The influence of lavage on peritonitis

Effect of intraoperative abdominal lavage versus suction alone on postoperative wound infection in patients with appendicitis: A meta-analysis

There is much controversy about the application of abdominal irrigation in the prevention of wound infection (WI) and intra-abdominal abscess (IAA) in the postoperative period. Therefore, we performed a meta-analysis of the effect of suctioning and lavage on appendectomy to assess the efficacy of either suctioning or lavage. Data were collected and estimated with RevMan 5.3 software. Based on our research, we found 563 publications in our database, and we eventually chose seven of them to analyse. The main results were IAA after the operation and WI. Inclusion criteria were clinical trials of an appendectomy with suctioning or lavage. In the end, seven trials were chosen to meet the eligibility criteria, and the majority were retrospective. The results of seven studies showed that there was no statistically significant difference between abdominal lavage and suctioning treatment for post-operative WI (OR, 1.82; 95% CI, 0.40, 2.61; p = 0.96); There was no statistically significant difference between the two groups in the risk of postoperative abdominal abscess after operation (OR, 1.16; 95% CI, 0.71, 1.89; p = 0.56). No evidence has been found that the use of abdominal lavage in the treatment of postoperative infectious complications after appendectomy is superior to aspiration.

Failure of peritoneal lavage to prevent operative site infection and peritoneal tumor recurrence in pancreatic surgery

BACKGROUND

Although intraoperative peritoneal lavage often is performed routinely with the aim of reducing peritoneal contamination, evidence of lavage benefit in elective pancreatic surgery is limited.

METHODS

We retrospectively classified patients who had undergone pancreatic surgery to groups given or not given peritoneal lavage, then comparing clinical results. This saline lavage was performed at the end of the operation. The primary endpoint was rate of surgical site infection. Frequency of peritoneal recurrence also was evaluated.

RESULTS

Among all 104 patients in the study, incidence of infectious complications in the lavage group (n = 65) was significantly higher than in the non-lavage group (n = 39; 35% vs. 15%, P = 0.041), while incidences of postoperative complications overall and surgical site infection did not differ between lavage (80% and 26%) and non-lavage groups (67% and 10%, P = 0.162 and 0.076, respectively). Among 63 patients undergoing pancratoduodenectomy, frequencies of positive bacterial cultures of drainage fluids on postoperative days 1 and 3 were greater in the non-lavage group (P < 0.001 and P = 0.012), but surgical site infection was significantly more frequent in the lavage group (P = 0.043). Among patients with pancreatic and biliary cancers, lavage did not affect frequency of peritoneal recurrence.

CONCLUSION

Intraoperative lavage did not prevent surgical site infection or peritoneal recurrence of pancreatobiliary cancer.

Impact of large amount of intra-abdominal lavage on surveillance of surgical site infection after hepato-pancreato-biliary surgery: A prospective cohort study

BACKGROUND/PURPOSE

In hepatobiliary and pancreatic (HBP) surgery, the role and significance of intra-abdominal lavage (IAL) for surgical site infection (SSI) is controversial.

METHODS

This prospective study was performed between July 2020 and July 2022. A total of 150 patients, 10-L IAL was performed. The lavage fluid at 1-L, 5-L, and 10-L was subjected to bacterial culture examination. Risk factors for SSI were evaluated.

RESULTS

Bacterial positivity rate significantly decreased as follows: 1-L, 36% (n = 54); 5-L, 27% (n = 41); 10-L, 23% (n = 35) (36% vs 23%, p = .001). Patients with positive lavage fluid culture at 10-L had significantly higher incidence of both incisional (37% vs 6%, p < .01) and organ/space (54% vs 3%, p < .01) SSI. Multivariate analysis revealed positivity for bacterial culture at 10-L as the strongest independent risk factor for incisional SSI (OR 13.0, 95% CI: 3.86-43.6, p < .01), followed by postoperative pancreatic fistula (OR 11.7, 95% CI: 3.03-45.6, p < .01). Likewise, in organ/space SSI, positivity for bacterial culture at 10-L was the strongest independent risk factor (OR 48.9, 95% CI:12.1-197.7, p < .01), followed by digestive reconstruction (OR 5.20, 95% CI: 1.45-18.6, p = .01).

CONCLUSION

IAL decreased the intraperitoneal contamination rate in a volume-dependent manner and can be useful in the surveillance of SSI development in HBP surgery.

Irrigation of peritoneal cavity with cold atmospheric plasma treated solution effectively reduces microbial load in rat acute peritonitis model

Accurate and timely diagnosis of appendicitis in children can be challenging, which leads to delayed admittance or misdiagnosis that may cause perforation. Surgical management involves the elimination of the focus (appendectomy) and the reduction of the contamination with peritoneal irrigation to prevent sepsis. However, the validity of conventional irrigation methods is being debated, and novel methods are needed. In the present study, the use of cold plasma treated saline solution as an intraperitoneal irrigation solution for the management of acute peritonitis was investigated. Chemical and in vitro microbiological assessments of the plasma-treated solution were performed to determine the appropriate plasma treatment time to be used in in-vivo experiments. To induce acute peritonitis in rats, the cecal ligation and perforation (CLP) model was used. Sixty rats were divided into six groups, namely, sham operation, plasma irrigation, CLP, dry cleaning after CLP, saline irrigation after CLP, and plasma-treated saline irrigation after CLP group. The total antioxidant and oxidant status, oxidative stress index, microbiological, and pathological evaluations were performed. Findings indicated that plasma-treated saline contains reactive species, and irrigation with plasma-treated saline can effectively inactivate intraperitoneal contamination and prevent sepsis with no short-term local and/or systemic toxicity.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: updated meta-analysis of randomized controlled trials

Background

Selection of intracorporeal anastomosis (IA) or extracorporeal anastomosis (EA) in laparoscopic right colectomy (LRC) remains controversial. This meta-analysis aimed to evaluate the effectiveness and safety of IA compared with EA in LRC patients.

Methods

Literature was searched systematically for randomized controlled trials (RCTs) that compared IA with EA in LRC patients until May 2021. The eligible studies for risk of bias were assessed using the Cochrane Risk of Bias Tool. Data were extracted and analysed for the following outcomes of interest: operative time, length of incision, nodal harvest, bowel function recovery, postoperative pain, postoperative complications (wound infection, anastomotic leak, ileus, obstruction, reoperation), death at 30 days, duration of hospital stay and 30-day readmission.

Results

Five RCTs, including a total of 559 patients, were eligible for meta-analysis. All of the trials reported adequate random sequence generation and allocation concealment. There were significantly better outcomes in the IA group than in the EA group in time to first flatus (mean difference (MD) −0.71 (95 per cent c.i. −1.12 to −0.31), P = 0.0005), time to first passage of stool (MD −0.53 (95 per cent c.i. −0.69 to −0.37), P < 0.00001), visual analogue scale of pain on postoperative day (POD) 3 (MD −0.76 (95 per cent c.i. −1.23 to −0.28), P = 0.002), POD 4 (MD −0.83 (95 per cent c.i. −1.46 to −0.20), P = 0.01), POD 5 (MD −0.60 (95 per cent c.i. −0.95 to −0.25), P = 0.0007), length of incision (MD −1.52 (95 per cent c.i. −2.30 to −0.74), P = 0.0001) and wound infection (relative risk 0.46 (95 per cent c.i. 0.23 to 0.91), P = 0.02). However, there were no statistically significant differences between the two groups in duration of hospital stay (P = 0.47), operative time (P = 0.07), number of lymph nodes harvested (P = 0.70), anastomotic leak (P = 0.88), postoperative ileus (P = 0.48), bleeding (P = 0.15), bowel obstruction (P = 0.24), reoperation (P = 0.34), readmission within 30 days (P = 0.26), and death (P = 0.70).

Conclusion

Compared with EA, IA shows a faster recovery of bowel function with fewer wound infections.

Irrigation during laparoscopic appendectomy for complicated appendicitis increases the operative time and reoperation rate: a meta-analysis of randomized clinical trials

This meta-analysis of randomized clinical trials (RCT) aimed to compare peritoneal irrigation followed by suction with aspiration only during laparoscopic surgery for complicated appendicitis (LA). PRISMA guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates. We retained six eligible RCT published between 2012 and 2019. They involved a total of 1019 patients (541 patients in the aspiration group and 478 patients in the irrigation group). Aspiration only during LA is associated with shorter operative time (MD = 8.50 min, 95% CI [- 12.97 to - 4.02], p = 0.0002) and lower reoperation rate (OR = 0.37 95% CI [0.14-0.96], p = 0.04). There was no difference between aspiration group and irrigation group in terms of Intraperitoneal abscess (IPA) (OR = 0.99 95% CI [0.54-1.81], p = 0.95), morbidity rate (OR = 1.14 95% CI [0.44-2.98], p = 0.79), wound infection (OR = 0.94 95% CI [0.20-4.40], p = 0.94), and hospital stay (MD = 0.65 day, 95% CI [- 0.52 to 1.82], p = 0.27). Irrigation during LA prevents post-appendectomy IPA in neither adults nor pediatric patients. However, it lengthens the operative time and involves a higher reoperation rate.

Microorganisms associated with incisional infections after gastrointestinal surgery in dogs and cats

OBJECTIVE

To determine the rate of incisional infections after gastrointestinal surgery in dogs and cats and describe the aerobic bacteria isolated from these infections.

STUDY DESIGN

Retrospective study.

ANIMALS

Client-owned dogs (n = 210) and cats (n = 66).

METHODS

Records of dogs and cats that underwent gastrointestinal surgery at the Matthew J. Ryan Veterinary Hospital at the University of Pennsylvania were reviewed for surgical procedures, presence of an infection, bacterial species isolated, perioperative antimicrobials administered, and outcome.

RESULTS

The median duration of follow-up was 14 days (4-35). Incisional infections were recorded in 7% (20/276) of cases. Among those 20 cases, culture results were available in 12 of 20 cases. The most common bacterial isolate cultured was Escherichia coli. The most common perioperative antimicrobials administered to treat incisional infection were cefazolin and cefoxitin. Only two of the bacterial isolates were susceptible to these antimicrobials. Bacteria isolated from incisional infections were most often susceptible to chloramphenicol, imipenem, and gentamicin.

CONCLUSION

Bacterial isolates from incisional infections in this population consisted of native gastrointestinal flora, which was often resistant to the most commonly used perioperative antimicrobials.

CLINICAL SIGNIFICANCE

Contamination at time of surgery is the most likely source of incisional infection after gastrointestinal surgery. This rate of infection justifies more rigorous intraoperative hygiene protocols and evaluation of the antimicrobials' susceptibility of causative bacteria to guide antimicrobial treatment.

Adjuvant intraperitoneal ceftriaxone in the treatment of septic peritonitis in horses

BACKGROUND

Intraperitoneal administration of ceftriaxone maintains therapeutic abdominal concentrations for 24 hours in healthy horses. Therefore, it is a possible treatment for septic peritonitis. The aim of this study was to evaluate the efficacy of ceftriaxone as an adjuvant treatment in horses with septic peritonitis.

METHODS

Twenty-six horses with clinical signs, sonography and/or laboratory findings of septic peritonitis were included. Peritoneal fluid was collected for microbiological culture and in vitro microbial sensitivity profile assessment. Daily intraperitoneal administration of ceftriaxone (25 mg/kg) was initiated with supportive and systemic antimicrobial treatment. The animals were divided into three groups: group 1-gastrointestinal tract injuries and abdominal surgery (excluding perforations/ruptures); group 2-not related to changes in the gastrointestinal tract; group 3-secondary to intestinal rupture and/or faeces contamination.

RESULTS

The mean success rate of the treatment was 77 per cent (20/26 animals), with success rates of 84.6 per cent in group 1; 87.5 per cent, group 2; and 40 per cent, group 3.

CONCLUSIONS

This is the first study to report adjuvant intraperitoneal treatment ceftriaxone for septic peritonitis in horses and indicates that this treatment can successfully treat septic peritonitis in horses.

Peritoneal irrigation vs suction alone during pediatric appendectomy for perforated appendicitis: A meta-analysis

BACKGROUND

There currently exists no substantial evidence reporting the efficacy of peritoneal irrigation in reducing the incidence of postoperative intra-abdominal abscess in pediatric patients. The purpose of our study was to perform a meta-analysis to compare rates of intra-abdominal abscess after appendectomy between irrigation and suction alone groups.

METHODS

We identified studies by a systematic search in EMBASE, PubMed, Web of Science, and the Cochrane Library to recognize randomized controlled trials and case control studies from the 1950 to May 2019. We limited the English language studies. We checked the reference list of studies to recognize other potentially qualified trials. We analyzed the merged data with use of the Review Manager 5.3.

RESULTS

We identified 6 eligible papers enrolling a total of 1633 participants. We found no significant difference in the incidence of postoperative intraabdominal abscess, wound infection, and the length of hospitalization between 2 group, but duration of surgery is longer in irrigation group (MD = 6.76, 95% CI = 4.64 to 8.87, P < .001; heterogeneity, I = 25%, P = .26).

CONCLUSION

Our meta-analysis did not provide strong evidence allowing definite conclusions to be drawn, but suggested that peritoneal irrigation during appendectomy did not decrease the incidence of postoperative IAA. This meta-analysis also indicated the need for more high-quality trials to identify methods to decrease the incidence of postoperative IAA in pediatric perforated appendicitis patients.Trial registration number Standardization of endoscopic treatment of acute abdomen in children: 14RCGFSY00150.

Outcome and Adequacy of Empirical Antibiotherapy in Post-Operative Peritonitis: A Retrospective Study

Background: Empirical antibiotherapy (EA) should target all bacteria in post-operative peritonitis (PP). Nevertheless, recent studies failed to prove a link between adequacy of EA and prognosis of PP. We sought to confirm this loss of association between adequate EA and prognosis and to analyze the evolution of patients' characteristics and antimicrobial strategies. Methods: This is was retrospective study. Patients with a positive fungal culture were excluded. The cohort was divided into two time periods. Data of survivors and non-survivors were compared within each time period. Differences between the two periods were assessed. A multivariable analysis searched for parameters associated with a higher hospital mortality rate. Results: Two hundred fifty-one patients were included, with 92 patients in the first period (P1) and 152 patients in the second period (P2). Inadequate EA was associated with a worse outcome only in P1. The multivariable analysis in the whole cohort showed that inadequate EA was associated with a higher mortality rate. When the differences noticed between the two periods were entered in the model (presence of resistant gram-positive cocci and EA comprising glycopeptides), inadequate EA was no longer associated with worse outcome. In P1, the most severe patients had more resistant bacteria, hence, had a higher rate of inadequate EA. This artifact disappeared in P2, during which broader antibiotherapies with triple EA were more often prescribed for the most severe patients. Conclusion: This study showed that the link between inadequate EA and outcome of patients with PP was at least partly artifactual in older studies.

Effect of peritoneal lavage on bacterial isolates in 40 dogs with confirmed septic peritonitis

OBJECTIVE

To evaluate bacterial isolates, antimicrobial drug susceptibility, and change in resistance among pre- and post-lavage culture samples in dogs with septic peritonitis.

DESIGN

Prospective observational study.

SETTING

Private practice referral hospital.

ANIMALS

Forty client-owned dogs with confirmed septic peritonitis requiring surgical intervention.

INTERVENTIONS

All dogs had perioperative abdominal lavage following source control with 200 to 300 mL/kg 0.9% sterile saline. Pre- and post-lavage aerobic and anaerobic culture samples were evaluated.

MEASUREMENTS AND MAIN RESULTS

Thirty-five of 40 dogs (87.5%) survived to hospital discharge. The likelihood of an aerobic organism to have multidrug resistance (resistance to 3 or more antimicrobial classes) post-lavage was a third of that pre-lavage (odds ratio [OR] 0.34, 95% CI [0.17-0.68], P = 0.01). Thirty-nine of 40 dogs (97.5%) received appropriate empiric antimicrobial therapy based on pre- and post-lavage culture results, of which 5 (12.8%) did not survive to discharge. The single dog with inappropriate antimicrobial therapy survived to discharge. The most frequent isolates detected included Escherichia coli, Clostridium perfringens, and Enterococcus faecalis. The same organism based on species was isolated in pre- and post-lavage cultures in 32 dogs, accounting for 59 anaerobic and aerobic isolates. There was a new bacterial isolate detected in 20 dogs, accounting for 46 isolates and an overall total decrease of 14 isolates between pre- and post-lavage culture (P = 0.09).

CONCLUSIONS

This study suggests that there is a significant decrease in the likelihood of isolating a multidrug resistant organism following peritoneal lavage, and aerobic and anaerobic culture results have the potential to change following peritoneal lavage, although this cannot be confirmed without further studies. Overall survival rates were higher than previously reported in the literature for septic peritonitis.

Standardized irrigation technique reduces intraabdominal abscess after appendectomy

PURPOSE

The utility of irrigation at the time of appendectomy for acute appendicitis has been debated, with recent studies showing no benefit to irrigation. In our practice, two techniques have been used; one in which irrigation was at the discretion of the surgeon, and one in which irrigation was standardized. The standardized irrigation technique involved large volume (3-12 l) irrigation in small, focused, directed aliquots to achieve optimal dilution. We sought to retrospectively assess whether the standardized large volume irrigation technique was associated with measurably reduced intraabdominal infection. We hypothesized that there would be no difference in intraabdominal infection rate.

METHODS

Medical records for cases of appendectomies performed for acute appendicitis, years 2007 through 2017, were reviewed (n = 432). Rate of subsequent abdominal infection was compared between patients who underwent the standardized large volume irrigation technique compared to those who did not using Fisher's exact test; p < 0.05 was considered significant.

RESULTS

For patients that underwent the standardized large volume irrigation technique there were no (0/140) subsequent abdominal infections within the study period, compared with a rate of 6.2% (18/292) for all other patients (p value 0.001). Among cases that had a perforated appendix (n = 105), the rates were 0% (0/31) compared to 18.9% (14/74; p value 0.009).

CONCLUSIONS

Utilization of a standardized large volume irrigation technique with the objective of serial dilution is associated with a significantly lower rate of subsequent abdominal infection, even among cases with a perforated appendix. Prospective studies are needed to evaluate this technique.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Treatment study.

Association of postoperative organ space infection after intraoperative irrigation in appendicitis

BACKGROUND

The benefit of intraoperative irrigation on postoperative abscess rates compared to suction alone is unclear. The American Association for the Surgery of Trauma grading system provides distinct disease severity stratification to determine if prior analyses were biased by anatomic severity. We hypothesized that for increasing appendicitis severity, patients receiving (high, ≥2 L) intraoperative irrigation would have increased postoperative organ space infection (OSI) rate compared to (low, <2 L) irrigation.

METHODS

Single-institution review of adults (>18 years) undergoing appendectomy for appendicitis during 2010-2016. Demographics, operative details, irrigation volumes, duration of stay, and complications (Clavien-Dindo classification) were collected. American Association for the Surgery of Trauma grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and area under the receiver operating curve analyses were performed.

RESULTS

Patients (n = 1187) were identified with a mean (SD) age of 41.6 (18.4) years (45% female). Operative approach included laparoscopy (n = 1122 [94.5%]), McBurney incision (n = 10 [0.8%]), midline laparotomy (n = 16 [1.3 %]), and laparoscopy converted to laparotomy (n = 39 [3.4%)]. The mean (SD) volume of intraoperative irrigation was 410 (1200) mL. Complication rate was 26.1%. Median volume of intraoperative irrigation in patients who developed postoperative OSI was 3 [0-4] compared to 0 [0-0] in those without infection (p < 0.0001). Area under the receiver operating curve analysis determined that 2 or more liters of irrigation was associated with postoperative OSI (c statistic: 0.83, 95% confidence interval, 0.76-0.89; p < 0.001).

CONCLUSION

Irrigation is used for increasingly severe appendicitis with wide variation. Irrigation volumes of 2 L or greater are associated with postoperative OSI. Improving standardization of irrigation volume (<2 L) may prevent morbidity associated with this high-volume disease.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Continuous peritoneal lavage with vacuum peritoneostomy: an experimental study

OBJECTIVE

Despite advances in diffuse peritonitis treatment protocols, some cases develop unfavorably. With the advent of vacuum therapy, the use of laparostomy to treat peritonitis has gained traction. Another treatment modality is continuous peritoneal lavage. However, maintaining this technique is difficult and has been associated with controversial results. We propose a new model of continuous peritoneal lavage that takes advantage of the features and benefits of vacuum laparostomy.

METHOD

Pigs (Landrace and Large White) under general anesthesia were submitted to laparostomy through which a multiperforated tube was placed along each flank and exteriorized in the left and lower right quadrants. A vacuum dressing was applied, and intermittent negative pressure was maintained. Peritoneal dialysis solution (PDS) was then infused through the tubes for 36 hours. The stability of peritoneostomy with intermittent infusion of fluids, the system resistance to obstruction and leakage, water balance, hemodynamic and biochemical parameters were evaluated. Fluid disposition in the abdominal cavity was analyzed through CT.

RESULTS

Even when negative pressure was not applied, the dressing maintained the integrity of the system, and there were no leaks or blockage of the catheters during the procedure. The aspirated volume by vacuum laparostomy was similar to the infused volume (9073.5±1496.35 mL versus 10165±235.73 mL, p=0.25), and there were no major changes in hemodynamic or biochemical analysis. According to CT images, 60 ml/kg PDS was sufficient to occupy all intra-abdominal spaces.

CONCLUSION

Continuous peritoneal lavage with negative pressure proved to be technically possible and may be an option in the treatment of diffuse peritonitis.

Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery

BACKGROUND

Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery.

METHODS

A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded.

RESULTS

A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4-17.8)]. The organ-space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1-11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028).

CONCLUSIONS

The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ-space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

Animal model of continuous peritoneal lavage with vacuum peritoneostomy

Purpose:

To establish and evaluate the feasibility of continuous peritoneal lavage with vacuum peritoneostomy in an animal model.

Methods:

Eight pigs aged 3-4 months, females, were anesthetized and submitted to laparotomy and installation of a continuous peritoneal lavage with vacuum peritoneostomy. The sta-bility of the system, the physiological effects of washing with NaCl 0.9% and the sys-tem clearance were evaluated.

Results:

Stability of vacuum peritoneostomy was observed, with no catheter leaks or obstructions and the clearance proved adequate, however, the mean volume of fluids aspirated by the peritoneostomy at the end of the experiment was higher than the volume infused by the catheters (p=0.02). Besides that, the animals presented a progressive increase in heart rate (p=0.04) and serum potassium (p=0.02).

Conclusion:

The continuous peritoneal lavage technique with vacuum peritoneostomy is feasible and presents adequate clearance.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

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.

Evaluation of antibiotic pressurized pulse lavage for contaminated retromuscular abdominal wall reconstruction

BACKGROUND

Despite patient risk factors such as diabetes and obesity, contamination during surgery remains a significant cause of infections and subsequent wound morbidity. Pressurized pulse lavage (PPL) has been utilized as a method to reduce bacterial bioburden with promising results in many fields. Although existing methods of lavage have been utilized during abdominal operations, no studies have examined the use of PPL during complex hernia repair.

METHODS

Patients undergoing abdominal wall reconstruction (AWR) in clean-contaminated or contaminated fields with antibiotic PPL, from January 2012 to May 2013, were prospectively evaluated. Primary outcome measures studied were conversion of retrorectus space culture from positive to negative after PPL and 30-day surgical site infection (SSI) rate.

RESULTS

A total of 56 patients underwent AWR, with 44 patients (78.6 %) having clean-contaminated fields and 12 patients (21.4 %) having contaminated ones. Twenty-two patients (39.3 %) had positive pre-PPL cultures, 18 of which (81.8 %) converted to negative cultures after PPL. Eleven patients (19.6 %) developed SSIs. Those with persistently positive cultures after PPL had the highest rate of SSI, where two out of four patients (50.0 %) developed an SSI. Contrastingly, only 5 of 18 patients (27.8 %) who converted from a positive to negative culture after PPL developed an SSI.

CONCLUSION

Our findings demonstrate that antibiotic PPL is an effective method to reduce bacterial bioburden during AWR in clean-contaminated and contaminated fields. While complete conversion and eradication of SSI were not achieved, we believe that PPL may be a useful adjunct to standard operative asepsis in preventing prosthetic contamination during contaminated AWR.

Effect of Peritoneal Lavage with Clindamycin-Gentamicin Solution on Post-Operative Pain and Analytic Acute-Phase Reactants after Laparoscopic Sleeve Gastrectomy

BACKGROUND

Peritoneal lavage has been proposed to remove bacterial contamination and other materials promoting bacterial proliferation and pro-inflammatory cytokines that may enhance local inflammation. The aims of this study were to evaluate the effects of peritoneal lavage with physiologic saline or an antibiotic solution (clindamycin-gentamicin) on post-operative pain and analytic acute-phase reactants and to determine the microbiologic impact of both irrigations on peritoneal contamination in patients undergoing laparoscopic sleeve gastrectomy (LSG) as a bariatric procedure.

METHODS

The patients were randomized into two groups: Those undergoing an intra-abdominal lavage with physiologic saline (Group 1; n = 40) and those undergoing a similar lavage with a gentamicin-clindamycin solution (Group 2; n = 40). Peritoneal contamination, post-operative pain, and analytic acute-phase reactants 24 h after surgery were investigated.

RESULTS

The median pain score 24 h after surgery was 3.5 in Group 1 and 1.5 in Group 2 (p = 0.021). The glucose concentration (mean difference 33.1 mg/dL; p = 0.004), aspartate aminotransferase (AST) concentration (mean difference 41.8 U/L; p = 0.009), alanine aminotransferase (ALT) concentration (mean difference 34.2 U/L; p = 0.029), white blood cell count (mean difference 1930/mm(3); p = 0.029); C-reactive protein concentration (mean difference 27.3 mg/L; p = 0.036), and serum lactic acid concentration (mean difference 0.34 mg/L; p = 0.049) were significantly higher in Group 1. Peritoneal contamination also was significantly higher in Group 1 (17.5% vs 0; p = 0.006).

CONCLUSIONS

Intra-peritoneal irrigation with a gentamicin and clindamycin solution in patients undergoing LSG leads to a reduction in post-operative pain and peritoneal contamination, less alteration of acute-phase reactants, lower blood glucose concentration, a smaller increase in liver enzymes, and a shorter hospital stay.

Irrigation versus suction alone during laparoscopic appendectomy; A randomized controlled equivalence trial

INTRODUCTION

The objective of this study was to compare operative peritoneal irrigation versus suction alone during laparoscopic appendectomy in adult patients; our hypothesis was that the two methods are equivalent in terms of rate of post-operative intra-abdominal abscess. There has been only one prospective, randomized, superiority trial in children, that showed non-significant difference in the rate of intra-abdominal abscess comparing irrigation to suction alone during laparoscopic appendectomy for perforated appendicitis. Non-significant difference in a superiority trial does not imply equivalence.

METHODS

This was a single-institution, prospective, randomized controlled equivalence study based on a null-hypothesis of non-equivalence between irrigation and suction alone. Adult patients with intra-operative findings of an acutely inflamed appendix, with suppuration or perforation localized to the right iliac fossa, paracolic gutter or pelvis were randomized to irrigation or suction alone. The primary endpoint was the rate of intra-abdominal abscess. An unconditional exact test of equivalence was used to test the null-hypothesis.

RESULTS

Eighty-one patients were included for analysis. Two (5%) of 40 patients in the irrigation group and two (4.9%) of 41 in the suction-only group developed postoperative intra-abdominal abscess. The 95% confidence interval for the difference between the two groups was -0.1200 to 0.1244, captured within the pre-defined δ limits (-0.15, 0.15). With reference to the rate of intra-abdominal abscess, equivalence was demonstrated between irrigation and suction-only techniques.

CONCLUSIONS

In patients with suppurative or perforated appendicitis, the rate of intra-abdominal abscess is equivalent between groups treated with peritoneal irrigation and suction alone.

Effect of the Bioadhesive, BioGlue, on Impaired Colonic Anastomose Healing in Rats

Colonic anastomotic leakage is still a problem in general surgery practice. We sought to investigate the effect of a new tissue adhesive, BioGlue, on the healing of normal and impaired colonic anastomoses. Sixty-four rats were randomized into 4 groups. In all animals, a 1-cm segment of the left colon was resected, and an end-to-end sutured anastomosis was created. Animals were then divided into 2 groups: normal and impaired anastomosis. These 2 groups were further subdivided into 2 additional groups: animals that received BioGlue and those that did not. All rats received intraperitoneal injections of either 0.9% NaCl or 5-fluorouracil (5-FU). Anastomotic evaluation was done 7 days after surgery. Macroscopic healing, mechanical strength, and histopathologic healing parameters were evaluated. Leakage of the anastomosis was significantly higher in rats in the impaired group compared with those in the BioGlue groups (P = 0.043). The adhesion formation score was significantly higher in rats in the impaired anastomosis group compared with the other groups. Bursting pressures were significantly lower in the impaired anastomosis group than in the other ones (P = 0.001). Neoangiogenesis and fibroblast activity were different among the groups (P = 0.001). Inflammatory cell infiltration and collagen deposition did not differ among the groups (P = 0.07). Immediate postoperative intraperitoneal administration of 5-FU after colonic anastomosis inhibits intestinal wound healing. Covering colon anastomoses with BioGlue after suturing conferred beneficial effect on healing.

Effect of Peritoneal Lavage with Clindamycin-Gentamicin Solution during Elective Colorectal Cancer Surgery on the Oncologic Outcome

BACKGROUND

Antibiotics combined with lavage have demonstrated a reduction in the bacterial contamination and decreases surgical site infection (SSI) rate. SSI leads to an immunocompromised situation, as immunologic defense is focused on controlling the septic focus, leaving unattended the neoplasm. It has been described that SSI may result in a worse oncologic outcome. The aim of this study is to evaluate prospectively the effect of peritoneal lavage with clindamycin and gentamicin on the oncologic outcome of colorectal tumors.

METHODS

A randomized study of patients with diagnosis of colorectal neoplasms and undergoing elective surgery was performed at our institutions between January and September 2011. Patients were randomly assigned into two groups: Those undergoing an intra-abdominal lavage with normal saline (Group 1) and those undergoing an intra-abdominal lavage with a gentamicin-clindamycin solution (Group 2). Recurrence, global survival, and disease-free survival were investigated.

RESULTS

One hundred and four patients were analyzed, with 52 in each group. After a minimum follow-up of 42 mo, mean disease-free survival was 37.2 ± 14.2 mo in Group 1 and 25.8 ± 16.3 mo in Group 2 (mean difference 11.4; confidence interval (CI) 95% (2.2-25.1); p = 0.009). Mean global survival was 44.2 ± 11.9 mo in Group 1 and 34.1 ± 14.1 mo in Group 2 (mean difference 10.1; CI 95% (2.2-18);p = 0.016).

CONCLUSION

The intra-peritoneal lavage with gentamicin and clindamycin increases the disease-free and global survival colorectal tumors.

Impact of bacterial contamination of the abdominal cavity during pancreaticoduodenectomy on surgical-site infection

Background

Several risk factors for complications after pancreaticoduodenectomy have been reported. However, the impact of intraoperative bacterial contamination on surgical outcome after pancreaticoduodenectomy has not been examined in depth.

Methods

This retrospective study included patients who underwent pancreaticoduodenectomy and peritoneal lavage using 7000 ml saline between July 2012 and May 2014. The lavage fluid was subjected to bacterial culture examination. The influence of a positive bacterial culture on surgical-site infection (SSI) and postoperative course was evaluated. Risk factors for positive bacterial cultures were also evaluated.

Results

Forty-six (21·1 per cent) of 218 enrolled patients had a positive bacterial culture of the lavage fluid. Incisional SSI developed in 26 (57 per cent) of these 46 patients and in 13 (7·6 per cent) of 172 patients with a negative lavage culture (P &lt; 0·001). Organ/space SSI developed in 32 patients with a positive lavage culture (70 per cent) and in 43 of those with a negative culture (25·0 per cent) (P &lt; 0·001). Grade B/C pancreatic fistula was observed in 22 (48 per cent) and 48 (27·9 per cent) respectively of patients with positive and negative lavage cultures (P = 0·010). Postoperative hospital stay was longer in patients with a positive lavage culture (28 days versus 21 days in patients with a negative culture; P = 0·028). Multivariable analysis revealed that internal biliary drainage, combined colectomy and a longer duration of surgery were significant risk factors for positive bacterial culture of the lavage fluid.

Conclusion

Intraoperative bacterial contamination has an adverse impact on the development of SSI and grade B/C pancreatic fistula following pancreaticoduodenectomy.

Irrigation of abdomen with imipenem solution decreases surgical site infections in patients with perforated appendicitis: a randomized clinical trial

Background:

Perforated appendicitis is one of the most common causes of acute abdomen requiring emergent surgery for immediate appendectomy and peritoneal cavity irrigation; however, the efficacy of irrigation with antibiotic solutions is controversial.

Objectives:

The aim of this study was to assess the efficacy of imipenem solution irrigation on post-operative surgical site infections (SSIs), hospital length of stay, and hospital costs. We hypothesized that there would be lower rate of SSIs, a shorter hospital stay, and lower hospital cost in patients with perforated appendicitis who received peritoneal cavity irrigation with imipenem solution in comparison to their counterparts who received irrigation with normal saline.

Patients and Methods:

In this randomized single-blind parallel-group clinical trial, we enrolled 90 patients with perforated appendicitis with 12-50 years of age and randomly allocated them into experimental group (n = 45) and control group (n = 45). The control group received peritoneal irrigation with normal saline (0.9%) and experimental group underwent peritoneal irrigation with imipenem solution (1 mg/mL). All surgical procedures were performed in Imam Reza Hospital of Kermanshah University of Medical Sciences. The study primary outcome was surgical site infections (including wound infection and abdominal abscess) and the secondary outcomes were length of hospital stay and hospital cost. Chi-squared and t-tests were used to analyze the study data.

Results:

Imipenem solution irrigation was associated with significant clinical improvement at one-month follow-up. The experimental group presented with significantly lower rate of SSIs and shorter length of hospital stay. The experimental group had lower rate of SSIs compared to the control group (4.4% vs. 22.2%, respectively) (p= 0.013). The duration of hospital stay was nearly one day longer in control group (5.84 ± 2.58 days) vs. experimental group (4.91 ± 1.29 days) (P = 0.034), and hospital costs were $50 lower in experimental group ($500 ± $292) vs. control group ($450 ± $170) (P = 0.281).

Conclusions:

The study findings revealed that peritoneal lavage with imipenem solution (1 mg/mL) decreases the rate of post-operative SSIs in patients with perforated appendicitis in comparison to patients irrigated with normal saline alone. These patients also had shorter hospital stay, and lower hospital costs.

[Prevention of surgical site infection in abdominal surgery. A critical review of the evidence]

Surgical site infection (SSI) is associated with prolonged hospital stay, increased morbidity, mortality and sanitary costs, and reduced patients quality of life. Many hospitals have adopted guidelines of scientifically-validated processes for prevention of surgical site and central-line catheter infections and sepsis. Most of these guidelines have resulted in an improvement in postoperative results. A review of the best available evidence on these measures in abdominal surgery is presented. The best measures are: avoidance of hair removal from the surgical field, skin decontamination with alcoholic antiseptic, correct use of antibiotic prophylaxis (administration within 30-60 min before incision, use of 1(st) or 2(nd) generation cephalosporins, single preoperative dosis, dosage adjustments based on body weight and renal function, intraoperative re-dosing if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss), prevention of hypothermia, control of perioperative glucose levels, avoid blood transfusion and restrict intraoperative liquid infusion.

Effect of peritoneal cavity lavage with 0.9% and 3.0% saline solution in the lung and spleen of gerbils with induced peritonitis

BACKGROUND

Peritoneal cavity lavage is used widely in the treatment of peritonitis. Nonetheless, some studies question its rationale and prove it to be deleterious to the mesothelium. The present study aims to determine whether 0.9% and 3.0% saline lavage of the peritoneal cavity have an effect on the early systemic inflammatory response, namely, in the lung injury and splenic cellularity of gerbils with induced peritonitis.

METHODS

Thirty-four male gerbils were divided into four groups: Control (n=9), submitted to laparotomy at time zero, re-laparotomy after 2 h, and sacrificed after a total of 6 h from start; untreated (n=8), submitted to peritonitis induction through cecal ligation and puncture (CLP) at time zero, re-laparotomy intended for drying of abdominal cavity and resection of the ischemic cecum after 2 h, and sacrifice after a total of 6 h from start; saline (n=8), submitted to peritonitis induction through CLP at time zero, re-laparotomy intended for warm 0.9% saline lavage of the abdominal cavity and resection of the ischemic cecum after 2 h, and sacrificed after a total of 6 h from start; and hypertonic (n=9), submitted to peritonitis induction through CLP at time zero, re-laparotomy intended for warm hypertonic saline (3.0%) lavage of the abdominal cavity and resection of the ischemic cecum after 2 h, and sacrificed after a total of 6 h from start. After sacrifice, we collected the left lung and the spleen for morphometric analysis.

RESULTS

In the both the saline and hypertonic groups, there was significant decrease in the mean nuclei count in the lungs, compared with the untreated group (p<0.01). There was no difference in terms of nuclei count in the spleen among groups (p>0.05).

CONCLUSIONS

The present study demonstrated that the peritoneal lavage with large volumes of warm 0.9% and 3.0% saline has a beneficial effect on the early systemic inflammatory response in infected animals, modulating and reducing the lung injury but having no effect on splenic cell count.

Effect of peritoneal lavage with clindamycin-gentamicin solution on infections after elective colorectal cancer surgery

BACKGROUND

Colorectal surgery may lead to infections because despite meticulous aseptic measures, extravasation of microorganisms from the colon lumen is unavoidable.

STUDY DESIGN

A prospective, randomized study was performed between January 2010 and December 2010. Patient inclusion criteria were a diagnosis of colorectal neoplasms and plans to undergo an elective curative operation. Patients were divided into 2 groups: Group 1 (intra-abdominal irrigation with normal saline) and Group 2 (intraperitoneal irrigation with a solution of 240 mg gentamicin and 600 mg clindamycin). The occurrence of wound infections and intra-abdominal abscesses were investigated. After the anastomosis, a microbiologic sample of the peritoneal surface was obtained (sample 1). A second sample was collected after irrigation with normal saline (sample 2). Finally, the peritoneal cavity was irrigated with a gentamicin-clindamycin solution and a third sample was obtained (sample 3).

RESULTS

There were 103 patients analyzed: 51 in Group 1 and 52 in Group 2. There were no significant differences between the groups in age, sex, comorbidities, or type of colorectal surgery performed. Wound infection rates were 14% in Group 1 and 4% in Group 2 (p = 0.009; odds ratio [OR] 4.94; 95% CI 1.27 to 19.19). Intra-abdominal abscess rates were 6% in Group 1 and 0% in Group 2 (p = 0.014; OR 2.14; 95% CI 1.13 to 3.57). The culture of sample 1 was positive in 68% of the cases, sample 2 was positive in 59%, and sample 3 in 4%.

CONCLUSIONS

Antibiotic lavage of the peritoneum is associated with a lower incidence of intra-abdominal abscesses and wound infections.

Treatment with chlorhexidine modifies the healing of colon anastomosis in rats

PURPOSE

To investigate the effects of chlorhexidine on the healing of colon anastomosis in the presence of peritonitis.

METHODS

Peritonitis was induced in male Wistar rats by cecal ligation and puncture (CLP). The abdominal cavities of experimental animals were irrigated with warm solutions containing 0.9% saline (SAL group; n = 8) or 0.05% chlorhexidine (CHD group; n = 8), following which colon anastomosis was performed. Rats of the control group (n = 8) were submitted to colon anastomosis but not to CLP. Animals were euthanized seven days after surgery, and healing was assessed by histopathological examination and by measuring anastomotic burst pressure.

RESULTS

Post-operative survival rates were 100, 87.5 and 75% for the control, SAL, and CHD groups, respectively. The degree of inflammation was significantly lower (ρ = 0.01) in the CHD group compared with the other groups, whilst the anastomotic burst pressure within the CHD group (156.7 ± 53.2 mmHg) was lower than, but not significantly different from, those of the control and SAL groups (196.3 ± 49.8, 208.6 ± 72.7 mmHg, respectively).

CONCLUSIONS

Peritoneal irrigation with chlorhexidine solution is effective in the control of inflammation promoted by peritonitis but does not improve healing of colon anastomosis in rats.

Ergonomics and Technical Aspects of Minimal Access Surgery in Acute Surgery

BACKGROUND

Following the general trend in the evolution of minimal access surgery (MAS), the place of laparoscopy for diagnostic and therapeutic procedures in the emergency setting is well defined. As for all laparoscopic procedures, the ergonomic and technical aspects of MAS in acute surgery are important issues.

METHODS

Review of the literature.

RESULTS

The ergonomic and technical aspects of emergency laparoscopy include the surgeon's and the patient's position; the operating room setup, including the table, the monitor, and the specific equipment; patient preparation adapted as required to potential changes necessary as adapted to the pathology and conversion; the trocar setup, also adapted to the organ and pathology. Specific needs and variations can be necessary, dependent on the patient status, body build, and the pathology being treated. The operating room used for acute surgery should be adapted to evolving laparoscopic techniques, as well as new intraoperative diagnostic and therapeutic modalities.

CONCLUSION

High-tech equipment and associated procedures have modified the needs for a modern operating room setup. Laparoscopic procedures for emergency surgery must make use of well-known ergonomic principles and be adapted to the patient and the pathology.

Meta-analysis of the effect of peritoneal lavage on survival in experimental peritonitis

Background

Morbidity and mortality associated with bacterial peritonitis remain a challenge for contemporary surgery. Despite great surgical improvements, death rates have not improved. A secondary debate concerns the volume and nature of peritoneal lavage or washout—what volume, what carrier and what, if any, antibiotic or antiseptic?

Methods

A literature search of experimental studies assessing the effect of peritoneal lavage following peritonitis was conducted using Medline, EMBASE and Cochrane databases. Twenty-three trials met predetermined inclusion criteria. Data were pooled and relative risks calculated.

Results

In an experimental peritonitis setting a mortality rate of 48·9 per cent (238 of 487) was found for saline lavage compared with 16·4 per cent (106 of 647) for antibiotic lavage (absolute risk reduction (ARR) 32·5 (95 per cent confidence interval (c.i.) 27·1 to 37·7) per cent; (P &lt; 0·001). An ARR of 25·0 (95 per cent c.i. 17·9 to 31·7) per cent P &lt; 0·001) was found for the use of saline compared with no lavage at all. The survival benefit persisted regardless of systemic antibiotic therapy. Antiseptic lavage was associated with a very high mortality rate (75·0 per cent).

Conclusion

Pooled data from studies in experimental peritonitis demonstrated a significant reduction in mortality with antibiotic lavage.

The incidence of anastomotic leaks in patients undergoing colorectal surgery

BACKGROUND

There is evolving interest in auditing and credentialling the performance of surgeons. The incidence of anastomotic leakage has been proposed as a measure of performance following colorectal surgery. The aim of this study was to evaluate the incidence and risk factors associated with anastomotic leakage in patients undergoing resections of the colon and rectum.

METHODS

A prospective database was developed for all patients undergoing colorectal surgery. Anastomotic leakage was defined prior to the commencement of the study. A logistic regression analysis was performed to determine independent predictors of leakage. The variables analysed included age, sex, American Society of Anesthesiology (ASA) score, anatomical location, pathology, emergency surgery, type of anastomosis, a covering stoma and radiotherapy. Significance was defined as the probability of a type 1 error of < 5%. The results are presented as odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

There were 1598 patients who underwent 1639 anastomoses. Their mean age was 63 years, 34% of patients were ASA 3 or 4, and 16% of the operations were emergencies. Anastomotic leaks occurred in 2.4% (40/1639) of anastomoses. The leak rate for intraperitoneal anastomoses was 1.5% (19/1283) vs 6.6% for extraperitoneal anastomoses (21/316). Half of these leaks (20/40) were managed with re-operation or percutaneous drainage procedures. Ultra-low anterior resections were associated with the highest leak rate (8%, 18/225). A logistic regression analysis identified a covering stoma (P = 0.0001, OR 5.078, 95% CI 2.527-10.23) and diverticular disease (P = 0.037, OR 2.304, 95% CI 1.053-5.042) as independent predictors of a leak.

CONCLUSIONS

Within this surgical unit, the incidence of leaks from intraabdominal anastomoses was relatively low. However, leaks in patients undergoing extraperitoneal anastomoses continue to be a major cause of morbidity and mortality.

Influence of antiseptic agents on interleukin-8 release and transmigration of polymorphonuclear neutrophils in a human in vitro model of peritonitis

BACKGROUND

The aim of this study was to evaluate the influence of taurolidine (TAU) and polyhexanid (POLY) on basic inflammatory reactions during peritonitis by using an in vitro model of human peritoneum.

MATERIALS AND METHODS

Human umbilical vein endothelial cells (HUVEC) and human peritoneal mesothelial cells (HPMC; concentration: 2x10(5)/cm2) were brought on a collagen-coated filter insert with 3-microm pore size (HUVEC on the bottom, HPMC on the top), thus resulting in a two-chamber peritoneal model. After 5 days, confluence of the cells was reached, and HPMC were stimulated with 0.5 mL of TNF-alpha (10 microg/mL) for 4 h. Afterwards, 0.5 mL of TAU (1% and 2%) or 0.5 mL of POLY (0.1% and 0.2%) solution were added to the upper (HPMC) compartment. Polymorphonuclear neutrophils (PMN, 10(6)/mL) were placed in the lower compartment 1 h later. After 2 and 6 h, aliquots were taken from the upper compartment and transmigrated PMN were counted. Interleukin-8 (IL-8) concentrations were measured in both compartments by chemiluminescent enzyme immunometric assay. Expression of the adhesion molecules P-selectin and intercellular adhesion molecule-1 (ICAM-1) was assessed by immunohistochemistry. Controls were either TNF-alpha-stimulated HPMC without any antiseptic agents, or stimulated HPMC where TNF-alpha had been substituted by culture medium. Each experiment was performed in triplicate.

RESULTS

Stimulation with TNF-alpha led to a time-dependent increase of IL-8 secretion to the apical compartment resulting in a gradient between both chambers, as well as to a time-dependent increase of PMN transmigration and expression of adhesion molecules. IL-8 gradients and PMN migration were significantly higher as compared to the other groups (p<0.05). After substitution of the stimulus by culture medium, significantly less IL-8 was measured in both compartments. PMN transmigration was almost absent (p<0.05). Addition of POLY and TAU led to comparable low IL-8 gradients with concomitant low PMN transmigration. The initially detected expression of adhesion molecules significantly decreased during the observation time. The IL-8 gradient in all groups correlated significantly with PMN transmigration (r=0.74226; p<0.0001).

CONCLUSION

The diminished IL-8 response together with low PMN transmigration rates after addition of TAU and POLY may reflect either antiinflammatory effects or cellular damage.

Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer

The primary goal of this study was to describe epidemiology and management strategies of the perforated duodenal ulcer, as well as the most common methods of laparoscopic perforated duodenal ulcer repair. The secondary goal was to demonstrate the value of prospective and retrospective studies regarding the early results of surgery and the risk factors. The tertiary goal was to emphasize the benefits of this operation, and the fourth goal was to clarify the possible risk factors associated with laparoscopic repair of the duodenal ulcer. The Medline/Pubmed database was used. Review was done after evaluation of 96 retrieved full-text articles. Thirteen prospective and twelve retrospective studies were selected, grouped, and summarized. The spectrum of the retrospective studies' results are as follows: median overall morbidity rate 10.5 %, median conversion rate 7%, median hospital stay 7 days, and median postoperative mortality rate 0%. The following is the spectrum of results of the prospective studies: median overall morbidity rate was slightly less (6%); the median conversion rate was higher (15%); the median hospital stay was shorter (5 days) and the postoperative mortality was higher (3%). The risk factors identified were the same. Shock, delayed presentation (> 24 hours), confounding medical condition, age > 70 years, poor laparoscopic expertise, ASA III-IV, and Boey score should be considered preoperative laparoscopic repair risk factors. Each of these factors independently should qualify as a criterion for open repair due to higher intraoperative risks as well as postoperative morbidity. Inadequate ulcer localization, large perforation size (defined by some as > 6 mm diameter, and by others as > 10 mm), and ulcers with friable edges are also considered as conversion risk factors.

Surgical Site Infections

This article examines the epidemiology and risk factors for the development of surgical site infections (SSIs), the importance of appropriate administration of prophylactic antibiotics, nonpharmacologic strategies, and the role of new "active" devices in reducing SSIs. A review of the pertinent English-language literature shows that many factors contribute to the risk of a patient developing an SSI. These include the patient's health status, preparation of the patient before surgery, and the use of appropriate antibiotic prophylaxis. Careful preparation of the patient and care after surgery is especially important. The use of new "active" antibacterial devices may reduce risk further. Surgeons can minimize the risk to the patient of the development of SSI through strict adherence to established surgical guidelines for perioperative care.

Antibiotic Prophylaxis in Surgery—2005 and Beyond

TARGET AUDIENCE

Surgeons, pharmacists, and other physicians who prescribe prophylactic antibiotics.

LEARNING OBJECTIVES

After reading this article, the reader should be able to: Outline the attributes of antibiotics that are suitable for prophylaxis; review the activity and safety profiles of commonly-prescribed prophylactic antibiotics; and discuss the importance of proper administration as well as proper choice of an agent to minimize the risk of infection.

CME ACCREDITATION

The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide Continuing Medical Education (CME) for physicians. NFID takes responsibility for the content, quality, and scientific integrity of this CME activity. NFID designates this CME activity for a maximum of one (1.0) category 1 credit toward the AMA Physician's Recognition Award. Physicians should only claim those hours of credit that he/she actually spent in the educational activity.

SUPPORT

This CME ctivity has been made possible by an unrestricted educational grant from Cubist Pharmcaeuticals, Inc.

DISCLOSURE

Dr. Barie serves as a consultant for Cubist Pharmaceuticals, Inc. Dr. Nichols serves on the surgery advisory board for Cubist Pharmaceuticals, Inc. Dr. Condon has no financial relationship to disclose.

CME INSTRUCTIONS

To receive CME credits after reading the entire publication, please go to the following website <www.nfid.org/cme/surgicalinfections2005> to complete the self-assessment examination and evaluation. Requests for credit must be received no later than six months following the publication date.

Management of peritonitis in cattle

Peritonitis commonly is included in a list of differential diagnoses in food animal practice. Understanding the physiology of the ruminant peritoneal cavity and its response to injury is important to institute an adequate therapeutic plan. Ancillary procedures are used often and are necessary to confirm the diagnosis and should be well-organized.

Lavage enhances the production of proinflammatory mediators by peritoneal mesothelial cells in an experimental model

PURPOSE

There is a lack of clinical evidence supporting the use of lavage in patients with peritonitis. It is known that fluids such as normal saline cause temporary damage to the peritoneum and that increased production of proinflammatory mediators is associated with a poor outcome. This study used an experimental model to evaluate the effect of lavage on the peritoneal mesothelium and the ability of peritoneal mesothelial cells to produce a battery of proinflammatory mediators (TNFalpha, IL-1beta, GROalpha, and ICAM-I.).

METHODS

Wistar rats were allocated into four groups (control, peritonitis, lavage, peritonitis plus lavage). Peritonitis was induced by exposure to zymosan and saline was used for lavage. After 18, 24, and 43 hours, mesothelial imprints were taken from the peritoneum for histology, semiquantitative reverse transcription-polymerase chain reaction, Western blot analyses, and immunocytochemistry.

RESULTS

Both peritonitis and lavage caused peritoneal damage at 18 and 24 hours, and this effect was additive. At varying times, peritoneal mesothelial cells from animals undergoing lavage had greater up-regulation (P < 0.05) of mRNA expression for TNFalpha, IL-1beta, GROalpha, and ICAM-I and greater production (P < 0.05) of TNFalpha, IL-1RII, GROalpha, and ICAM-I. The latter was heavily concentrated at the cell membrane.

CONCLUSIONS

Lavage causes self-limiting peritoneal damage and this is associated with an up-regulation of proinflammatory mediators in animals with peritonitis.

Source control in the management of severe sepsis and septic shock: An evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for source control in the management of severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Source control represents a key component of success in therapy of sepsis. It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function. Although highly logical, since source control is the best way to reduce quickly the bacterial inoculum, most recommendations are, however, graded as D or E due to the difficulty to perform appropriate randomized clinical trials in this respect. Appropriate source control should be part of the systematic checklist we have to keep in mind in setting up the therapeutic strategy in sepsis.