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

Systems Anesthesiology: Systems of Care Delivery and Optimization in the Operating Room

Anesthesiology presents a challenge to a traditional simplifying approach given the ever-increasing amount of medical data and a more demanding environment. Systems anesthesiology is a modern approach to perioperative care, integrating the complexity of multifactorial knowledge and data to achieve a more adequate representation of reality, while including both patient-related medical aspects as well as economic and organizational challenges. We discuss the value of some innovative technologies such as the emergence of anesthesia information systems, the use of tele-medicine, predictive monitoring, or closed-loop systems as it pertains to the changes in the current standards of care in anesthesiology. Furthermore, we highlight the importance of systems anesthesiology in operating room planning, anesthesia research, and education.

Decision curve analysis confirms higher clinical utility of multi-domain versus single-domain prediction models in patients with open abdomen treatment for peritonitis

BACKGROUND

Prediction modelling increasingly becomes an important risk assessment tool in perioperative systems approaches, e.g. in complex patients with open abdomen treatment for peritonitis. In this population, combining predictors from multiple medical domains (i.e. demographical, physiological and surgical variables) outperforms the prediction capabilities of single-domain prediction models. However, the benefit of these prediction models for clinical decision-making remains to be investigated. We therefore examined the clinical utility of mortality prediction models in patients suffering from peritonitis with a decision curve analysis.

METHODS

In this secondary analysis of a large dataset, a traditional logistic regression approach, three machine learning methods and a stacked ensemble were employed to examine the predictive capability of demographic, physiological and surgical variables in predicting mortality under open abdomen treatment for peritonitis. Calibration was examined with calibration belts and predictive performance was assessed with the area both under the receiver operating characteristic curve (AUROC) and under the precision recall curve (AUPRC) and with the Brier Score. Clinical utility of the prediction models was examined by means of a decision curve analysis (DCA) within a treatment threshold range of interest of 0-30%, where threshold probabilities are traditionally defined as the minimum probability of disease at which further intervention would be warranted.

RESULTS

Machine learning methods supported available evidence of a higher prediction performance of a multi- versus single-domain prediction models. Interestingly, their prediction performance was similar to a logistic regression model. The DCA demonstrated that the overall net benefit is largest for a multi-domain prediction model and that this benefit is larger compared to the default "treat all" strategy only for treatment threshold probabilities above about 10%. Importantly, the net benefit for low threshold probabilities is dominated by physiological predictors: surgical and demographics predictors provide only secondary decision-analytic benefit.

CONCLUSIONS

DCA provides a valuable tool to compare single-domain and multi-domain prediction models and demonstrates overall higher decision-analytic value of the latter. Importantly, DCA provides a means to clinically differentiate the risks associated with each of these domains in more depth than with traditional performance metrics and highlighted the importance of physiological predictors for conservative intervention strategies for low treatment thresholds. Further, machine learning methods did not add significant benefit either in prediction performance or decision-analytic utility compared to logistic regression in these data.

[Surgical wound closure in advanced peritonitis]

To date, mortality in widespread peritonitis is still high (15-20%) and increased up to 70-80% in case of septic shock. Surgeons actively discuss wound closure technique in these patients considering intraoperative findings and severity of illness. The authors present scientific data and opinions of national and foreign surgeons regarding the methods of laparotomy closure. There are still no generally accepted criteria for choosing the method of laparotomy closure in secondary widespread peritonitis. Indications and clinical efficacy of each procedure require additional research.

[Choice of surgical approach and option for completing laparotomy in widespread peritonitis]

OBJECTIVE

To create a system for choosing surgical approach and completing laparotomy in advanced secondary peritonitis via combination of clinical, visual intra-abdominal criteria and systems for predicting the outcomes of peritonitis.

MATERIAL AND METHODS

The study included 686 patients with peritonitis between May 2015 and December 2022. Age of patients ranged from 16 to 95 years (mean 53.4±8.7). Male-to-female ratio was 1.2:11 (377:309). Destructive appendicitis was the cause of peritonitis in 274 (39.9%) patients, gastroduodenal ulcer perforation - 160 (23.3%) patients, colonic perforation - 188 (27.4%) patients, other causes - 64 (9.4%) patients. At baseline, 481 (70.1%) patients underwent diagnostic laparoscopy, and laparoscopic surgery was possible in 302 (62.8%) cases. Primary median laparotomy was performed in 205 (29.9%) patients. The closed method of completing laparotomy was used in 345 patients (77 - 22.3% died), staged elective surgeries - 28 (18 - 64.3% died), open abdomen technique was used in 11 patients (5 - 45.5% died). Redo laparotomy on demand was performed in 44 patients. Of these, 21 (47.7%) ones died. Overall mortality was 15.0% (n=103). The main causes of mortality were sepsis/septic shock (67 cases, 65.0%), acute cardiovascular and respiratory failure (15 patients, 14.6%).

RESULTS

The developed index of approach and completion of surgery in secondary peritonitis is valuable to make a decision on access and completion of surgery in patients with widespread peritonitis.

CONCLUSION

Integral systems for assessment of clinical status and choice of treatment strategy are effective in systematizing the results, evaluating treatment outcomes and conducting researches.

Prognostic Significance of Simple Scoring Systems in the Prediction of Diffuse Peritonitis Morbidity and Mortality

Introduction: Diffuse peritonitis is a serious disease. It is often addressed within urgent management of an unstable patient in shock. The therapy consists of treatment of the source of peritonitis, decontamination of the abdominal cavity, stabilization of the patient and comprehensive resuscitation care in an intensive care unit. A number of scoring systems to determine patient prognosis are available, but most of them require complex input data, making their practical application a substantial problem. Objective: Our aim was to assess simple scoring systems within a cohort, evaluate the level of mortality, morbidity, and duration of hospital stay, followed by a comparison of the acquired data with the literature and determination of an easily implementable scoring system for use in clinical practice. Material and Methods: We evaluated a group of patients with diffuse peritonitis who underwent surgery in the 2015–2019 period. Medical history, surgical findings, and paraclinical examinations were used as the input for four scoring systems commonly used in practice—MPI, qSOFA, ECOG, and ASA. We compared the results between the systems and with the literature. Results: Our cohort included 274 patients diagnosed with diffuse peritonitis. Mortality was 22.6%, morbidity 73.4%, with a 25.2 day average duration of hospital stay. Mortality and morbidity increased with rising MPI and qSOFA, well-established scoring systems, but also with rising ASA and ECOG, similarly to MPI and qSOFA. Conclusions: The utilized scoring systems correlated well with the severity of the condition and with predicted mortality and morbidity as reported in the literature. Simple scoring systems primarily used in other indications (i.e., ASA and ECOG) have a similar predictive value in our cohort as commonly used systems (MPI, qSOFA). We recommend them in routine clinical practice due to their simplicity.

Closed-Loop Bowel Obstruction Years After an Open Abdominal Aortic Aneurysm Repair

A 68-year-old male has a significant past medical history of severe aortic stenosis, peripheral arterial disease, chronic kidney disease, and an abdominal aortic aneurysm treated with a bifurcated interposition aortobiiliac graft. He was admitted to the hospital for an elective one-vessel coronary artery bypass graft and placement of a bioprosthetic aortic valve. Postoperatively, he developed worsening abdominal pain, leukocytosis, and inability to tolerate nutrition by mouth. Computed tomography revealed moderately dilated loops of the small bowel with two transition points in the right lower quadrant. He was taken emergently to the operating room for an exploratory laparotomy, and a 28-cm necrotic jejunal loop was entrapped posterior to the right iliac segment of the graft. In a patient with an intra-abdominal synthetic vascular graft, a closed-loop bowel obstruction caused by entrapment by the vascular graft is exceptionally rare; however, it should be considered in the presence of bowel obstruction.