1
|
Acosta S. Laparostomy May Be Indicated Either When The Abdomen Cannot Be Closed or Should Not Be Closed. Eur J Vasc Endovasc Surg 2024; 67:611. [PMID: 37839662 DOI: 10.1016/j.ejvs.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Stefan Acosta
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden; Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.
| |
Collapse
|
2
|
Atemnkeng F, Al-Ttkrit A, David S, Alataby H, Nagaraj A, Diaz K, Nfonoyim J. An Unusual Case of Intraabdominal Abscess After a Colonoscopy With Polypectomy. J Med Cases 2021; 12:301-305. [PMID: 34434477 PMCID: PMC8383595 DOI: 10.14740/jmc3730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/15/2021] [Indexed: 11/11/2022] Open
Abstract
The use of colonoscopies in the screening of colorectal cancers has helped in the early detection and treatment of these cancers. Less than 0.5% of patients develop colonoscopy complications, mostly bleeding, and less frequently, perforations. There have been very few reported cases of micro-perforations following colonoscopies. We present a case of a 66-year-old female smoker who had undergone a screening colonoscopy for colorectal cancer with two polyps removed 3 weeks prior, who was brought to the hospital because of altered mental status and hypotension. A computed tomography (CT) scan of the abdomen and pelvis with contrast demonstrated intraabdominal abscess which was drained by interventional radiology. A culture of the pus grew Streptococcus constellatus, a pus-forming bacterium. She was treated with ceftriaxone and metronidazole for a total of 6 weeks, and a repeat CT of abdomen and pelvis demonstrated complete resolution. The only contributing factor to the formation of the intraabdominal abscess was a screening colonoscopy with polypectomy, which might have caused micro-perforations in the colon with the seeding of Streptococcus constellatus. The occurrence of intraabdominal abscess following a colonoscopy is very rare, and requires a high index of suspicion in patients who present with sepsis following colonoscopies.
Collapse
Affiliation(s)
| | - Amna Al-Ttkrit
- Richmond University Medical Center, Staten Island, NY, USA
| | - Sharoon David
- Richmond University Medical Center, Staten Island, NY, USA
| | - Harith Alataby
- Richmond University Medical Center, Staten Island, NY, USA
| | | | - Keith Diaz
- Richmond University Medical Center, Staten Island, NY, USA
| | - Jay Nfonoyim
- Richmond University Medical Center, Staten Island, NY, USA
| |
Collapse
|
3
|
Outcome in patients with open abdomen treatment for peritonitis: a multidomain approach outperforms single domain predictions. J Clin Monit Comput 2021; 36:1109-1119. [PMID: 34247307 PMCID: PMC9294021 DOI: 10.1007/s10877-021-00743-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/07/2021] [Indexed: 11/12/2022]
Abstract
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.
Collapse
|
4
|
Ramirez Mendez LN, Vega-Peña NV, Domínguez-Torres LC. Abdomen abierto y cierre temprano de la pared abdominal. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
El abdomen abierto es una opción terapéutica en pacientes críticamente enfermos. Se utiliza cuando el cierre de la cavidad abdominal no puede o no debe ser realizado. No obstante, su utilidad como parte de una estrategia tradicionalmente aceptada ha disminuido, en la medida en que se han incrementado las secuelas en la pared abdominal, en especial la hernia ventral. Los procedimientos requeridos para la reconstrucción anatómica y funcional de la pared abdominal, como parte del tratamiento de una hernia ventral, revisten una alta complejidad y constituyen un nuevo escenario quirúrgico. Igualmente, conllevan incertidumbre respecto a su naturaleza y posibles complicaciones, además de que condicionan mayores gastos al sistema de salud. Para evitar los problemas del cierre tardío de la pared abdominal, se han desarrollado alternativas para superar el abordaje tradicional de “tratar y esperar”, hacia “tratar y reconstruir” tempranamente. El objetivo de la presente revisión es realizar una descripción de los principales avances en el tratamiento del abdomen abierto y el papel del cierre temprano de la pared abdominal, haciendo énfasis en la importancia de un cambio conceptual en el mismo.
Collapse
|
5
|
Petersen S, Deder A, Prause A, Pohland C, Richter D, Mansfeld T, Puhl G. Transverse vs. median laparotomy in peritonitis and staged lavage: a single center case series. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc07. [PMID: 32973421 PMCID: PMC7492753 DOI: 10.3205/000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/22/2020] [Indexed: 12/02/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sven Petersen
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - Alice Deder
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - Axel Prause
- Department of Anesthesia, Intensive Care & Emergency, Asklepios Hospital Altona, Hamburg, Germany
| | - Christopher Pohland
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - Dominik Richter
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - Thomas Mansfeld
- Department of Surgery, Westklinikum Hamburg Rissen, Hamburg, Germany
| | - Gero Puhl
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| |
Collapse
|
6
|
Zosimas D, Lykoudis PM, Ivanov B, Hepworth C. Laparostomy and temporary abdominal closure outcomes in emergency non-trauma surgery and parameters affecting early definite primary fascial closure. MINERVA CHIR 2020; 75:419-425. [PMID: 32456399 DOI: 10.23736/s0026-4733.20.08320-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The open abdomen or laparostomy is a great advance of surgery based on the concept of damage control surgery. Aim of the study is to review the laparostomy outcomes of non-trauma emergency surgery patients in a district general hospital and identify parameters affecting early definite primary fascial closure. METHODS The records of all non-trauma emergency surgical patients who underwent laparostomy in a three-year period in a single institute were studied retrospectively. Outcomes included length of stay, morbidity, mortality, readmission rates, number of re-look operations, rate of definite primary fascial closure and time to closure. RESULTS Thirty-two patients were included. Morbidity was 84.4% and mortality rates were 21.9% (in-hospital), 18.8% (30-day) and 46.9% (overall). Median length of hospital stay was 22 days. Rate of primary fascial closure was 87.5% and median time to closure was two days. The number of relook operations was the only independent prognostic factor of definite early primary fascial closure, with higher rates of closure in patients with 1-2 relooks. CONCLUSIONS Although the open abdomen has been demonstrated to improve survival, the precise role in abdominal sepsis has not been elucidated. Current consensus does not support use of open abdomen routinely, however in selected situations it becomes unavoidable. Laparostomy is a valid option in non-trauma emergency surgery and can be managed safely in a district hospital. High closure rates can be achieved if one or two re-look operations are performed with an early attempt for closure.
Collapse
Affiliation(s)
- Dimitrios Zosimas
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK -
| | - Panagis M Lykoudis
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Bogdan Ivanov
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK
| | - Clive Hepworth
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK
| |
Collapse
|
7
|
Outcomes of open abdomen versus primary closure following emergent laparotomy for suspected secondary peritonitis: A propensity-matched analysis. J Trauma Acute Care Surg 2019; 87:623-629. [DOI: 10.1097/ta.0000000000002345] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
8
|
Scheingraber S, Boehme J, Scharbert G, Dralle H. Monitoring of Acid-base and Regulating Variables during Abdominal Lavage. Anaesth Intensive Care 2019; 32:637-43. [PMID: 15535485 DOI: 10.1177/0310057x0403200505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This prospective clinical study was performed to determine acid-base regulating variables during abdominal lavage treatment for patients with severe peritonitis or after abdominal surgery. Arterial blood was sampled from twelve patients with secondary peritonitis and nine patients after abdominal surgery without peritonitis at three time points: immediately before, immediately after and 15 minutes after abdominal lavage with normal saline solution. The total++ – amount of irrigant fluid, the strong ion difference [(Na+ +K+)-(Cl- +lactate-)], and total protein concentrations were determined and standard bicarbonate, standard base excess were calculated from pH and PaCO2. Peritonitis patients developed a moderate alkalaemia (pH 7.440-7.485). The alkalaemia was unmasked after optimization of mild hypoventilation, but was supported by a decrease in protein concentration of about 3.4 mEql/l in the first 15 minutes after the lavage. There was no marked increase in chloride concentration in either the peritonitis or the control group. The data indirectly exclude major fluid absorption during abdominal lavage with 3000 to 6000 ml normal saline, given that we found no clinically relevant electrolyte and acid-base changes that might be expected after rapid fluid absorption. The factors of major influence in acid-base regulation were ventilation and protein loss in the course of abdominal lavage. Monitoring of the Stewart variables is an easily applicable method of monitoring acid-base regulating variables in the perioperative course of patients undergoing abdominal lavage therapy.
Collapse
Affiliation(s)
- S Scheingraber
- Department of Surgery, University Hospital, Homburg/Saar, Halle/Saale, Germany
| | | | | | | |
Collapse
|
9
|
Coccolini F, Montori G, Ceresoli M, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Sartelli M, De Moya M, Velmahos G, Fraga GP, Pereira BM, Leppaniemi A, Boermeester MA, Kirkpatrick AW, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Martin-Loeches I, Sugrue M, Di Saverio S, Griffiths E, Soreide K, Mazuski JE, May AK, Montravers P, Melotti RM, Pisano M, Salvetti F, Marchesi G, Valetti TM, Scalea T, Chiara O, Kashuk JL, Ansaloni L. The role of open abdomen in non-trauma patient: WSES Consensus Paper. World J Emerg Surg 2017; 12:39. [PMID: 28814969 PMCID: PMC5557069 DOI: 10.1186/s13017-017-0146-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
Collapse
Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | | | - Rao Ivatury
- Trauma Surgery, Virginia Commonwealth University, Richmond, VA 23284 USA
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI 96813 USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, 15213 USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, 92103 USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Marc De Moya
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM) – Unicamp Campinas, São Paulo, Brazil
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, 98104 USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | | | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ewen Griffiths
- Upper Gatrointestinal Surgery, Birmigham Hospital, Birmigham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, MO 63130 USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN 37232 USA
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | | | - Michele Pisano
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Trauma Surgery department, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy
| | - Jeffry L. Kashuk
- General Surgery department, Assuta Medical Centers, Tel Aviv, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| |
Collapse
|
10
|
Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 306] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
Collapse
Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
| |
Collapse
|
11
|
Abstract
Secondary peritonitis remains associated with high mortality and morbidity rates. Treatment of secondary peritonitis is challenging even in modern medicine. Surgical intervention for source control remains the cornerstone of treatment, beside adequate antimicrobial therapy and resuscitation. A randomized clinical trial showed that relaparotomy on demand (ROD) after initial emergency surgery is the preferred treatment strategy, irrespective of the severity and extent of peritonitis. The effective and safe use of ROD requires intensive monitoring of the patient in a setting where diagnostic tests and decision making about relaparotomy are guaranteed round the clock. The lack of knowledge on timely and adequate patient selection, together with the lack of use of easy but reliable monitoring tools, seems to hamper full implementation of ROD. The accuracy of the relap decision tool is reasonable for prediction of ongoing peritonitis and selection for computer tomography (CT). The value of CT in an early postoperative phase is unclear. Future research and innovative technologies should focus on the additive value of CT in cases of operated secondary peritonitis and on the further optimization of bedside prediction tools to enhance adequate patient selection for intervention in a multidisciplinary setting.
Collapse
Affiliation(s)
- O van Ruler
- Department of Surgery, Academic Medical Center, 1100 DD, P.O. Box 22660, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Center, 1100 DD, P.O. Box 22660, Amsterdam, The Netherlands.
| |
Collapse
|
12
|
van Ruler O, Boermeester MA. [Surgical treatment of secondary peritonitis: A continuing problem. German version]. Chirurg 2015; 87:13-9. [PMID: 26689581 DOI: 10.1007/s00104-015-0115-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Secondary peritonitis remains associated with high mortality and morbidity rates. Treatment of secondary peritonitis is still challenging even in the era of modern medicine. Surgical intervention for source control remains the cornerstone of treatment besides adequate antimicrobial therapy and when necessary intensive medical care measures and resuscitation. A randomized clinical trial showed that relaparotomy on demand (ROD) after initial emergency surgery was the preferred treatment strategy, irrespective of the severity and extent of peritonitis. RESULTS AND DISCUSSION The effective and safe use of ROD requires intensive monitoring of the patient in a setting where diagnostic tests and decision making about relaparotomy are guaranteed round the clock. The lack of knowledge on timely and adequate patient selection, together with the lack of use of easy but reliable monitoring tools seem to hamper full implementation of ROD. The accuracy of the relaparotomy decision tool is reasonable for prediction of the formation of peritonitis and necessary selection of patients for computed tomography (CT). The value of CT in the early postoperative phase is unclear. Future research and innovative technologies should focus on the additive value of CT after surgical treatment for secondary peritonitis and on the further optimization of bedside prediction tools to enhance adequate patient selection for interventions in a multidisciplinary setting.
Collapse
Affiliation(s)
- O van Ruler
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, Niederlande
| | - M A Boermeester
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, Niederlande.
| |
Collapse
|
13
|
Membrilla-Fernández E, Sancho-Insenser JJ, Girvent-Montllor M, Álvarez-Lerma F, Sitges-Serra A. Effect of initial empiric antibiotic therapy combined with control of the infection focus on the prognosis of patients with secondary peritonitis. Surg Infect (Larchmt) 2015; 15:806-14. [PMID: 25397738 DOI: 10.1089/sur.2013.240] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In patients with intra-abdominal infection, inappropriate initial empiric antibiotic therapy is associated with greater morbidity. We evaluated the impact of adequate empiric antibiotic treatment together with control of the infection focus on the morbidity and mortality rates of patients with secondary peritonitis. METHODS This was a prospective, observational study with the participation of 24 Spanish hospitals and 362 patients with secondary peritonitis (262 community-acquired, 100 post-operative). Therapeutic failure (infectious complications or death) was classified into four categories according to whether empiric antibiotic treatment was appropriate and the infection focus was controlled. RESULTS The rates of therapeutic failure, re-operation, and mortality were 48%, 13%, and 8%, respectively. Empiric antibiotic treatment was inappropriate in 39% of cases, which was associated with a higher rate of surgical site infection (53% vs. 40%; p=0.031) and death (12% vs. 5%; p=0.021) than was observed in patients receiving appropriate initial empiric therapy. Eight percent of patients in whom control of the infection focus was not obtained suffered from more infectious complications (76% vs. 52%; p=0.01) and surgical site infections (69% vs. 44%; p=0.01); and in this group, both therapeutic failure and mortality rates were similar, independent of whether the empiric antibiotic therapy was appropriate. CONCLUSION Inappropriate initial empiric antibiotic therapy was associated with higher rates of therapeutic failure, surgical site infection, re-operation, and death. Classification of therapeutic failure into four categories according to the appropriateness of empiric antibiotic therapy and the success of infection control provided excellent discrimination of morbidity and death.
Collapse
Affiliation(s)
- Estela Membrilla-Fernández
- 1 Unit of Emergency Surgery and Service of General and Digestive Surgery, Universitat Autònoma de Barcelona , Barcelona, Spain
| | | | | | | | | | | |
Collapse
|
14
|
Mabewa A, Seni J, Chalya PL, Mshana SE, Gilyoma JM. Etiology, treatment outcome and prognostic factors among patients with secondary peritonitis at Bugando Medical Centre, Mwanza, Tanzania. World J Emerg Surg 2015; 10:47. [PMID: 26448784 PMCID: PMC4595331 DOI: 10.1186/s13017-015-0042-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 09/27/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Secondary peritonitis due to perforation of the gastrointestinal tract is one of the most common surgical emergencies all over the world and is associated with significantly morbidity and mortality. Previous studies conducted at Bugando Medical Centre (BMC) were retrospective and each was focused on single etiology; therefore there was an obvious need to evaluate the etiologies, treatment outcome and their prognostic factors altogether. METHODS This was a descriptive cross-sectional study involving patients with secondary peritonitis admitted at BMC from May 2014 to April 2015. Sociodemographic and clinical characteristics among consented patients were collected using questionnaires. Peritoneal aspirate, biopsy and blood were collected perioperatively and processed using standard operating procedures. Analysis was done using STATA version 11 software. RESULTS The study enrolled 97 patients with the female to male ratio of 1:1.8 and approximately 41.2 % (40/97) were in their third and fourth decades of life. Only 3 (3.09 %) patients arrived to the hospital within 24 hours of onset of illness, 26 (26.80 %) patients presented with shock and HIV seropositivity among all patients was 13.40 % (13/97). The common etiologies of secondary peritonitis were perforated appendicitis 23 (23.71 %), peptic ulcer disease 18 (18.56 %), ischemia 18 (18.56 %) and typhoidal perforation 15 (15.46 %). Of the 97 patients, 35 (36.08 %) had complications and 15 (15.46 %) died. Presence of premorbid illness and post-operative complication were found to be associated with death (p values = 0.004 and <0.001 respectively). CONCLUSIONS The most common etiologies of secondary peritonitis at BMC are perforated appendicitis, peptic ulcer disease, ischemia and typhoidal perforation. Premorbid illness and postoperative complications in this setting are associated with death and as the matter of fact proper screening on admission should be done to identify patients with premorbid illness and confer prompt management.
Collapse
Affiliation(s)
- Amri Mabewa
- Department of Surgery, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania ; Department of Surgery, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania
| | - Jeremiah Seni
- Department of Microbiology and Immunology, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania
| | - Phillipo L Chalya
- Department of Surgery, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania ; Department of Surgery, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania
| | - Stephen E Mshana
- Department of Microbiology and Immunology, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania
| | - Japhet M Gilyoma
- Department of Surgery, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania ; Department of Surgery, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania
| |
Collapse
|
15
|
Coccolini F, Biffl W, Catena F, Ceresoli M, Chiara O, Cimbanassi S, Fattori L, Leppaniemi A, Manfredi R, Montori G, Pesenti G, Sugrue M, Ansaloni L. The open abdomen, indications, management and definitive closure. World J Emerg Surg 2015; 10:32. [PMID: 26213565 PMCID: PMC4515003 DOI: 10.1186/s13017-015-0026-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/10/2015] [Indexed: 12/17/2022] Open
Abstract
The indications for Open Abdomen (OA) are generally all those situations in which is ongoing the development an intra-abdominal hypertension condition (IAH), in order to prevent the development of abdominal compartmental syndrome (ACS). In fact all those involved in care of a critically ill patient should in the first instance think how to prevent IAH and ACS. In case of ACS goal directed therapy to achieve early opening and early closure is the key: paradigm of closure shifts to combination of therapies including negative pressure wound therapy and dynamic closure, in order to reduce complications and avoid incisional hernia. There have been huge studies and progress in survival of critically ill trauma and septic surgical patients: this in part has been through the great work of pioneers, scientific societies and their guidelines; however future studies and continued innovation are needed to better understand optimal treatment strategies and to define more clearly the indications, because OA by itself is still a morbid procedure.
Collapse
Affiliation(s)
- Federico Coccolini
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Fausto Catena
- />General surgery Department, Ospedale Maggiore, Parma, Italy
| | - Marco Ceresoli
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Osvaldo Chiara
- />Niguarda Trauma Center, Ospedale Niguarda Ca’Granda, Milan, Italy
| | | | - Luca Fattori
- />Unità Operativa di Chirurgia d’Urgenza, Azienda Ospedaliera “San Gerardo”, Monza, Italy
| | - Ari Leppaniemi
- />Department of Abdominal Surgery, University of Helsinki, Helsinki, Finland
| | - Roberto Manfredi
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giovanni Pesenti
- />Unità Operativa di Chirurgia d’Urgenza, Azienda Ospedaliera “San Gerardo”, Monza, Italy
| | - Michael Sugrue
- />Letterkenny Hospital and the Donegal Clinical Research Academy, Donegal, Ireland
- />University College Hospital, Galway, Ireland
| | - Luca Ansaloni
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| |
Collapse
|
16
|
Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA, Biffl WL, Catena F, Chiara O, Coccolini F, Coimbra R, Demetrashvili Z, Demetriades D, Diaz JJ, Di Saverio S, Fraga GP, Ghnnam W, Griffiths EA, Gupta S, Hecker A, Karamarkovic A, Kong VY, Kafka-Ritsch R, Kluger Y, Latifi R, Leppaniemi A, Lee JG, McFarlane M, Marwah S, Moore FA, Ordonez CA, Pereira GA, Plaudis H, Shelat VG, Ulrych J, Zachariah SK, Zielinski MD, Garcia MP, Moore EE. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg 2015; 10:35. [PMID: 26269709 PMCID: PMC4534034 DOI: 10.1186/s13017-015-0032-7] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/03/2015] [Indexed: 02/07/2023] Open
Abstract
The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.
Collapse
Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Walter L. Biffl
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, USA
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca’ Granda Hospital, Milan, Italy
| | | | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Science, San Diego, USA
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Demetrios Demetriades
- Trauma, Emergency Surgery, Surgical Critical Care, University of Southern California, Los Angeles, USA
| | - Jose J. Diaz
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | | | - Gustavo P. Fraga
- Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Wagih Ghnnam
- Department of Surgery Mansoura, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Sanjay Gupta
- Department of Surgery Government Medical College and Hospital, Chandigarh, India
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | | | - Victor Y. Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, Republic of South Africa
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Thorax and Transplant Surgery, University of Innsbruck, Innsbruck, Austria
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Rifat Latifi
- Department of Surgery, Trauma Research Institute, University of Arizona, Tucson, AZ USA
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Michael McFarlane
- Department of Surgery, University Hospital of the West Indies, Kingston, Jamaica
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | | | - Carlos A. Ordonez
- Department of Surgery, Fundación Valle del Lili, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Gerson Alves Pereira
- Division of Emergency and Trauma Surgery, Ribeirão Preto Medical School, Ribeirão Preto, Brazil
| | - Haralds Plaudis
- Department of General and Emergency Surgery, Riga East Clinical University Hospital “Gailezers”, Riga, Latvia
| | - Vishal G. Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jan Ulrych
- 1st Surgical Department of First Faculty of Medicine, General University Hospital, Prague Charles University, Prague, Czech Republic
| | | | | | - Maria Paula Garcia
- Centro de investigaciones clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, USA
| |
Collapse
|
17
|
Rausei S, Dionigi G, Boni L, Rovera F, Minoja G, Cuffari S, Dionigi R. Open Abdomen Management of Intra-Abdominal Infections: Analysis of a Twenty-Year Experience. Surg Infect (Larchmt) 2014; 15:200-6. [DOI: 10.1089/sur.2012.180] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Stefano Rausei
- Department of Surgery, University of Insubria, Varese, Italy
| | | | - Luigi Boni
- Department of Surgery, University of Insubria, Varese, Italy
| | | | - Giulio Minoja
- Department of Critical Care Medicine, University of Insubria, Varese, Italy
| | | | - Renzo Dionigi
- Department of Surgery, University of Insubria, Varese, Italy
| |
Collapse
|
18
|
Kiewiet JJS, van Ruler O, Boermeester MA, Reitsma JB. A decision rule to aid selection of patients with abdominal sepsis requiring a relaparotomy. BMC Surg 2013; 13:28. [PMID: 23870702 PMCID: PMC3750491 DOI: 10.1186/1471-2482-13-28] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 07/11/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accurate and timely identification of patients in need of a relaparotomy is challenging since there are no readily available strongholds. The aim of this study is to develop a prediction model to aid the decision-making process in whom to perform a relaparotomy. METHODS Data from a randomized trial comparing surgical strategies for relaparotomy were used. Variables were selected based on previous reports and common clinical sense and screened in a univariable regression analysis to identify those associated with the need for relaparotomy. Variables with the strongest association were considered for the prediction model which was constructed after backward elimination in a multivariable regression analysis. The discriminatory capacity of the model was expressed with the area under the curve (AUC). A cut-off analysis was performed to illustrate the consequences in clinical practice. RESULTS One hundred and eighty-two patients were included; 46 were considered cases requiring a relaparotomy. A prediction model was build containing 6 variables. This final model had an AUC of 0.80 indicating good discriminatory capacity. However, acceptable sensitivity would require a low threshold for relaparotomy leading to an unacceptable rate of negative relaparotomies (63%). Therefore, the prediction model was incorporated in a decision rule were the interval until re-assessment and the use of Computed Tomography are related to the outcome of the model. CONCLUSIONS To construct a prediction model that will provide a definite answer whether or not to perform a relaparotomy seems a utopia. However, our prediction model can be used to stratify patients on their underlying risk and could guide further monitoring of patients with abdominal sepsis in order to identify patients with suspected ongoing peritonitis in a timely fashion.
Collapse
Affiliation(s)
- Jordy J S Kiewiet
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.
| | | | | | | |
Collapse
|
19
|
Kreis BE, de Mol van Otterloo AJ, Kreis RW. Open abdomen management: a review of its history and a proposed management algorithm. Med Sci Monit 2013; 19:524-33. [PMID: 23823991 PMCID: PMC3706408 DOI: 10.12659/msm.883966] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 05/10/2013] [Indexed: 12/13/2022] Open
Abstract
In this review we look into the historical development of open abdomen management. Its indication has spread in 70 years from intra-abdominal sepsis to damage control surgery and abdominal compartment syndrome. Different temporary abdominal closure techniques are essential to benefit the potential advantages of open abdomen management. Here, we discuss the different techniques and provide a new treatment strategy, based on available evidence, to facilitate more consistent decision making and further research on this complicated surgical topic.
Collapse
|
20
|
Trastulli S, Cirocchi R, Boselli C, Noya G, Guarino S. Planned relaparotomy versus relaparotomy on demand for treatment of secondary peritonitis. Hippokratia 2013. [DOI: 10.1002/14651858.cd010396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Roberto Cirocchi
- University of Perugia; Department of General Surgery; Terni Italy
| | - Carlo Boselli
- University of Perugia; Department of General Surgery; Terni Italy
| | - Giuseppe Noya
- University of Perugia; Department of General Surgery; Terni Italy
| | - Salvatore Guarino
- Royal Free Hospital - UCL Partner; University Department of Surgery; Pond Street London UK NW3 2QG
| |
Collapse
|
21
|
Abstract
Planned ventral hernia is a management strategy in which the abdominal fascial layer has been left unclosed and the viscera are covered only with original or grafted skin. Leaving the fascia open can be deliberate or unavoidable and most commonly results from staged repair of the abdominal wall due to trauma, peritonitis, pancreatitis, abdominal vascular emergencies, or abdominal compartment syndrome. The abdominal wall defects can be categorized as type I or II defects depending on whether there is intact, stable skin coverage. In defects with intact skin coverage, the most commonly used methods are the components separation technique and a prosthetic repair, sometimes used in combination. The advantages of the components separation technique is the ability to close the linea alba at the midline, creating a better functional result than a repair with inert mesh. Although the reherniation risk seems higher after components separation, the risk of infection is considerably lower. With a type II defect, with absent or unstable skin coverage, fascial repair alone is inadequate. Of the more complex reconstruction techniques, the use of a free tensor fasciae latae (TFL) flap utilizing a saphenous vein arteriovenous loop is the most promising. The advantages of the TFL flap include constant anatomy of the pedicle, a strong fascial layer, large-caliber vessels matching the size of the AV loop, and the ability to use large flaps (up to 20 × 35 cm). Whatever technique is used, the repair of complex abdominal wall defects requires close collaboration with plastic and abdominal surgeons, which is best managed in specialized centers.
Collapse
|
22
|
van Ruler O, Kiewiet JJS, Boer KR, Lamme B, Gouma DJ, Boermeester MA, Reitsma JB. Failure of available scoring systems to predict ongoing infection in patients with abdominal sepsis after their initial emergency laparotomy. BMC Surg 2011; 11:38. [PMID: 22196238 PMCID: PMC3268736 DOI: 10.1186/1471-2482-11-38] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 12/23/2011] [Indexed: 12/25/2022] Open
Abstract
Background To examine commonly used scoring systems, designed to predict overall outcome in critically ill patients, for their ability to select patients with an abdominal sepsis that have ongoing infection needing relaparotomy. Methods Data from a RCT comparing two surgical strategies was used. The study population consisted of 221 patients at risk for ongoing abdominal infection. The following scoring systems were evaluated with logistic regression analysis for their ability to select patients requiring a relaparotomy: APACHE-II score, SAPS-II, Mannheim Peritonitis Index (MPI), MODS, SOFA score, and the acute part of the APACHE-II score (APS). Results The proportion of patients requiring a relaparotomy was 32% (71/221). Only 2 scores had a discriminatory ability in identifying patients with ongoing infection needing relaparotomy above chance: the APS on day 1 (AUC 0.61; 95%CI 0.52-0.69) and the SOFA score on day 2 (AUC 0.60; 95%CI 0.52-0.69). However, to correctly identify 90% of all patients needing a relaparotomy would require such a low cut-off value that around 80% of all patients identified by these scoring systems would have negative findings at relaparotomy. Conclusions None of the widely-used scoring systems to predict overall outcome in critically ill patients are of clinical value for the identification of patients with ongoing infection needing relaparotomy. There is a need to develop more specific tools to assist physicians in their daily monitoring and selection of these patients after the initial emergency laparotomy. Trial registration number ISRCTN: ISRCTN 51729393
Collapse
Affiliation(s)
- Oddeke van Ruler
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
23
|
|
24
|
Anderson O, Putnis A, Bhardwaj R, Ho-Asjoe M, Carapeti E, Williams AB, George ML. Short- and long-term outcome of laparostomy following intra-abdominal sepsis. Colorectal Dis 2011; 13:e20-32. [PMID: 21040361 DOI: 10.1111/j.1463-1318.2010.02441.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM This study reports the short- and long-term outcomes of laparostomy for intra-abdominal sepsis. METHOD Twenty-nine sequential patients with intra-abdominal sepsis treated with a laparostomy over 6 years were included. RESULTS The median age of the patients was 51 years, postoperative intensive care unit stay was 8 days, postoperative length of hospital stay was 87 days and follow up was 2 years. The expected mortality of 25% was insignificantly different from the observed mortality of 33% (P = 0.35). Seven per cent of patients required percutaneous drainage of intra-abdominal collections. An enterocutaneous fistula developed in 31% of all patients and in 15% of those treated with vacuum dressings. Component-separation fascial reconstruction was successful and uncomplicated in 83% of recipients compared with 25% of mesh repairs. CONCLUSION Laparostomy does not significantly reduce mortality from the expected rate and commits the patient to a prolonged recovery with a high risk of enterocutaneous fistulation. Component-separation fascial reconstruction has a better outcome than mesh repair.
Collapse
Affiliation(s)
- O Anderson
- Departments of Colorectal Surgery Plastic Surgery, St Thomas' Hospital, London, UK.
| | | | | | | | | | | | | |
Collapse
|
25
|
Pressure at the Bowel Surface during Topical Negative Pressure Therapy of the Open Abdomen: An Experimental Study in a Porcine Model. World J Surg 2011; 35:917-23. [DOI: 10.1007/s00268-010-0937-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
26
|
Torer N, Yorganci K, Elker D, Sayek I. Prognostic factors of the mortality of postoperative intraabdominal infections. Infection 2010; 38:255-60. [PMID: 20393782 DOI: 10.1007/s15010-010-0021-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Accepted: 03/17/2010] [Indexed: 12/27/2022]
Abstract
PURPOSE We investigated the relationship between the prognostic factors of postoperative peritonitis and mortality. METHODS Data from 56 patients re-operated for postoperative secondary peritonitis in our hospital between 1991 and 2001 were collected retrospectively. Demographic features, comorbidity, malignancy, organ failure, type and timing of the primary operation, intraoperative findings, etiology of postoperative peritonitis, number of relaparotomies, source control failure, Mannheim peritonitis index (MPI), and mortality were noted. The time intervals between the first operation and relaparotomy, and between symptom onset and the second operation were also noted. RESULTS The overall mortality rate was 32% (n = 18). Organ failure (p = 0.001), time elapse between symptoms and the second operation (p = 0.046), severity of peritonitis (p = 0.035), source control failure (0.047), and MPI scores (p = 0.032) were significantly related with the mortality of postoperative peritonitis in a univariate analysis. MPI score >30 had a higher mortality rate. CONCLUSION Delaying relaparotomy for more than 24 h and presence of organ failure result in higher mortality.
Collapse
Affiliation(s)
- N Torer
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | | | | | | |
Collapse
|
27
|
Cheadle W, Lee JT, Napolitano LM, Nichols RL. Clinical Update on the Use of Moxifloxacin in the Treatment of Community-Acquired Complicated Intraabdominal Infections. Surg Infect (Larchmt) 2010; 11:487-94. [DOI: 10.1089/sur.2009.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- William Cheadle
- Department of Surgery, University of Louisville, Louisville, Kentucky
- Research and Development, Veterans Affairs Medical Center, Louisville, Kentucky
| | - James T. Lee
- Department of Surgery (Retired), University of Minnesota Medical School, Minneapolis, Minnesota
| | - Lena M. Napolitano
- Acute Care Surgery [Trauma, Burn, Critical Care, Emergency Surgery], University of Michigan Health Care System, Ann Arbor, Michigan
- Department of Surgery, University of Michigan Health Care System, Ann Arbor, Michigan
| | - Ronald Lee Nichols
- Department of Surgery-Emeritus, Tulane School of Medicine, New Orleans, Louisiana
| |
Collapse
|
28
|
Abstract
This article is one of ten reviews selected from the Yearbook of Intensive Care and Emergency Medicine 2010 (Springer Verlag) and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/yearbook. Further information about the Yearbook of Intensive Care and Emergency Medicine is available from http://www.springer.com/series/2855.
Collapse
|
29
|
Leppäniemi AK. Laparostomy: Why and When? Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
30
|
Buyne OR, van Goor H, Verweij PE, Bleichrodt RP, Hendriks T. Timing and Dose of Tissue Plasminogen Activator to Prevent Abscess Formation After Surgical Treatment of Secondary Peritonitis in the Rat. Surg Innov 2009; 16:299-305. [DOI: 10.1177/1553350609355807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Early administration of fibrinolytics after surgical treatment of peritonitis in the rat reduces abscess formation. The current study investigates the effect of various treatment protocols using intraperitoneal recombinant tissue plasminogen activator (rtPA). Peritonitis was induced in rats and surgical debridement was performed after 1 hour. Animals were treated with rtPA at different time points. Abdominal fluid samples were taken at 24, 72, and 120 hours for cytokine measurements and cell counts. After 5 days the abdomen was inspected for abscesses. Early administration of rtPA significantly reduced the number of rats with abscesses and the abscess load per rat. Delayed treatment significantly reduced abscess load but not the incidence of abscesses. No meaningful differences in the local inflammatory response were found. rtPA was most effective when applied early and continued for 72 hours, although mortality increased after prolonged treatment. rtPA consistently reduces intra-abdominal abscess formation, and a clinical study seems warranted.
Collapse
Affiliation(s)
- Otmar R. Buyne
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Harry van Goor
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Paul E. Verweij
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Thijs Hendriks
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands,
| |
Collapse
|
31
|
Buyne OR, Bleichrodt RP, De Man BM, Lomme RM, Verweij PE, van Goor H, Hendriks T. Tissue-type plasminogen activator prevents abscess formation but does not affect healing of bowel anastomoses and laparotomy wounds in rats with secondary peritonitis. Surgery 2009; 146:939-46. [DOI: 10.1016/j.surg.2009.04.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 04/22/2009] [Indexed: 01/01/2023]
|
32
|
Surgical Classification of Open Abdomen: Which Clinical Implications? World J Surg 2009; 34:599-600; author reply 601. [DOI: 10.1007/s00268-009-0212-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
33
|
Kennedy R, Jenkins I, Finan PJ. Controversial topics in surgery: Splenic flexure mobilisation for anterior resection performed for sigmoid and rectal cancer. Ann R Coll Surg Engl 2009; 90:638-42. [PMID: 18990277 DOI: 10.1308/003588408x358774] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
|
34
|
Moussavian MR, Richter S, Kollmar O, Schuld J, Schilling MK. Staged lavage versus single high-volume lavage in the treatment of feculent/purulent peritonitis: a matched pair analysis. Langenbecks Arch Surg 2008; 394:215-20. [DOI: 10.1007/s00423-008-0444-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 11/27/2008] [Indexed: 02/06/2023]
|
35
|
Buyne OR, Bleichrodt RP, van Goor H, Verweij PE, Hendriks T. Plasminogen activator, but not systemic antibiotic therapy, prevents abscess formation in an experimental model of secondary peritonitis. Br J Surg 2008; 95:1287-93. [DOI: 10.1002/bjs.6309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Intra-abdominal abscesses are sources of recurrent or ongoing abdominal sepsis. They are an important target for prevention and treatment during or after surgical treatment of peritonitis. Experimental data suggest that fibrinolytic therapy may be effective when antibiotics are not.
Methods
Peritonitis was induced via intra-abdominal injection of a faeces and bacteria mixture in male Wistar rats. Surgical debridement was performed after 1 h. Next to untreated controls, animals were treated with antibiotics (ceftriaxone plus metronidazole), recombinant tissue plasminogen activator (rtPA) or both. Abdominal fluid samples were taken at 24, 72 and 120 h for interleukin 6, interleukin 10 and tumour necrosis factor α measurements and cell counts. After 5 days the abdomen was inspected for the presence of abscesses.
Results
Antibiotics did not significantly affect abscess formation. However, giving rtPA significantly reduced the number of rats with abscesses and the abscess load per rat, both in the absence and presence of concomitant antibiotic therapy. No adverse side-effects were observed and no meaningful differences in the local inflammatory response were found.
Conclusion
In this rat model, rtPA consistently reduced abscess formation after surgical treatment of secondary peritonitis. It therefore represents a promising adjuvant to conventional therapy.
Collapse
Affiliation(s)
- O R Buyne
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - R P Bleichrodt
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Nijmegen University Centre for Infectious Diseases, Nijmegen, The Netherlands
| | - H van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Nijmegen University Centre for Infectious Diseases, Nijmegen, The Netherlands
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Nijmegen University Centre for Infectious Diseases, Nijmegen, The Netherlands
| | - T Hendriks
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Nijmegen University Centre for Infectious Diseases, Nijmegen, The Netherlands
| |
Collapse
|
36
|
Abstract
The choice of optimal concept in the therapy of severe peritonitis is essential to outcome. In approximately 10-15% of patients suffering severe peritonitis, single-stage surgery is not sufficient and additional operative therapy is required. Different therapeutic strategies such as the open-package procedure, staged abdominal repair, and on-demand relaparotomy have been developed for these situations. However, it is difficult to compare the effectiveness of each regimen because stratification tools are lacking. This paper describes advantages and disadvantages of the various therapeutic options in peritonitis and their clinical implementation.
Collapse
|
37
|
Buyne O, van Goor H, Bleichrodt R, Verweij P, Hendriks T. Both tissue-type plasminogen activator and urokinase prevent intraabdominal abscess formation after surgical treatment of peritonitis in the rat. Surgery 2008; 144:66-73. [DOI: 10.1016/j.surg.2008.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2007] [Accepted: 03/31/2008] [Indexed: 11/25/2022]
|
38
|
Intraabdominal Infections. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
39
|
Buyne OR, Bleichrodt RP, van Goor H, Verweij PE, Hendriks T. Tissue-type plasminogen activator prevents formation of intra-abdominal abscesses after surgical treatment of secondary peritonitis in a rat model. Int J Colorectal Dis 2007; 22:819-25. [PMID: 17089129 DOI: 10.1007/s00384-006-0222-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND Optimal therapy of secondary peritonitis frequently results in the formation of residual abscesses, which bear a substantial mortality and morbidity. This study aims to prove that fibrinolytic therapy with recombinant tissue plasminogen activator (rtPA) can reduce abscess formation after surgical treatment of secondary peritonitis in a rat model, without causing unwanted side effects. MATERIALS AND METHODS Male Wistar rats received an intra-abdominal injection with a suspension of sterile feces, 10(5) cfu Escherichia coli and 10(4) cfu Bacteroides fragilis. Surgical debridement was performed 1 h after inoculation. Animals were randomized into four groups (n = 14 each). Three groups received human rtPA at 1 h (rtPA1); 1 h and 6 h (rtPA2); and 1, 6, and 24 h (rtPA3), respectively. Each dose contained 1.25 mg rtPA. Controls received saline only. Animals were killed after 5 days. RESULTS rtPA treatment reduced abscess formation in surviving animals, depending on number of doses given. Animals in group rtPA3 had no abscesses in contrast to 88% of the controls (mean 3.6 +/- 2.7 abscesses per rat; p < 0.05). In the rtPA1 and rtPA2 group, frequency of abscess formation was 58 and 33%, respectively. Mortality, course of body weight, and bacteremia were not affected by rtPA and neither were peritoneal cell counts and levels of TNF-alpha, IL-1beta, IL-6 and IL-10. No bleeding complications were observed. CONCLUSION rtPA reduces intra-abdominal abscess formation after surgical treatment of generalized peritonitis without increasing mortality or affecting the local inflammatory response.
Collapse
Affiliation(s)
- Otmar R Buyne
- Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 91091, 6500, HB Nijmegen, The Netherlands
| | | | | | | | | |
Collapse
|
40
|
Barquist ES, Gomez-Fein E, Block EFJ, Collin G, Alzamel H, Martinez O. Bioavailability of Oral Fluconazole in Critically Ill Abdominal Trauma Patients With and Without Abdominal Wall Closure: a Randomized Crossover Clinical Trial. ACTA ACUST UNITED AC 2007; 63:159-63. [PMID: 17622884 DOI: 10.1097/01.ta.0000232011.59630.93] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with non-apposed fascial edges, known as laparostomy patients, have traditionally been given intravenous medications, because enteral absorption of medications was thought to be unpredictable. We hypothesized that critically ill patients with "open abdomens" would have bioavailability similar to that of matched patients with closed fascial edges. METHODS Fluconazole, a commonly prescribed anti-fungal with good bioavailability was used as a marker of absorption. Postoperative abdominal trauma patients were enrolled in a case-control (laparostomy versus closed abdomen) crossover design study to receive either an oral or parenteral fluconazole (400 mg loading dose followed by 200 mg QD) for one week. After a washout period, the alternate route of administration was used for the second week. Blood levels were collected at the end of each week of therapy. Rectal swab stool specimens were cultured for fungi on days 0, 7, and 15. RESULTS Sixteen patients were studied. The mean injury severity score was 23 (range 9-41). The bioavailability of enteral fluconazole was 51% +/- 30% in the open abdomen and 63% +/- 19% (p = 0.347) in the closed abdomen patients. There was great variation in the bioavailability between the individual patients, with a range of 30%-100% in both groups. Three patients developed rectal colonization with Candida krusei. CONCLUSION The bioavailability of enterally dosed fluconazole was highly variable in both the open and closed abdomen patients. Intravenous administration of pharmaceuticals may provide more reliable serum levels in the first 2 weeks after trauma-related laparotomy.
Collapse
Affiliation(s)
- Erik S Barquist
- DeWitt Daughtry Family Department of Surgery, University of Miami School of Medicine, Miami, Florida 33176, USA.
| | | | | | | | | | | |
Collapse
|
41
|
van Ruler O, Lamme B, Gouma DJ, Reitsma JB, Boermeester MA. Variables associated with positive findings at relaparotomy in patients with secondary peritonitis. Crit Care Med 2007; 35:468-76. [PMID: 17205025 DOI: 10.1097/01.ccm.0000253399.03545.2d] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The decision whether and when to perform a relaparotomy in secondary peritonitis is largely subjective and based on professional experience. No existing scoring system aids in this decisional process. Our aim was to search for variables that could predict positive findings at relaparotomy. DESIGN Retrospective, clinical study. SETTING Tertiary university hospital. PATIENTS Two hundred and nineteen patients of a consecutive series who underwent an emergency laparotomy for secondary peritonitis. INTERVENTIONS None. Sequential prediction models were constructed by accumulation of clinical information in chronological order using logistic regression to determine the strength of association between predictive variables and positive findings at relaparotomy outcome. Positive findings were defined as persistent peritonitis or a new infectious focus at relaparotomy. MEASUREMENTS AND MAIN RESULTS Relaparotomy (planned or on demand) for secondary peritonitis was performed in 117 of 219 patients (53%), yielding either positive (n=62) or negative (n=55) findings. Discriminatory power for positive findings at relaparotomy improved in the successive (multivariate) models: general patient characteristics (area under the curve, 0.60; 95% confidence interval, 0.52-0.68), adding peritonitis-related variables (area under the curve, 0.73; 95% confidence interval, 0.66-0.80), adding operation-related variables (area under the curve, 0.74; 95% confidence interval, 0.67-0.81), and adding postoperative variables (area under the curve, 0.87; 95% confidence interval, 0.82-0.92). Bootstrap resampling reduced the areas under the curve of the subsequent models only slightly. Sensitivity and specificity of the final model were 82% and 76%, respectively, at a total error rate of 16%. One preoperative predictor and five postoperative predictors significantly increased the need for relaparotomy: younger age, decreased hemoglobin levels, temperature>39 degrees C, lower Pao2/Fio2 ratio, increased heart rate, and increased sodium levels. CONCLUSIONS These data suggest that the causes of secondary peritonitis and findings at emergency laparotomy for peritonitis are poor indicators for whether patients will need a relaparotomy. Factors indicative of progressive or persistent organ failure during early postoperative follow-up are the best indicators for ongoing infection and associated positive findings at relaparotomy.
Collapse
Affiliation(s)
- Oddeke van Ruler
- Department of Surgery, Academic Medical Center/University of Amsterdam, the Netherlands
| | | | | | | | | |
Collapse
|
42
|
Abstract
Severe secondary peritonitis carries significant mortality, despite advancements in critical care support and other therapies. Surgical management requires a multidisciplinary approach to guide the timing and the number of interventions necessary to eradicate the septic foci and create optimal healing with the fewest complications. Research is needed regarding the best surgical strategy for very severe cases. The use of deferred primary anastomosis seems safe in patients presenting with hemodynamic instability and hypoperfusion. These patients have a high risk of anastomotic failure and fistula formation. Allowing for aggressive resuscitation and judicious assessment of the progression of local inflammation are safe strategies to achieve the highest success and minimize serious and protracted complications in patients who survive the initial septic insult.
Collapse
Affiliation(s)
- Carlos A. Ordoñez
- Universidad del Valle, Fundación Clínica Valle del Lili, Autopista Simón Bolívar, Carrera 98 No. 18-49, Cali, Colombia
| | - Juan Carlos Puyana
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center Presbyterian, Suite F-1265, 200 Lothrop Street, Pittsburgh, P A 15213, USA
| |
Collapse
|
43
|
Schachtrupp A, Jansen M, Bertram P, Kuhlen R, Schumpelick V. [Abdominal compartment syndrome: significance, diagnosis and treatment]. Anaesthesist 2006; 55:660-7. [PMID: 16775730 DOI: 10.1007/s00101-006-1019-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
A pathological increase of intraabdominal pressure (IAP) is frequently observed in severely ill patients suffering from surgical diseases. This may lead to the abdominal compartment syndrome (ACS) which is characterized by an IAP >20 mmHg (>2.67 kPa) and failure of one or more organ systems. The mortality of ACS exceeds 60%. Knowledge concerning the sequelae of ACS is abundant, however, measurement of IAP is not routinely performed even if patients present with corresponding risk factors. This is probably due to a variable incidence of ACS and scepticism regarding the results of bladder pressure measurement. However, measurement of IAP can now be performed semi-automatically, continuously and in a standardized fashion. The therapy of ACS, i.e. decompression laparotomy and laparostomy, is undisputed. Since a heterogeneous group of patients can be affected, monitoring of IAP is indicated in patients needing intensive care. A consistent registration of IAP will improve knowledge and guidelines regarding the therapy of a pathologically increased IAP. Nevertheless, patients in whom ACS is suspected should be decompressed as soon as possible.
Collapse
Affiliation(s)
- A Schachtrupp
- Klinik für Allgemein-, Gefäss- und Viszeral-Chirurgie, Marienhospital, Rochusstrasse 2, 40479 Düsseldorf
| | | | | | | | | |
Collapse
|
44
|
Abstract
A recent hypothesis postulates that sepsis moves through different phases, with periods of enhanced inflammation alternating with periods of immune suppression. In this study we determined the levels of inflammation present during early and late septic deaths to examine whether death was due to hyperinflammation or immunosuppression. The murine model of sepsis induced by cecal ligation and puncture (CLP) was used. Complete blood counts, plasma interleukin-6 (IL-6) levels, and body weights were determined. Mice that died within the first 4 days had increased plasma levels of IL-6, indicating that there was activation of the immune system. Cecal resection on day 4 after CLP resulted in decreased abscess size, lower circulating neutrophil counts, decreased anemia, and improved survival compared to the results for mice that received only antibiotic and fluid therapy. All of the mice that died in the chronic phase of infection (after day 4) had positive peritoneal cultures containing significantly more bacteria than the cultures for surviving mice. After day 4, none of the surviving mice exhibited increases in the plasma levels of IL-6. Dying mice exhibited mixed IL-6 responses; for 41% of the mice there was never an increase in the IL-6 levels in the chronic phase, while for other mice the levels of IL-6 transiently increased prior to death. Peritoneal macrophages were obtained in the late phase of sepsis from moribund and healthy mice and were stimulated ex vivo. The cells from the moribund mice produced significantly less IL-6 than the cells obtained from healthy mice produced. These results indicate that in mice that die in the early phase there is uniformly increased inflammation. However, during the chronic phase of sepsis, some mice die with evidence of immunosuppression (increased bacterial growth and low IL-6 levels), while other mice die with immunostimulation (high IL-6 levels and bacterial growth). Determining the inflammatory status of individual patients may help guide appropriate, targeted therapy.
Collapse
Affiliation(s)
- Hongyan Xiao
- Department of Pathology, University of Michigan, 2210 Medical Science I Building, 1301 Catherine Road, Ann Arbor, MI 48109-0602, USA
| | | | | |
Collapse
|
45
|
van Till JWO, Lamme B, van Esch TJH, van der Poll T, van Gulik TM, Boermeester MA. Surgical Therapy Attenuates Abdominal and Extra-Abdominal Inflammation in Experimental Peritonitis. Eur Surg Res 2006; 38:76-82. [PMID: 16557024 DOI: 10.1159/000092303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Accepted: 01/26/2006] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study examines the influence of surgical management (elimination of the infectious focus and abdominal lavage) on survival and the inflammatory response in the various compartments of the body: local (abdomen), systemic (blood) and distant organ (lungs). MATERIALS AND METHODS Peritonitis was established in mice by cecal ligation and puncture (CLP). After 24 h, a group was made in which the infected cecum was resected and the abdominal cavity was lavaged (RES), and another group that received no surgical resection (NoRES). Survival was examined over a period of 96 h. Mice were sacrificed at 24 (sham and CLP), 48 and 72 h after CLP to measure inflammatory parameters. RESULTS Survival was significantly lower is NoRES compared to sham and RES (p = 0.006, p = 0.014, respectively). Intraperitoneal parameters were improved in the RES group compared to sham but results were not significantly different between groups. In plasma, levels of interleukin-6 (IL-6) were decreased in RES (p = 0.048). Accordingly, anti-inflammatory IL-10 in plasma was increased in this group (p = 0.031). In the lung, keratinocyte-derived chemokine (KC) and myeloperoxidase (MPO) was reduced indicating decreased granulocytes accumulation in the lung in the RES group (p = 0.012 and p = 0.004, respectively). CONCLUSIONS In experimental secondary peritonitis surgical management improves survival and attenuates the inflammatory response predominantly in the extra-abdominal compartments. This illustrates the importance of surgery in prevention of multiple organ failure and denotes the compartmentalized character of the inflammatory response. This polymicrobial model with implicated surgical intervention reflects the clinical situation and may be more appropriate to test therapeutic interventions than a model involving only CLP.
Collapse
Affiliation(s)
- J W O van Till
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
46
|
Davis SS, Goldblatt MI, Hazey JW, Melvin WS. Unexpected gastrointestinal tract conditions. Curr Probl Surg 2006; 43:74-118. [PMID: 16459160 DOI: 10.1067/j.cpsurg.2005.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- S Scott Davis
- The Ohio State University Medical Center, The Ohio State University School of Medicine and Public Health, USA
| | | | | | | |
Collapse
|
47
|
Lamme B, Mahler CW, van Till JWO, van Ruler O, Gouma DJ, Boermeester MA. [Relaparotomy in secondary peritonitis Planned relaparotomy or relaparotomy on demand?]. Chirurg 2005; 76:856-67. [PMID: 16133555 DOI: 10.1007/s00104-005-1086-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Secondary peritonitis is associated with serious morbidity and a persistent high mortality in recent decades, this despite improvement in antibiotic, intensive care and surgical treatment. The available literature regarding the surgical treatment of secondary peritonitis was searched through Pubmed (1966- January 2005) as well as a hand search of references of retrieved articles. Definitions, pathophysiology and classification of secondary peritonitis are discussed, as well as the scientific rationale for the surgical treatment in secondary peritonitis. The historical development and the scientific foundation of present-day relaparotomy strategies in secondary peritonitis are evaluated, with an emphasis on two frequently applied surgical treatment strategies: planned relaparotomy and relaparotomy on demand. Criteria for relaparotomy after the initial laparotomy and potential areas for further research to reduce both morbidity and mortality are discussed. Furthermore, the care of patients with secondary peritonitis is evolving from a surgical entity to a more multidisciplinary challenge uniting surgeons, intensivists, radiologists and microbiologists. Research needs to be expanded into novel fields to further decrease morbidity and mortality.
Collapse
Affiliation(s)
- B Lamme
- Chirurgische Klinik, Academic Medical Center, Amsterdam, Niederlande
| | | | | | | | | | | |
Collapse
|
48
|
Mkandawire NC. Giant cell tumour of the neck of femur treated by total hip replacement. Malawi Med J 2005; 17:21-8. [PMID: 27528994 PMCID: PMC3346041 DOI: 10.4314/mmj.v17i1.10867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- N C Mkandawire
- Department of Surgery, Queen Elizabeth Central Hospital and College of Medicine, Blantyre, Malawi
| |
Collapse
|
49
|
Mazuski JE. Clinical Challenges and Unmet Needs in the Management of Complicated Intra-abdominal Infections. Surg Infect (Larchmt) 2005. [DOI: 10.1089/sur.2005.6.s-49] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
|
50
|
Agalar F, Eroglu E, Bulbul M, Agalar C, Tarhan OR, Sari M. Staged abdominal repair for treatment of moderate to severe secondary peritonitis. World J Surg 2005; 29:240-4. [PMID: 15645335 DOI: 10.1007/s00268-004-7502-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to evaluate the effects of planned relaparotomy and to assess factors that may contribute to mortality in patients with moderate to severe secondary peritonitis. A total of 36 consecutive patients with an Acute Physiologic and Clinical Health Evaluation (APACHE) II score of >10 were enrolled the study for a 2-year period. The mean age of the patients was 56 years (17-92 years), and 23% of them were male. One-third of them had postoperative peritonitis; 152 scheduled operations were done, and the overall mortality rate was 36%. For patients whose septic source was in the upper gastrointestinal system, control of the source was more difficult (p = 0.004). Overall, 28 complications developed in 61% of the patients. Initial and second-day APACHE II scores were 14.5 (11-27) and 12.0 (9-25), respectively. The initial APACHE II score of survivors was lower than that of nonsurvivors [p = 0.0001, 95% confidence interval (CI) -9.5, -3.6]. Second-day APACHE II scores were not different (p = 0.19; 95% CI -3.79, 0.80). Striking end or lateral duodenal leaks were clearly associated with high mortality. It is found that the initial APACHE II score, the success of controlling the source, the occurrence of complications, and the type of illness are independent factors that may affect mortality. We concluded that staged abdominal repair should be used with caution in the treatment of lateral or end duodenal leaks. It is a good alternative to conventional laparotomy for moderate to severe forms of secondary peritonitis from other sources.
Collapse
Affiliation(s)
- Fatih Agalar
- Department of Surgery, Kirikkale University School of Medicine, Kirikkale, Turkey
| | | | | | | | | | | |
Collapse
|