[Surgical management of post-operative peritonitis]

Management of gastro-intestinal emergencies in patients with ileal conduit ureteral diversion

Radical cystectomy with urinary deviation is performed increasingly in France. Ileal conduit ureteral diversion (ICUD), described by Bricker and widely used after this type of radical resection, leads to substantial anatomic modifications that are potential danger zones during subsequent gastro-intestinal or urinary tract operations. Injury to the urinary diversion apparatus can lead to disastrous complications in these patients who are often elderly and frail. General surgeons are most often called upon to re-operate these patients, either for an ICUD-related gastro-intestinal complication, or for an unrelated abdominal emergency that arises later (bowel obstruction, infection, cancer). During such operations, certain anatomic structures are particularly exposed to injury that may be irreversible, particularly, the mesentery of the ileal conduit and the left ureter. Approaching the right lower quadrant, the dissection of the ileo-ileal anastomosis or of the left mesocolon are the procedures or maneuvers that pose the most risk. A number of simple but effective preventive measures are available and must be known, such as to operate the patient with an urologist or to insert ureteral stents before surgery. Preoperative contrast-enhanced computed tomography with late phase urinary imaging is essential to assess the anatomic modifications and anticipate the operative procedural steps. Finally, one should not hesitate to disinsert the stoma and proceed with retrograde dissection, thus facilitating the identification of the ileal conduit, the mesentery and the ureters.

Clinical evaluation of the Mannheim Prognostic Index in post-operative peritonitis: a prospective cohort study

Postoperative peritonitis (PoP), despite their relatively low incidence, are associated with high mortality. Such poor outcomes are also related to the high proportion of aged patients, whose intra-abdominal infections are difficult to manage. The study included 84 consecutive patients with PoP. The aim was the validation of the Mannheim Prognostic Index (MPI) in the context of PoP and the assessment of the prognostic impact of age and other clinical factors in a large series from a tertiary center. PoP had an incidence of 3.9% in all the abdominal surgeries in the study period. Surgical control of POP focus was achieved in 90.5% of cases and a complete abdominal clearance in 58.3%. Complication rate was 75% with a mortality of 26.2%. For MPI score, the ROC curve indicated a cut-off value of 29 with a sensitivity of 72.7% and specificity of 67.7% in predicting death. At univariate analysis, factors significantly related to poorer prognosis included advanced age (p 0.001), site of primary surgery (p 0.05), lack of abdominal clearance (p 0.003), generalized peritonitis (p 0.04) and high MPI score (p < 0.001). Age, MPI score and absence of abdominal clearance resulted in independent prognostic factors at multivariate analysis. MPI showed good efficacy in identifying POP patients at high risk of death. The increased risk of mortality related to advanced age should be considered with MPI score in planning the treatment. An aggressive and early diagnostic-therapeutic approach is required to reduce the MPI score and improve the prognosis.

Management of supra-mesocolic peritonitis using the Levy helicoid drain (Hélisonde®)

INTRODUCTION

Postoperative peritonitis arising in the upper abdomen requiring reoperative surgery has a mortality rate of up to 50%. One therapeutic modality for these patients is the use of the Hélisonde(®) drain, designed by Levy, the Levy Helical Drain (LHD), but it has not seen widespread use. In this paper, we describe our experience in managing supramesocolic peritonitis with this drain at the University Surgical Center at Amiens and we analyze our results.

PATIENTS AND METHODS

Between 2005 and 2010, we cared for 190 patients with supramesocolic peritonitis in our unit. Of these, 22 patients with gastric or duodenal fistula underwent transorificial intubation with the LHD. There were 12 men and 10 women with a mean age of 66 years. At surgery, the helical drain was screwed into the fistular orifice, two more flat drains were left adjacent to the fistula, and a jejunal feeding tube was placed. The mean interval between the initial surgery and the drainage procedure was 16.1 ± 14 days.

RESULTS

The mean APACHE II score was 20 (10-28). The Mannheim score averaged 28 (19-34). The LHD was completely removed at a mean interval of 35.5 ± 11 days. Six patients (27%) died postoperatively. Postoperative complications included intraperitoneal abscess (n = 3), pneumonia (n=1), and evisceration (n = 2). Two patients required reoperation. The average hospital stay was 70.7 days. Four patients had a persistent chronic fistula.

CONCLUSION

The LHD is a useful technical device in the treatment of supramesocolic peritonitis. Its management requires close oversight.