It is unlikely that surgeons or hospitals will be prepared to absorb these costs. There needs to be a public debate about the funding implications of surgical training in the private sector.
Correspondence to: Mr R. J. Aitken, University Department of Clinical Surgery, The Royal Infirmary, Edinburgh EH39YW. UK Psoas abscesses are an unusual complication of Crohn's disease that originate from a communication with adherent bowel. We report a patient with Crohn's disease in whom a psoas abscess led to a spinal extradural abscess that required emergency laminectomy.
Case reportA 36-year-old man with Crohn's disease underwent an intersphincteric excision of the anorectum with end sigmoid colostomy because of unremitting perianal fistulas with associated pelvic sepsis. The perineal wound was closed primarily over a suction and irrigation drain. He made an uneventful recovery, but during the subsequent 6 months was admitted with three episodes of subacute small bowel obstruction, all of which settled with conservative management. During the seventh month he was admitted with septicaemia (temperature 39°C) and pain in his right iliac fossa. A prominent and distressing feature was severe unremitting low lumbar back pain. Urgent radiological investigations, including ultrasonography but not computerized tomography (CT), were unhelpful but an indium-labelled white cell scan demonstrated a hot focus in the pelvis. Following recuscitation and the administration of antibiotics he underwent surgery and a large pelvic inflammatory mass was found. Thirty-five centimetres of terminal ileum was resected with a segment of sigmoid colon adherent to the pelvic mass. Pelvic and bilateral psoas abscesses were drained. A Brooke ileostomy was constructed and the right colon was closed and returned to the peritoneal cavity. Histology of the terminal ileum confirmed Crohn's disease. One week later a pulmonary embolus was confirmed by chest Xray and ventilation/perfusion scan and he was heparinized. His severe backache persisted; spinal X-rays and CT scan did not demonstrate a focal cause although a bone scan showed increased uptake in the area of the right sacro-iliac joint. One week later a further laparotomy was required for recurrent septicaemia but no intra-abdominal focus was found. His presumed sacro-iliitis was treated symptomatically with nonsteroidal anit-inflammatory drugs and he was discharged. Three weeks later he was admitted with worsening of back pain and sudden onset of paralegia. Urgent myelogram demonstrated a spinal extradural abscess and decompressive L,-L, laminectomy was performed (Figure I). The bacteriology of mixed faecal flora was similar to that obtained from his psoas abscess. Laminectomy provided immediate relief from backache and allowed resolution of the paragraphs of the paraplegia. Further laminectomy of L,-SI was required one month later for osteitis.He was finally discharged 9f months after his presentation with a psoas abscess and remains well 6 months later.
DiscussionA literature search in 1982 revealed only 28 reported cases of psoas abscess complicating Crohn's disease. Previous reports have emphasized the difficult clinical course that these patients follow' -3 . The majority present ...
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