Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality, a Cohort of 191 Patients

Abdominal emergency surgery in patients with hematological malignancies: a retrospective single-center analysis

BACKGROUND

Hematologic patients requiring abdominal emergency surgery are considered to be a high-risk population based on disease- and treatment-related immunosuppression. However, the optimal surgical therapy and perioperative management of patients with abdominal emergency surgery in patients with coexisting hematological malignancies remain unclear.

METHODS

We here report a single-center retrospective analysis aimed to investigate the impact of abdominal emergency surgery due to clinically suspected gastrointestinal perforation (group A), intestinal obstruction (group B), or acute cholecystitis (group C) on mortality and morbidity of patients with coexisting hematological malignancies. All patients included in this retrospective single-center study were identified by screening for the ICD 10 diagnostic codes for gastrointestinal perforation, intestinal obstruction, and ischemia and acute cholecystitis. In addition, a keyword search was performed in the database of all pathology reports in the given time frame.

RESULTS

A total of 56 patients were included in this study. Gastrointestinal perforation and intestinal obstruction occurred in 26 and 13 patients, respectively. Of those, 21 patients received a primary gastrointestinal anastomosis, and anastomotic leakage (AL) occurred in 33.3% and resulted in an AL-related 30-day mortality rate of 80%. The only factor associated with higher rates of AL was sepsis before surgery. In patients with suspected acute cholecystitis, postoperative bleeding events requiring abdominal packing occurred in three patients and lead to overall perioperative morbidity of 17.6% and surgery-related 30-day mortality of 5.9%.

CONCLUSION

In patients with known or suspected hematologic malignancies who require emergency abdominal surgery due to gastrointestinal perforation or intestinal obstruction, a temporary or permanent stoma might be preferred to a primary intestinal anastomosis.

Damage-control surgery in patients with nontraumatic abdominal emergencies: A systematic review and meta-analysis

BACKGROUND

After the successful implementation in trauma, damage-control surgery (DCS) is being increasingly used in patients with nontraumatic emergencies. However, the role of DCS in the nontrauma setting is not well defined. The aim of this study was to investigate the effect of DCS on mortality in patients with nontraumatic abdominal emergencies.

METHODS

Systematic literature search was done using PubMed. Original articles addressing nontrauma DCS were included. Two meta-analyses were performed, comparing (1) mortality in patients undergoing nontrauma DCS versus conventional surgery (CS) and (2) the observed versus expected mortality rate in the DCS group. Expected mortality was derived from Acute Physiology And Chronic Health Evaluation, Simplified Acute Physiology Score, and Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity scores.

RESULTS

A total of five nonrandomized prospective and 16 retrospective studies were included. Nontrauma DCS was performed in 1,238 and nontrauma CS in 936 patients. Frequent indications for surgery in the DCS group were (weighted proportions) hollow viscus perforation (28.5%), mesenteric ischemia (26.5%), anastomotic leak and postoperative peritonitis (19.6%), nontraumatic hemorrhage (18.4%), abdominal compartment syndrome (17.8%), bowel obstruction (15.5%), and pancreatitis (12.9%). In meta-analysis 1, including eight studies, mortality was not significantly different between the nontrauma DCS and CS group (risk difference, 0.09; 95% confidence interval, -0.06 to 0.24). Meta-analysis 2, including 14 studies, revealed a significantly lower observed than expected mortality rate in patients undergoing nontrauma DCS (risk difference, -0.18; 95% confidence interval, -0.29 to -0.06).

CONCLUSION

This meta-analysis revealed no significantly different mortality in patients undergoing nontrauma DCS versus CS. However, observed mortality was significantly lower than the expected mortality rate in the DCS group, suggesting a benefit of the DCS approach. Based on these two findings, the effect of DCS on mortality in patients with nontraumatic abdominal emergencies remains unclear. Further prospective investigation into this topic is warranted.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Increased mortality and altered local immune response in secondary peritonitis after previous visceral operations in mice

Postoperative peritonitis is characterized by a more severe clinical course than other forms of secondary peritonitis. The pathophysiological mechanisms behind this phenomenon are incompletely understood. This study used an innovative model to investigate these mechanisms, combining the models of murine Colon Ascendens Stent Peritonitis (CASP) and Surgically induced Immune Dysfunction (SID). Moreover, the influence of the previously described anti-inflammatory reflex transmitted by the vagal nerve was characterized. SID alone, or 3 days before CASP were performed in female C57BL/6 N mice. Subdiaphragmatic vagotomy was performed six days before SID with following CASP. The immune status was assessed by FACS analysis and measurement of cytokines. Local intestinal inflammatory changes were characterized by immunohistochemistry. Mortality was increased in CASP animals previously subjected to SID. Subclinical bacteremia occurred after SID, and an immunosuppressive milieu occurred secondary to SID just before the induction of CASP. Previous SID modified the pattern of intestinal inflammation induced by CASP. Subdiaphragmatic vagotomy had no influence on sepsis mortality in our model of postoperative peritonitis. Our results indicate a surgery-induced inflammation of the small intestine and the peritoneal cavity with bacterial translocation, which led to immune dysfunction and consequently to a more severe peritonitis.

Outcome in patients with open abdomen treatment for peritonitis: a multidomain approach outperforms single domain predictions

Numerous patient-related clinical parameters and treatment-specific variables have been identified as causing or contributing to the severity of peritonitis. We postulated that a combination of clinical and surgical markers and scoring systems would outperform each of these predictors in isolation. To investigate this hypothesis, we developed a multivariable model to examine whether survival outcome can reliably be predicted in peritonitis patients treated with open abdomen. This single-center retrospective analysis used univariable and multivariable logistic regression modeling in combination with repeated random sub-sampling validation to examine the predictive capabilities of domain-specific predictors (i.e., demography, physiology, surgery). We analyzed data of 1,351 consecutive adult patients (55.7% male) who underwent open abdominal surgery in the study period (January 1998 to December 2018). Core variables included demographics, clinical scores, surgical indices and indicators of organ dysfunction, peritonitis index, incision type, fascia closure, wound healing, and fascial dehiscence. Postoperative complications were also added when available. A multidomain peritonitis prediction model (MPPM) was constructed to bridge the mortality predictions from individual domains (demographic, physiological and surgical). The MPPM is based on data of n = 597 patients, features high predictive capabilities (area under the receiver operating curve: 0.87 (0.85 to 0.90, 95% CI)) and is well calibrated. The surgical predictor “skin closure” was found to be the most important predictor of survival in our cohort, closely followed by the two physiological predictors SAPS-II and MPI. Marginal effects plots highlight the effect of individual outcomes on the prediction of survival outcome in patients undergoing staged laparotomies for treatment of peritonitis. Although most single indices exhibited moderate performance, we observed that the predictive performance was markedly increased when an integrative prediction model was applied. Our proposed MPPM integrative prediction model may outperform the predictive power of current models.

Priorities in peritonitis

PURPOSE OF REVIEW

Timely and adequate management are the key priorities in the care of peritonitis. This review focuses on the cornerstones of the medical support: source control and antiinfective therapies.

RECENT FINDINGS

Peritonitis from community-acquired or healthcare-associated origins remains a frequent cause of admission to the ICU. Each minute counts for initiating the proper management. Late diagnosis and delayed medical care are associated to dramatically increased mortality rates. The diagnosis of peritonitis can be difficult in these ICU cases. The signs of organ failures are more relevant than biological surrogates. A delayed source control and a late anti-infective therapy are of critical importance. The quality of source control and medical management are other key elements of the prognosis. The conventional rules applied for sepsis are applicable for peritonitis, including hemodynamic support and anti-infective therapy. Growing proportions of multidrug resistant pathogens are reported from surgical samples, mainly related to Gram-negative bacteria. The increasing complexity in the care of these critically ill patients is a strong incentive for a multidisciplinary approach.

SUMMARY

Early clinical diagnosis, timely and adequate source control and antiinfective therapy are the essential pillars of the management of peritonitis in ICU patients.

Transverse vs. median laparotomy in peritonitis and staged lavage: a single center case series

Background: Staged lavage was first introduced in the 1970s and now serves as a therapeutic option for septic patients with peritonitis. A central aspect of this treatment concept is leaving the abdomen open after a wide incision. To evaluate the influence of transverse vs. median access to the abdomen in staged lavage, data from the authors’ patients were analyzed.

Methods: To evaluate patients with peritonitis, prospective intensive care data were examined together with data on the surgical details. The main aspects covered here were the surgical details of the lavage (namely, transverse vs. median laparotomy), number of lavages, fascia closure, wound-healing disorders, and observed lethality, in combination with the preoperatively evaluated SAPS-II score, expected hospital lethality, patient age, and the Mannheim Peritonitis Index.

Results: Between January 2008 and December 2018, 522 patients were treated with open abdomen and staged lavage. The mean age of the patients was 66.0 years (standard deviation (SD) 15.9 years). A median incision was used in 140 cases, and transverse laparotomy was performed in 382. The mean SAPS-II score was 46.5 (SD 15.7), expected lethality was 39.6% (SD 26.3%), and observed lethality was 19.9%. On average, two lavages were performed after the index operation. Transverse incision was significantly less likely to cause wound-healing disorder (p=0.03), and fascial dehiscence was observed less frequently in the transverse laparotomies group than in median incisions in the statistical trend (p=0.06).

Conclusion: In summary, staged lavage reduced expected lethality in patients with peritonitis. Transverse incision caused wound-healing disorders and fascial dehiscence less often. Therefore, the indication for transverse laparotomy should be generous, as this form of treatment is advantageous in case of peritonitis.

A differentiated approach to repeat small-bowel anastomoses in patients with postoperative peritonitis: a prospective cohort study

BACKGROUND

Postoperative peritonitis still remains the cause of a high mortality rate in emergency abdominal surgery. Here we aimed to evaluate the efficacy of different surgical strategies for small-bowel perforations that resulted in postoperative peritonitis.

METHODS

Surgical management results for 140 patients with postoperative peritonitis due to small-bowel perforations, necrosis and anastomotic leakage were comparatively analyzed. Using the APACHE-II and MPI scoring systems, different surgeon attitudes were examined in three patient groups (primary anastomosis, delayed anastomosis, and enterostomy).

RESULTS

The surgical approach in patient group I (n = 47, APACHE-II 11.7 ± 1.2, MPI 14.7 ± 1.3) involved the closure of small-bowel perforations or small-bowel resection to place primary anastomosis. The mortality rate was 17%. Patient group II (n = 48, APACHE-II 16.8 ± 0.7, MPI 19.3 ± 0.3) underwent delayed small-bowel anastomosis during planned relaparotomies. The mortality rate was 18.8%. Because patients in patient group III (n = 45, APACHE-II 22.3 ± 1.3, MPI 24.6 ± 1.2) were in very critical condition, anastomoses were not placed after bowel resection, and the surgical procedure was completed with enterostomy. The highest mortality rate of 37.8% was documented in this patient group.

CONCLUSION

The differentiated surgical approach undertaken herein using delayed small-bowel anastomosis in more serious patients with postoperative peritonitis was able to mitigate the risk of recurrent anastomotic leaks and was not accompanied by a considerable rise in mortality. The mortality for primary repair and delayed primary closure was basically the same (17.0% and 18.8%, p = 0.03); however, delayed anastomosis in the patients with postoperative peritonitis at higher APACHE-II and MPI scores for severity of illness showed 15.1% less complications in the form of anastomotic leaks (p = 0.04).