute cholecystitis in patients with poor general condition, caused by cholecystolithiasis, which were successfully treated by PC and so we wish to add some comments regarding this topic. Our initial intention was for PC to be used as a temporizing measure whereas, awaiting resolution of sepsis and optimization of comorbidities before performing elective surgery. But, majority of those cases required no further surgical treatment after PC. Therefore, we believe that ultrasound-guided PC should be considered a reasonable option in the therapeutic spectrum for both acalculous and calculous cholecystitis and a good alternative for patients unfit to undergo immediate surgery because of severe sepsis or an underlying comorbidity.