Severe secondary peritonitis following gastrointestinal tract perforation

Wound healing responses of urinary extravasation after urethral injury

The post-surgical fluid leakage from the tubular tissues is a critical symptom after gastrointestinal or urinary tract surgeries. Elucidating the mechanism for such abnormalities is vital in surgical and medical science. The exposure of the fluid such as peritonitis due to urinary or gastrointestinal perforation has been reported to induce severe inflammation to the surrounding tissue. However, there have been no reports for the tissue responses by fluid extravasation and assessment of post-surgical and injury complication processes is therefore vital. The current model mouse study aims to investigate the effect of the urinary extravasation of the urethral injuries. Analyses on the urinary extravasation affecting both urethral mesenchyme and epithelium and the resultant spongio-fibrosis/urethral stricture were performed. The urine was injected from the lumen of urethra exposing the surrounding mesenchyme after the injury. The wound healing responses with urinary extravasation were shown as severe edematous mesenchymal lesions with the narrow urethral lumen. The epithelial cell proliferation was significantly increased in the wide layers. The mesenchymal spongio-fibrosis was induced by urethral injury with subsequent extravasation. The current report thus offers a novel research tool for surgical sciences on the urinary tract.

Vacuum-assisted closure versus on-demand relaparotomy in patients with secondary peritonitis-the VACOR trial: protocol for a randomised controlled trial

Background

Secondary peritonitis is a severe condition with a 20–32% reported mortality. The accepted treatment modalities are vacuum-assisted closure (VAC) or primary closure with relaparotomy on-demand (ROD). However, no randomised controlled trial has been completed to compare the two methods potential benefits and disadvantages.

Methods

This study will be a randomised controlled multicentre trial, including patients aged 18 years or older with purulent or faecal peritonitis confined to at least two of the four abdominal quadrants originating from the small intestine, colon, or rectum. Randomisation will be web-based to either primary closure with ROD or VAC in blocks of 2, 4, and 6. The primary endpoint is peritonitis-related complications within 30 or 90 days and one year after index operation. Secondary outcomes are comprehensive complication index (CCI) and mortality after 30 or 90 days and one year; quality of life assessment by (SF-36) after three and 12 months, the development of incisional hernia after 12 months assessed by clinical examination and CT-scanning and healthcare resource utilisation. With an estimated superiority of 15% in the primary outcome for VAC, 340 patients must be included. Hospitals in Denmark and Europe will be invited to participate.

Discussion

There is no robust evidence for choosing either open abdomen with VAC treatment or primary closure with relaparotomy on-demand in patients with secondary peritonitis. The present study has the potential to answer this important clinical question.

Trial Registration

The study protocol has been registered at clinicaltrials.gov (NCT03932461). Protocol version 1.0, 9 January 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00427-x.

Risk factors influencing postoperative outcome in patients with perforated peptic ulcer: a prospective cohort study

BACKGROUND

Perforated peptic ulcer (PPU) has been associated with substantially high incidence of morbidity and mortality. The aim of this study was to analyze the factors affecting the outcome of patients having perforated peptic ulcer undergoing surgical intervention.

MATERIALS AND METHODS

Medical records of 112 patients with PPU who underwent emergency laparotomy between December 2014 and November 2016 were prospectively analyzed. Primary suture of the perforation and pedicled omentoplasty was done in all the patients. Data regarding patients was collected and correlated with the postoperative outcome.

RESULTS

The overall postoperative morbidity and mortality were 62.5% and 30.4%, respectively. On univariate analysis advanced age (≥ 60 years) [(p = 0.005), (OR = 3.6), (95% CI = 1.5-8.8)], pre-operative shock [(p < 0.001), (OR = 7.4), (95% CI = 2.6-21.0)], delayed presentation (> 24 h) [(p = 0.007), (OR = 4.0), (95% CI = 1.5-11.2)] and raised serum creatinine [(p < 0.001), (OR = 7.7), (95% CI = 3.1-19.0)] were found to be significantly associated with the post-operative morbidity. For mortality, advanced age (≥ 60 year) [(p < 0.001), (OR = 5.02), (95% CI = 2.1-11.9)], pre-operative shock [(p < 0.001), (OR = 19.3), (95% CI = 6.9-53.6)], comorbidity [(p = 0.03), (OR = 6.6), (95% CI = 1.2-35.7)] and raised serum creatinine [(p < 0.001), (OR = 13.1), (95% CI = 4.5-37.8)] were statistically significant factors. Multivariate analysis showed advanced age (≥ 60 years) (p = 0.05) and raised serum creatinine (p = 0.004) as significant factors for increased risk of post-operative morbidity. Advanced age (≥ 60 years), pre-operative shock and raised serum creatinine were found to be independent risk factors influencing post-operative mortality (p < 0.05).

CONCLUSION

A thorough clinical evaluation, adequate resuscitation, sepsis control, addressing comorbidities and early access to hospital can reduce the risk morbidity and mortality in patients with PPU.

Drainage smell and peritonitis are efficient indicators of anastomotic leakage after laparoscopic rectal cancer resection

Objective

Anastomotic leakage (AL) is a frequent complication after laparoscopic rectal cancer resection (LRCR). The main objective of the present study was to identify accurate indicators of AL after LRCR.

Methods

A retrospective case-control study was performed of 185 patients who underwent laparoscopic surgery for rectal cancer between March 2012 and February 2017 at Beijing Friendship Hospital. Potential indicators of AL were examined via univariate and multivariate analyses. The performance of multivariate analysis was evaluated using receiver operating characteristic (ROC) curves.

Results

The overall AL rate was 17.84%. Multivariate analysis identified drainage smell (odds ratio [OR = 35.318, 95% confidence interval [CI] = 7.114 to 175.338) and peritonitis [OR = 17.475, 95% CI = 1.540 to 198.318) as independent indicators of AL. The area under the ROC curve was 0.720 (95% CI = 0.606 to 0.835).

Conclusion

Drainage smell and peritonitis could be reliable and accurate indicators of AL after LRCR.

Risk factors for postoperative sepsis in patients with gastrointestinal perforation

BACKGROUND

Sepsis is fatal in patients with gastrointestinal perforation (GIP). However, few studies have focused on this issue.

AIM

To investigate the risk factors for postoperative sepsis in patients with GIP.

METHODS

This was a retrospective study performed at the Department of General Surgery in our treatment center. From January 2016 to December 2018, the medical records of patients with GIP who underwent emergency surgery were reviewed. Patients younger than 17 years or who did not undergo surgical treatment were excluded. The patients were divided into the postoperative sepsis group and the non-postoperative sepsis group. Clinical data for both groups were collected and compared, and the risk factors for postoperative sepsis were investigated. The institutional ethical committee of our hospital approved the study.

RESULTS

Two hundred twenty-six patients were admitted to our department with GIP. Fourteen patients were excluded: Four were under 17 years old, and 10 did not undergo emergency surgery due to high surgical risk and/or disagreement with the patients and their family members. Two hundred twelve patients were finally enrolled in the study; 161 were men, and 51 were women. The average age was 62.98 ± 15.65 years. Postoperative sepsis occurred in 48 cases. The prevalence of postoperative sepsis was 22.6% [95% confidence interval (CI): 17.0%-28.3%]. Twenty-eight patients (13.21%) died after emergency surgery. Multiple logistic regression analysis confirmed that the time interval from abdominal pain to emergency surgery [odds ratio (OR) = 1.021, 95%CI: 1.005-1.038, P = 0.006], colonic perforation (OR = 2.761, CI: 1.821–14.776, P = 0.007), perforation diameter (OR = 1.062, 95%CI: 1.007-1.121, P = 0.027), and incidence of malignant tumor-related perforation (OR = 5.384, 95%CI: 1.762-32.844, P = 0.021) were associated with postoperative sepsis.

CONCLUSION

The time interval from abdominal pain to surgery, colonic perforation, diameter of perforation, and the incidence of malignant tumor-related perforation were risk factors for postoperative sepsis in patients with GIP.

Microbial findings, sensitivity and outcome in patients with postoperative peritonitis a retrospective cohort study

BACKGROUND

Acute postoperative peritonitis resulting from previous abdominal surgery is still a severe and potentially fatal disease, which is associated with high morbidity and mortality. The aim of the present study was to evaluate patients' outcome after postoperative peritonitis and identify the most effective empiric antibiotic regimes.

METHODS

422 patients with acute postoperative peritonitis as a result to earlier abdominal operation (e.g. anastomotic leakage) were analyzed retrospectively focusing on the origin of the peritonitis, microbial flora and resistance patterns. Furthermore, mortality was estimated according to sensitivity results of the tested antibiotics.

RESULTS

In 50% of the patients, anastomotic leakage was located in the colon. The predominantly cultured microorganisms were Escherichia coli and Enterobacteriaceae. The combination of meropenem and vancomycin was effective in 96% of these microbes. The frequently used combinations of piperacillin/sulbactam and cefotaxime/metronidazole were effective in only 67% and 43%, respectively.

CONCLUSIONS

We were able to show that the currently used antibiotic regimes with piperacillin/sulbactam and cefotaxime/metronidazole are ineffective in a relevant number of patients with anastomotic leakage. Only meropenem or meropenem/vancomycin cover most of the microbes predominant in postoperative peritonitis.

MANAGEMENT OF POSTOPERATIVE PERITONITIS IN LOW-RESOURCES SERVICES

Background. Postoperative peritonitis (PP) reminds one of the most difficult complications in abdominal surgery with mortality rate 22.3 – 90 %. Methods. In Ivano-Frankivsk Regional (tertiary level) Clinical Hospital (Ivano-Frankivsk, Ukraine) during 2010–2017 were operated 8762 patients with acute and chronic diseases of digestive system (appendicitis, pancreatitis, cholecystitis, bowel obstruction, complicated ulcer of upper gastrointestinal truck, mesenteric vessels thrombosis, abdominal adhesion diseases, hernia, Chron’s diseases, abdominal trauma), among them in 209 (2.4 %) patients developed PP. Local PP (abscess of abdominal cavity) had 142 (67.9 %), diffuse PP – 67 (42.1 %) patients. Results. Clear local symptoms of peritonitis were absent in 178 (85.1 %) of 209 patients. General complication, such as acute respiratory failure had 95 (45.5 %), cardiovascular insufficiency – 68 (32.5 %), hepato-renal dysfunction - 46 (22 %) patients with PP. 129 (61.7 %) patients were treated by minimally invasive approach: 24 patients had laparoscopic lavage with drain of abdominal cavity abscess and 105 - ultrasound guided drain of abscess with catheter. 80 (38.3 %) patients had re-laparotomy (RL): 61 (91 %) from 67 with diffuse PP, 19 (13.4 %) from 142 patients – with local PP. 46 (57.5 %) patients underwent one RL, 26 (32.5 %) – two, 8 (10 %) patients – three RL. With increasing numbers of RL, increase mortality rate: after first RL died 7 (15.2 %) of 46 patients, after second RL – 12 (63.2 %) of 19, after third RL 6 (75 %) of 8 patients. Conclusions. Together with standard surgical methods and precise technique were used lavage of abdominal cavity with 8 – 12 litres of antiseptic solutions, solution for peritoneal dialysis intraabdominally, nasointestinal drain tube, what was favourable for faster treatment of abdominal sepsis, reducing number of RL and postoperative mortality.

Complicated intra-abdominal infections: a prospective validation study of the WSES Sepsis Severity Score

INTRODUCTION

The World Society of Emergency Surgery (WSES) recently developed and validated a sepsis severity score for complicated intra-abdominal infections (cIAIs). We aimed to prospectively study the validity of this score in our local setting and compare it with global findings.

METHODS

In a prospective study of 100 consecutive adult patients with cIAIs treated at Al-Ain Hospital, United Arab Emirates, from October 2014 to January 2016, we studied patients' demographics, disease, risk factors, WSES Sepsis Severity Score, management, hospital stay and mortality. Our findings were compared with those from a recent global multicentre prospective study from 53 countries (n = 4,496).

RESULTS

Compared with global data, our patients were more likely to be male (p < 0.0001) and younger (p < 0.0001), with more appendicitis and perforated peptic ulcers (p < 0.0001), significantly lower sepsis severity score (p < 0.0001) and more delays in surgical intervention (p = 0.001). Nevertheless, they had similar adequate source control (p = 0.54) and surgical reinterventions (p = 0.63). Overall, our patients had a significantly lower mortality rate (1.0% vs. 9.3% in global data; p = 0.001). A direct logistic regression model showed that the WSES Sepsis Severity Score significantly predicted mortality (p < 0.0001), but our hospital's setting was not predictive of mortality compared with other hospitals (p = 0.18).

CONCLUSION

Although our patient demographics and hospital's setting significantly differed from those of other international hospitals, the WSES Sepsis Severity Score was very accurate in predicting mortality among our patients, which supports its generalisability for all patient populations worldwide.

Severe persistent hypocholesterolemia after emergency gastrointestinal surgery predicts in-hospital mortality in critically ill patients with diffuse peritonitis

Background

Plasma cholesterol acts as a negative acute phase reactant. Total cholesterol decreases after surgery and in various pathological conditions, including trauma, sepsis, burns, and liver dysfunction. This study aimed to determine whether hypocholesterolemia after emergency gastrointestinal (GI) surgery is associated with in-hospital mortality in patients with diffuse peritonitis.

Methods

The medical records of 926 critically ill patients who had undergone emergency GI surgery for diffuse peritonitis, between January 2007 and December 2015, were retrospectively analyzed. The integrated areas under the curve (iAUCs) were calculated to compare the predictive accuracy of total cholesterol values from postoperative days (PODs) 0, 1, 3, and 7. Cox proportional hazard regression modeling was performed for all possible predictors identified in the univariate and multivariable analyses.

Results

The total cholesterol level measured on POD 7 had the highest iAUC (0.7292; 95% confidence interval, 0.6696–0.7891) and was significantly better at predicting in-hospital mortality than measurements on other days. The optimal total cholesterol cut-off value for predicting in-hospital mortality was 61 mg/dL and was determined on POD 7. A Cox proportional hazard regression analysis revealed that a POD 7 total cholesterol level < 61 mg/dL was an independent predictor of in-hospital mortality after emergency GI surgery (hazard ratio, 3.961; 95% confidence interval, 1.786–8.784).

Conclusion

Severe persistent hypocholesterolemia (<61 mg/dL) on POD 7 independently predicted in-hospital mortality, after emergency GI surgery, in critically ill patients with diffuse peritonitis.

Correlation of Procalcitonin and C-Reactive Protein with Intra-Abdominal Hypertension in Intra-Abdominal Infections: Their Predictive Role in the Progress of the Disease

AIM

To analyse the correlation of procalcitonin (PCT) and C-reactive protein (CRP) values with increased intra-abdominal pressure and to evaluate their predictive role in the progression of Intra-abdominal infections.

MATERIALS AND METHODS

A non-randomized prospective study conducted in the group of 80 patients. We have measured the PCT, CRP and intra-abdominal pressure (IAP).

RESULTS

According to IAH grades (G), there was a significant difference of PCT values: G I 3.6 ± 5.1 ng/ml, G II 10.9 ± 22.6 ng/ml, G III 15.2 ± 30.2 ng/ml (p = 0.045) until: CRP values were increased in all IAH groups but without distinction between the groups: GI 183 ± 64.5, GII 196 ± 90.2, GIII 224 ± 96.3 (p = 0.17). According to the severity of the infection, we yielded increased values of PCT, IAP and CRP in septic shock, severe sepsis and SIRS/sepsis resulting in significant differences of PCT and IAP.

CONCLUSION

Based on the results of our research, we conclude that the correlation of PCT values with IAH grades is quite significant while the CRP results remain high in IAH but without significant difference between the different grades of IAH.

Bowel injury in lumbar spine surgery: a review of the literature

Although rarely documented in the medical literature, bowel perforation injury can be a severe complication of spine surgery. Our goal was to review current literature regarding this complication and study possible methods of avoidance. We conducted a literature search in the PubMed database between January 1960 and March 2016 using the terms abrasion, bowels, bowel, complication, injury, intestine, intra-abdominal sepsis/shock, perforation, lumbar, spine, surgery, visceral. Diagnostic criteria, outcomes, risk factors, surgical approach, and treatment strategy were the parameters extracted from the search results and used for review. Thirty-one patients with bowel injury were recognized in the literature. Bowel injury was more frequent in patients who underwent lumbar discectomy and microdiscectomy (18 of 31 patients, 58.1%). Minimally invasive surgery and lateral techniques involving fusions accounted for 10 of the reported cases (32.3%). Finally, 2 cases (6.5%) were reported in conjunction with sacrectomies and 1 case (3.2%) with posterior fusion plus anterior longitudinal ligament (ALL) release. Diagnosis was made mostly by clinical signs/symptoms of acute abdominal pain, post-surgical wound infection, and abscess or enterocutaneous fistulas. Significant risk factors for postoperative bowel injury were complex surgical anatomy, medical history of previous abdominal surgeries or infections, irradiation before surgery, errors related to surgical technique, lack of surgical experience, and instrumentation failure. The overall mortality rate from bowel injury was 12.9% (4 of 31 patients). The overall morbidity rate was 87.1% (27 of 31 patients). According to our review of the literature, bowel injury is linked to significant morbidity and mortality. It can be prevented with meticulous pre-surgical planning. When it occurs, timely treatment reduces the risks of morbidity and mortality.

Intraperitoneal lactate/pyruvate ratio and the level of glucose and glycerol concentration differ between patients surgically treated for upper and lower perforations of the gastrointestinal tract: a pilot study

BACKGROUND

Secondary peritonitis is a condition associated with high morbidity and mortality. Continuous postoperative monitoring of patients to ensure timely intervention to treat complications without delay is important for survival and outcome. We aimed to (1) investigate potential differences in postoperative intraperitoneal biomarker levels between patients with upper and lower gastrointestinal tract lesion, and (2) compare postoperative biomarker levels between complicated and uncomplicated patients.

METHODS

We included a total of 15 consecutive patients operated for upper (n = 7) and lower (n = 8) gastrointestinal tract perforation. We registered postoperative complications during a 30 days follow up-period. Complications were defined as intraabdominal complications, septic shock, and mortality. 5 patients were complicated. A microdialysis catheter was placed intraperitoneally in each patient. Samples were collected every 4th hour for up to 7 postoperative days. Samples were analysed for concentrations of glucose, lactate, pyruvate and glycerol.

RESULTS

Microdialysis results showed that patients with upper gastrointestinal tract lesions had significantly higher levels of postoperative intraperitoneal glucose and glycerol concentrations, as well as lower lactate/pyruvate ratios and lactate/glucose ratios. In the group with perforation of the lower gastrointestinal tract, those patients with a complicated course showed lower levels of postoperative intraperitoneal glucose concentration and glycerol concentration and higher lactate/pyruvate ratios and lactate/glucose ratios than those patients with an uncomplicated course.

CONCLUSION

Patients with upper and lower gastrointestinal tract lesions showed differences in postoperative biomarker levels. A difference was also seen between patients with complicated and uncomplicated postoperative courses.

Effect of intra-abdominally administered mesalazine (5-aminosalicylic acid) in experimental peritonitis

OBJECTIVE:

In this study, the effect of mesalazine was studied on TNF alpha IL-1 beta, IL-6, and C-reactive protein (CRP) levels and inflammatory changes in rat lungs with experimental peritonitis.

METHODS:

In total, 24 male Sprague–Dawley rats weighing 250–280 g were used in the study.The rats were divided into three groups based on no irrigation or irrigation with isotonic solution or mesalazine. Secondary peritonitis was generated by cecum penetrations. Group I, no irrigation was given after the development of peritonitis; Group II, irrigation was performed using isotonic solution 24 h after the development of peritonitis;

Group III:

irrigation was performed using mesalazine 24 h after the development of peritonitis. Blood samples were taken in the 48^th hour for measuring TNF alpha, IL-1 beta, IL-6, and CRP levels. Lung tissue samples were taken for examining the effect of mesalazine in the development of systemic sepsis.

RESULTS:

TNF alpha, IL-1 beta, and CRP levels were significantly low in Group III than in the other groups (p<0.005). In the histologic examination, leucocyte infiltration in the lung was found low in Group III.

CONCLUSION:

TNF alpha, IL-1 beta, and CRP levels and leucocyte infiltration in the lung were found to be low in rats that were administered peritoneal irrigation using mesalazine after the development of secondary peritonitis. Peritoneal irrigation using mesalazine may be useful in patients requiring surgery due to secondary peritonitis.

Assessment of Severity of Peritonitis Using Mannheim Peritonitis Index

INTRODUCTION

Peritonitis is one of the most common problems in general surgery practice with high mortality rate. One of the reasons for high mortality is that peritonitis affects the general condition and leads to complications causing multiple organ failure, renal failure, sepsis, and postoperative ventilatory support. Early prognostic evaluation of patients with peritonitis is desirable to select high-risk patients for intensive management and also to provide a reliable objective classification of severity and operative risk.

PATIENTS AND METHODS

Fifty cases with diagnosis of peritonitis coming to Government Medical College, Amritsar, were studied. Stratification of these patients was done according to Mannheim peritonitis index (MPI), and their outcome was examined.

RESULTS

Mortality steadily increases with increase in MPI score. For patients with a score <21, the mortality rate was 0%; for score 21-27, it was 27.28%; and for score >27, it was 100% (P < 0.001). For patients with a score <21, the morbidity rate was 13.33%; for score 21-27, it was 65.71%; and for score >27, it was 100% (P < 0.001). Duration of pain >24 h, organ failure on admission, female sex, and feculent exudate were found to be independently significant factors in predicting the mortality among the study population. For a score of 27, the sensitivity was 66.67%, specificity was 100%, and positive predictive value for mortality is 100% at an accuracy of 94%.

CONCLUSION

This study proves that MPI scoring system is a simple and effective tool for assessing the morbidity and mortality in patients with peritonitis.

Guidelines for management of intra-abdominal infections

Intra-abdominal infections are one of the most common gastrointestinal emergencies and a leading cause of septic shock. A consensus conference on the management of community-acquired peritonitis was published in 2000. A new consensus as well as new guidelines for less common situations such as peritonitis in paediatrics and healthcare-associated infections had become necessary. The objectives of these Clinical Practice Guidelines (CPGs) were therefore to define the medical and surgical management of community-acquired intra-abdominal infections, define the specificities of intra-abdominal infections in children and describe the management of healthcare-associated infections. The literature review was divided into six main themes: diagnostic approach, infection source control, microbiological data, paediatric specificities, medical treatment of peritonitis, and management of complications. The GRADE(®) methodology was applied to determine the level of evidence and the strength of recommendations. After summarising the work of the experts and application of the GRADE(®) method, 62 recommendations were formally defined by the organisation committee. Recommendations were then submitted to and amended by a review committee. After 2 rounds of Delphi scoring and various amendments, a strong agreement was obtained for 44 (100%) recommendations. The CPGs for peritonitis are therefore based on a consensus between the various disciplines involved in the management of these patients concerning a number of themes such as: diagnostic strategy and the place of imaging; time to management; the place of microbiological specimens; targets of empirical anti-infective therapy; duration of anti-infective therapy. The CPGs also specified the value and the place of certain practices such as: the place of laparoscopy; the indications for image-guided percutaneous drainage; indications for the treatment of enterococci and fungi. The CPGs also confirmed the futility of certain practices such as: the use of diagnostic biomarkers; systematic relaparotomies; prolonged anti-infective therapy, especially in children.

Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study)

BACKGROUND

To validate a new practical Sepsis Severity Score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression.

METHODS

The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period (October 2014-February 2015). Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18-99) were enrolled in the WISS study.

RESULTS

Univariate analysis has shown that all factors that were previously included in the WSES Sepsis Severity Score were highly statistically significant between those who died and those who survived (p < 0.0001). The multivariate logistic regression model was highly significant (p < 0.0001, R2 = 0.54) and showed that all these factors were independent in predicting mortality of sepsis. Receiver Operator Curve has shown that the WSES Severity Sepsis Score had an excellent prediction for mortality. A score above 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4.

CONCLUSIONS

WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.

Efficacy of Mannheim Peritonitis Index (MPI) Score in Patients with Secondary Peritonitis

BACKGROUND

Despite advances in diagnosis, management and critical care of patients with peritonitis due to hollow viscus perforation, prognosis remains poor. Early assessment by scoring systems will influence the management and prognosis.

AIM

Evaluation of Mannheim Peritonitis Index (MPI) score for predicting the outcome in patients with peritonitis.

MATERIALS AND METHODS

Prospective study of 50 patients admitted and operated for peritonitis in JSS Medical College Hospital. The structured scoring system i.e. MPI was applied along with other clinical and biochemical parameters recorded in pre-structured proforma. Data was analysed for predicting mortality and morbidity using EPI info and SPSS software.

RESULTS

The overall mortality and morbidity was 14% and 38% respectively. MPI scores of ≤ 20, 21-29, and ≥ 30 had a mortality of 5%, 14%, and 50% respectively. MPI score of 25 had highest sensitivity of 72.09% and specificity of 71.43% in predicting mortality, 80.65% sensitivity and 57.89% specificity for morbidity. MPI score of > 25 were associated with 6.45 times higher risk of mortality (p=0.03), 5.72 times higher risk of morbidity (p=0.005) compared to patients with MPI score ≤ 25.

CONCLUSION

MPI is disease specific, easy scoring system for predicting the mortality in patients with secondary peritonitis. Increasing scores are associated with poorer prognosis, needs intensive management and hence it should be used routinely in clinical practice.

Sepsis-induced leukocyte adhesion in the pulmonary microvasculature in vivo is mediated by CD11a and CD11b

Leukocyte accumulation is a rate-limiting step in inflammatory lung injury. The aim of this study was to define the role of CD11a/CD18 and CD11b/CD18 in sepsis-induced leukocyte rolling and adhesion in lung arterioles, capillaries and venules in male C57BL/6 mice using intravital fluorescence microscopy. Cecal ligation and puncture (CLP) markedly increased leukocyte rolling in arterioles and venules but not in capillaries in the lung. Immunoneutralization of CD11a, but not CD11b, decreased CLP-provoked leukocyte rolling in lung arterioles. Inhibition of CD11a or CD11b abolished CLP-induced arteriolar and venular leukocyte adhesion. Immunoneutralization of CD11a and CD11b reduced sepsis-induced leukocyte sequestration in pulmonary capillaries. Moreover, blocking CD11a or CD11b function improved microvascular blood flow in the lung of CLP animals. Considered together, our novel findings show that CD11a and CD11b mediate leukocyte adhesion in both arterioles and venules as well as trapping in capillaries in the lung. In addition, our data demonstrate that CD11a but not CD11b supports leukocyte rolling in pulmonary arterioles. Thus, these findings elucidate the molecular mechanisms behind leukocyte-endothelium interactions in the lung during systemic inflammation.

Predictors of mortality and morbidity in peritonitis in a developing country

OBJECTIVE

Generalized peritonitis is still a common emergency managed by most general surgeons throughout the world. If the outcome in these patients can be correctly predicted, then better management can be instituted to those patients in need. This study aims to identify factors in patients with peritonitis which have a significant bearing on morbidity and mortality. These factors could be later used to predict the outcome in patients with generalized peritonitis.

MATERIAL AND METHODS

A total of one hundred patients with peritonitis were studied. Factors including age, pulse and respiratory rate, temperature, hemoglobin, total leukocyte count, hematocrit, urea, creatinine, sodium, potassium, pH, PaO2 levels at the time of surgery along with peritoneal contamination and duration of surgery were noted. Using the Students t test, factors were identified which had a statistically significant influence on the outcome.

RESULTS

Thirty-six patients in the study developed complications and 17 died. Statistics showed that 8 factors influenced morbidity and 11 influenced mortality.

CONCLUSION

Identifying variables which influence the outcome of patients with peritonitis is an important initial step. Once these factors have been identified, the outcome of patients can be correctly predicted and better management can be instituted to those patients in need.

Urgent Redo-Laparotomies: Patterns and Outcome-A Single Centre Experience

A proportion of the operations performed in a surgical gastroenterology department are unplanned repeat laparotomies for complications of the original procedure. We examined why, in our department, these 'redo' laparotomies were performed and what was their outcome. We retrospectively analyzed 6530 patients operated between September 1996 - December 2010, of these 257 redo laparotomies were performed in 193(2.5 %) patients. There were 138 males and 55 females who had a mean age of 42 years (range 7-68 years). Eighty one (42 %) of the index surgeries were elective and 112 (58 %) performed in the emergency situation. Pancreas was the commonest organ for the index operation {50 (25.9 %)}, followed by the colon and rectum {45 (23.3 %)} and the small bowel {36 (18.7 %)}. Postoperative bleeding was the most common cause for re-exploration 66 (34.2 %) followed by an abscess or fluid collection that required surgical drainage 57 (29.6 %). The mortality rate after redo laparotomies was 33.2 % with sepsis and multi-organ failure being the commonest cause of death. Urgent redo-laparotomies that are performed following complicated abdominal operations have a high mortality rate. Postoperative bleeding, intrabdominal abscess and peritonitis are the commonest cause for redo-laparotomy. Multiple redolaparotomies and associated co-morbid conditions are significant predictors of mortality.

A focus on intra-abdominal infections

Complicated intra-abdominal infections are an important cause of morbidity and are frequently associated with poor prognosis, particularly in higher risk patients.

Well defined evidence-based recommendations for intra-abdominal infections treatment are partially lacking because of the limited number of randomized-controlled trials.

Factors consistently associated with poor outcomes in patients with intra-abdominal infections include increased illness severity, failed source control, inadequate empiric antimicrobial therapy and healthcare-acquired infection.

Early prognostic evaluation of complicated intra-abdominal infections is important to select high-risk patients for more aggressive therapeutic procedures.

The cornerstones in the management of complicated intra-abdominal infections are both source control and antibiotic therapy.

The timing and the adequacy of source control are the most important issues in the management of intra-abdominal infections, because inadequate and late control of septic source may have a negative effect on the outcomes.

Recent advances in interventional and more aggressive techniques could significantly decrease the morbidity and mortality of physiologically severe complicated intra-abdominal infections, even if these are still being debated and are yet not validated by limited prospective trials.

Empiric antimicrobial therapy is nevertheless important in the overall management of intra-abdominal infections. Inappropriate antibiotic therapy may result in poor patient outcomes and in the appearance of bacterial resistance.

Antimicrobial management is generally standardised and many regimens, either with monotherapy or combination therapy, have proven their efficacy. Routine coverage especially against Enterococci and candida spp is not always recommended, but can be useful in particular clinical conditions. A de escalation approach may be recommended in patients with specific risk factors for multidrug resistant infections such as immunodeficiency and prolonged antibacterial exposure.

Therapy should focus on the obtainment of adequate source control and adequate use of antimicrobial therapy dictated by individual patient risk factors. Other critical issues remain debated and more controversies are still open mainly because of the limited number of randomized controlled trials.

Urgent abdominal re-explorations

Background

Treatment of a number of complications that occur after abdominal surgeries may require that Urgent Abdominal Re-explorations (UARs), the life-saving and obligatory operations, are performed. The objectives of this study were to evaluate the reasons for performing UARs, outcomes of relaparotomies (RLs) and factors that affect mortality.

Methods

Demographic characteristics; initial diagnoses; information from and complications of the first surgery received; durations and outcomes of UAR(s) performed in patients who received early RLs because of complicated abdominal surgeries in our clinic between 01.01.2000 and 31.12.2004 were investigated retrospectively. Statistical analyses were done using the chi-square and Fisher exact tests.

Results

Early UAR was performed in 81 out of 4410 cases (1.8%). Average patient age was 50.46 (13–81) years with a male-to-female ratio of 60/21. Fifty one (62.96%) patients had infection, 41 (50.61%) of them had an accompanying serious disease, 24 (29.62%) of them had various tumors and 57 (70.37%) patients were operated under emergency conditions during first operation. Causes of urgent abdominal re-explorations were as follows: leakage from intestinal repair site or from anostomosis (n:34; 41.97%); hemorrhage (n:15; 18.51%); intestinal perforation (n:8; 9.87%); intraabdominal infection or abscess (n:8; 9.87%); progressive intestinal necrosis (n:7; 8.64%); stomal complications (n:5; 6.17%); and postoperative ileus (n:4; 4.93%). Two or more UARs were performed in 18 (22.22%) cases, and overall mortality was 34.97% (n:30). Interval between the first laparotomy and UAR averaged as 6.95 (1–20) days, and average hospitalization period was 27.1 (3–78) days.

Mortality rate was found to be higher among the patients who received multiple UARs. The most common (55.5%) cause of mortality was sepsis/multiple organ failure (MOF). The rates for common mortality and sepsis/MOF-dependent mortality that occured following UAR were significantly higher in patients who received GIS surgery than in those who received other types of surgeries (p:0.000 and 0.010, respectively).

Conclusion

UARs that are performed following complicated abdominal surgeries have high mortality rates. In particular, UARs have higher mortality rates following GIS surgeries or when infectious complications occur. The possibility of efficiently lowering these high rates depends on the success of the first operations that the patient had received.