Current concept of abdominal sepsis: WSES position paper

Surgical Trends in Chronic Pancreatitis From 2014 to 2021

OBJECTIVES

We analyzed annual surgical trends for benign chronic pancreatitis (CP), studying specifically mortality, morbidity, and pancreatic fistula rates. We also aimed to identify predictors of pancreatic fistula formation.

MATERIALS AND METHODS

For this analysis, we used data from the American College of Surgeons National Surgical Quality Improvement Program from 2014 to 2021. The study included patients who underwent surgery for benign CP. Data collected included patient demographics, preoperative variables, and postoperative outcomes. Data were analyzed with univariate and multivariate analyses, with significance defined as P  ≤ 0.05.

RESULTS

Over the study period, the number of pancreatic surgical procedures increased by 49.3%, although surgery specifically for CP declined by 31.7%. The rate of pancreatic fistula formation decreased 44.9%, and mortality decreased 31.9%. Significant predictors of a pancreatic fistula included no diabetes, preoperative sepsis, soft texture of the pancreatic gland, and greater patient weight.

CONCLUSION

Surgery for benign CP decreased substantially despite the established efficacy of surgical intervention for long-term pain management. The concurrent decline in mortality and rates of pancreatic fistula formation suggest advances over the study years in surgical and postoperative care.

Open abdomen versus primary closure in nontrauma patients: A weighted analysis of a single-center experience

INTRODUCTION

The open abdomen (OA) technique is nowadays a worldwide strategy both for trauma and emergency general surgery. Despite the attempt at conducting prospective studies, a high level of evidence is far from established. The aim of this study was to investigate if we overused this strategy and if it improved the postoperative course of our patients.

METHODS

Emergency laparotomies from 2017 and 2023 were reviewed and stratified according to OA and closed abdomen (CA). Differences were balanced by inverse probability weighting, and the 90-day mortality was estimated. Subgroup analysis was carried out for patients with a Mannheim Peritonitis Index (MPI) of >26, bowel obstruction, bowel ischemia (BI) and gastrointestinal perforation.

RESULTS

Of the 320 patients, 167 were CA and 153 were OA. Groups were different for American Society of Anesthesiologists, comorbidities, transfusion rate, Physiologic and Operative Severity Score for the Study of Mortality and Morbidity score, MPI, Clinical Frailty Scale score, diagnosis, and resection. Two balanced pseudo-populations were created. The 90-day survival rate was 50.8% for CA and 60.8% for OA (hazard ratio [HR], 0.79; confidence interval [CI], 0.40-1.55; p = 0.502). At the Cox regression, the Clinical Frailty Scale score (HR, 1.125; 95% CI, 1.01-1.25; p = 0.033) and BI (HR, 5.531; 95% CI, 2.37-12.89; p < 0.001) were independent risk factors for mortality. Transfusion rate (odds ratio [OR], 3.44; 95% CI, 1.44-8.23; p < 0.006) and length of stay in the intensive care unit (OR, 1.13; 95% CI, 1.07-1.20; p < 0.001) were associated with major complications. Open abdomen did not modify mortality in the case of bowel obstruction, MPI >26, or gastrointestinal perforation. Finally, OA (HR, 0.056; 95% CI, 0.01-0.22; p = 0.001) and large bowel resection (HR, 6.442; 95% CI, 1.28-32.31; p = 0.040) were predictors of longer survival in the subgroup of patients with BI.

CONCLUSION

Open abdomen was not associated with a higher complication rate or higher mortality but did result in a longer in-hospital stay. The only setting where OA seemed to be advantageous was in the BI population.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Monitoring Circulating Myeloid Cells in Peritonitis with an In Vivo Imaging Flow Cytometer

Peritonitis is a common and life-threatening inflammatory disease. Myeloid cells are elevated in the peripheral blood and contribute to peritonitis, but their circulating dynamics are not clear. In vivo flow cytometry (IVFC) is a noninvasive technique for monitoring the dynamics of circulating cells in live animals. It has been extensively used to detect circulating tumor cells, but rarely for monitoring immune cells. Here, we describe a method adapting an intravital microscope for IVFC so that we can monitor LysM-EGFP-labeled circulating myeloid cells in a tumor necrosis factor (TNF) α-induced peritonitis mouse model. Using this IVFC method, we quantified the blood flow velocity and cell concentration in circulation. We observed a significant increase in LysM-EGFP+ cells in circulation after TNFα intraperitoneal (i.p.) injection, which reached a plateau in ~20 min. Conventional cytometry analysis showed that most LysM-EGFP+ cells were neutrophils. Increasing blood neutrophils were accompanied by neutrophil recruitment to the peritoneal cavity and neutrophil emigration from the bone marrow. We then monitored neutrophil CD64 expression in vivo and found a significant increase in TNFα-induced peritonitis. We also found that CD18 blockade doubled the circulating neutrophil number in TNFα-induced peritonitis, suggesting that CD18 is critical for neutrophil recruitment in peritonitis. Overall, we demonstrate that IVFC techniques are useful for studying the circulating dynamics of immune cells during inflammatory diseases.

Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.

Sepsis-Related Lung Injury and the Complication of Extrapulmonary Pneumococcal Pneumonia

Globally, sepsis and pneumonia account for significant mortality and morbidity. A complex interplay of immune-molecular pathways underlies both sepsis and pneumonia, resulting in similar and overlapping disease characteristics. Sepsis could result from unmanaged pneumonia. Similarly, sepsis patients have pneumonia as a common complication in the intensive care unit. A significant percentage of pneumonia is misdiagnosed as septic shock. Therefore, our knowledge of the clinical relationship between pneumonia and sepsis is imperative to the proper management of these syndromes. Regarding pathogenesis and etiology, pneumococcus is one of the leading pathogens implicated in both pneumonia and sepsis syndromes. Growing evidence suggests that pneumococcal pneumonia can potentially disseminate and consequently induce systemic inflammation and severe sepsis. Streptococcus pneumoniae could potentially exploit the function of dendritic cells (DCs) to facilitate bacterial dissemination. This highlights the importance of pathogen-immune cell crosstalk in the pathophysiology of sepsis and pneumonia. The role of DCs in pneumococcal infections and sepsis is not well understood. Therefore, studying the immunologic crosstalk between pneumococcus and host immune mediators is crucial to elucidating the pathophysiology of pneumonia-induced lung injury and sepsis. This knowledge would help mitigate clinical diagnosis and management challenges.

Greater Omentum: Multifaceted Interactions in Neurological Recovery and Disease Progression

The greater omentum, a unique anatomical structure composed of adipocytes, loose connective tissue, and a dense vascular network. Plays a pivotal role beyond its traditional understanding. It houses specialized immunological units known as 'Milky spots,' making it a key player in immune response. Moreover, the omentum's capacity to enhance tissue perfusion, absorb edema fluid, boost acetylcholine synthesis, and foster neuron repair have rendered it a topic of interest in the context of various diseases, especially neurological disorders. This review provides a comprehensive overview of the intricate anatomy and histology of the greater omentum, casting light on its multifaceted functions and its associations with a spectrum of diseases. With a specific focus on neurological ailments, we delineate the intricate relationship that the omentum shares with other pathologies like stroke and we underly its contribution to serving as a therapeutic agent in neurological disorders. By deciphering the underlying mechanisms and emphasizing areas that demand further investigation. This review aims to spark renewed interest and pave the way for comprehensive studies exploring the greater omentum's potential in neurology and broader medicine overall. Given these diverse interactions that yet remain elusive, we must investigate and understand the nuanced relationship between the greater omentum and pathologies, especially its role in stroke's pathophysiology and therapeutic interventions so as to enhance patient care.

Factors Associated with Short-Term Surgical Outcomes Among Women Presenting with Pelvic Peritonitis at Bugando Medical Centre Mwanza, Tanzania

Background

Pelvic peritonitis is a rarely reported pathological condition in literature and emergency laparotomies are a common surgical procedure performed for these conditions in developing countries. This study was designed to investigate factors that are associated with short-term surgical outcomes among women with pelvic peritonitis.

Methods

The study included retrospective and prospective data obtained between November 2021 and May 2022 from Bugando Medical Centre (BMC). Standardized data collection tool was used to capture clinical, surgical and laboratory data. Descriptive data analysis was done using STATA version 13.

Results

A total of 101 participants were recruited; 22 prospectively and 79 retrospectively. The median age was 29[Interquartile range (IQR) 24 to 35] years. Majority (76.2%) of participants were referred patients. Obstetric related peritonitis 82.2% (83/101) was the most frequently detected with a necrotic and or dehiscent lower uterine segment (LUS) that necessitated a subtotal abdominal hysterectomy (STAH) being the commonest (40.8%) intraoperative finding. Postoperative complications were reported in 36.7% (36/98) and were significantly associated with pulse rates >100b/min (P=.041) and platelets <150 × 103 mm3 (P=.049). The median length of hospital stay was 19[IQR: 7 to 35] days and temperature >37.5°C (aOR=5.08, 95% CI 1.23-20.97, P=.025) independently predicted prolonged hospital stay. Death occurred in 9.2% of patients and having ASA score of 5 (P=.045) was associated with death. Multi-drug resistant (MDR) gram-negative bacteria (85.2%) were the predominant pathogens causing pelvic peritonitis.

Conclusion

A significant proportion of patients with pelvic peritonitis and deranged sepsis markers develop short-term surgical complications with a significant number of those with fever stay more than 14 days. There is a need of timely complete sepsis work up of the patients with pelvic peritonitis to ensure appropriate management is instituted to prevent associated morbidity and mortality.

Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part I

INTRODUCTION

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

AIM

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

MATERIAL AND METHODS

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

RESULTS AND CONCLUSIONS

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The first part of the guidelines covers 5 sections and the following challenges for surgical practice: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia and acute cholecystitis. Contraindications for laparoscopy and the ERAS program are discussed.

STOP Signs: A Population-based Interrupted Time Series Analysis of Antibiotic Duration for Complicated Intraabdominal Infection Before and After the Publication of a Landmark RCT

OBJECTIVE

To determine if the STOP-IT randomized controlled trial changed antibiotic prescribing in patients with Complicated Intraabdominal Infection (CIAI).

SUMMARY OF BACKGROUND DATA

CIAI is common and causes significant morbidity. In May 2015, the STOP-IT randomized controlled trial showed equivalent outcomes between four-day and clinically determined antibiotic duration.

METHODS

This was a population-based retrospective cohort study using interrupted time series methods. The STOP-IT publication date was the exposure. Median duration of inpatient antibiotic prescription was the outcome. All adult patients admitted to four hospitals in Calgary, Canada between July 2012 and December 2018 with CIAI who survived at least four days following source control were included. Analysis was stratified by infectious source as appendix or biliary tract (group A) versus other (group B).

RESULTS

Among 4384 included patients, clinical and demographic attributes were similar before vs after publication. In Group A, median inpatient antibiotic duration was 3 days and unchanged from the beginning to the end of the study period [adjusted median difference -0.00 days, 95% confidence interval (CI) -0.37 - 0.37 days]. In Group B, antibiotic duration was shorter at the end of the study period (7.87 vs 6.73 days; -1.14 days, CI-2.37 - 0.09 days), however there was no change in trend following publication (-0.03 days, CI -0.16 - 0.09).

CONCLUSIONS

For appendiceal or biliary sources of CIAI, antibiotic duration was commensurate with the experimental arm of STOP-IT. For other sources, antibiotic duration was long and did not change in response to trial publication. Additional implementation science is needed to improve antibiotic stewardship.

Peritoneal contamination and associated post-operative infectious complications after natural orifice specimen extraction for laparoscopic colorectal surgery

BACKGROUND

Peritoneal contamination is a major concern during natural orifice specimen extraction after laparoscopic colorectal resection (LCR-NOSE), but few data are available. We explored the prevalence, risk factors, and association between clinical outcomes and infectious complications in patients with positive peritoneal drain fluid culture (PDFC) after LCR-NOSE.

METHOD

We retrospectively analyzed patient records in our prospectively maintained registry database who underwent LCR-NOSE between 2011and 2020. Peritoneal drain fluid was collected within 12 h post-operative and cultures for microorganisms were obtained. The relationships between PDFC, clinical variables, and infectious complications were examined by univariate and multivariable analysis.

RESULTS

Of 241 consecutive patients who underwent LCR-NOSE and drainage fluid culture, 59 (24.5%) had PDFC. Anterior resection (Odds ratio OR 2.40) was identified as an independent predictor for PDFC. Twenty-eight patients (11.6%) developed infectious complications. Multivariable analysis identified low anterior resection (OR 2.74), prolonged operative time (OR 3.20), and PDFC (OR 5.14) as independent risk factors. Pseudomonas aeruginosa was the most frequently found microorganism (OR 5.19) responsible for infectious complications.

CONCLUSIONS

Microorganisms are commonly present in the peritoneum after LCR-NOSE and play a critical role in the development of infectious complications and related morbidity. Specific caution is warranted in patients contaminated with specific types of microorganisms.

Gut microbiome diversity of porcine peritonitis model of sepsis

Animal models are essential in understanding of the mechanisms of sepsis moreover the development and the assessment of emerging therapies. In clinically relevant porcine model, however, a significant variability in the host response has been observed among animals. Thus, there is a strong demand to better understand the potential sources of this heterogeneity. In this study, we compared faecal microbiome composition of 12 animals. Three samples were collected at different time points from each animal. Bacteriome was subjected to 16S rDNA profiling. A significant difference in bacterial composition was associated with the season (p < 0.001) but not with the sex of the pig (p = 0.28), the timing of sample collection (p = 0.59), or interactions thereof (all p > 0.3). The season batch explained 55% of the total variance in the bacteriome diversity. The season term was highly significant from the high-resolution level of the bacterial amplicon sequencing variants up to the level of phylum. The diversity of the microbiome composition could significantly influence experimental model of sepsis, and studies are warranted to demonstrate the effects of gut microbiome diversity on the host-response. If confirmed, control of the gut microbiome should become a standard part of the pre-clinical sepsis experiments.

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.

Comparison of Duration and Empiric Antibiotic Choice of Post-Operative Treatment in Abdominal Sepsis

Background: Although abdominal foci are the second most common source of sepsis, only few studies focus on the optimal length of post-operative antibiotic therapy in critically ill patients with abdominal sepsis. The aim of this study was to compare the outcomes of short versus long antibiotic therapy as well as broad-spectrum penicillin versus carbapenem in patients with abdominal sepsis. Patients and Methods: We performed a single center retrospective study in patients with abdominal sepsis who underwent emergency surgery. The study was conducted in a tertiary hospital in Germany during 2016-2018. We reviewed the duration of post-operative antibiotic therapy and the initially used agent, comparing patients treated shorter or longer than seven days with or without source control. Depending on the empirically given antibiotic, a subgroup analysis was conducted comparing patients treated with piperacillin-tazobactam versus carbapenems. Results: Longer duration of post-operative antibacterial treatment (>7 days) was not substantially advantageous. The group with a longer course of antibiotic therapy had more severe post-operative complications (82.4% [n = 61] vs. 62.5% [n = 20]; p = 0.01) requiring longer critical care support (18 days vs. 11 days; p = 0.027), prolonging the length of stay (28 days vs. 20 days; p = 0.044). Surgical re-interventions were more frequent in the long-course arm (70.3% vs. 40.6%; p = 0.004). The subgroup analysis comparing piperacillin-tazobactam versus carbapenems confirmed more severe complications (86.3% vs. 67.5%; p = 0.04) for the carbapenem arm. Conclusions: Post-surgical continuation of antibiotic agents beyond seven days was observed with more post-operative complications and delayed recovery. Piperacillin-tazobactam seems to be a potent alternative for patients with abdominal sepsis.

Tertiary peritonitis: considerations for complex team-based care

Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key-but not all-elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.

Comparison of Omental Patch Closure Versus Simple Closure for Laparoscopic Repair of Perforated Peptic Ulcer: A Systematic Review and Meta-Analysis

AIMS

To evaluate comparative outcomes of laparoscopic repair of perforated peptic ulcer with omental patch versus without omental patch.

METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic repair of perforated peptic ulcer (PPU) with and without omental patch were included. Operative time, postoperative complications, re-operation and mortality were the evaluated outcome parameters for the meta-analysis. Revman 5.3 was used for data analysis.

RESULTS

Four observational studies reporting a total number of 438 patients who underwent laparoscopic repair of PPU with (n = 268) or without (n = 170) omental patch were included. Operative time was significantly shorter in no-omental patch group (NOP) when compared to omental patch group (P = .02). There was no significant difference in the risk of postoperative ileus (Odd ratio (OR) .76, P = .61), leakage (OR 1.17, P = .80), wound infection (OR 1.89, P = .34), intra-abdominal abscess (OR 1.17, P = .87), re-operation (OR .00, P = .94) and mortality (OR .55, P = .48). Moreover, length of hospital stay was comparable between the two groups (P = .81).

CONCLUSION

Laparoscopic repair of PPU with or without omental patch have comparable postoperative complications and mortality rate. However, considering the shorter operative time, no-omental patch approach is an attractive and more favourable choice. Well-designed randomized controlled trials are needed to investigate this comparison.

Intra-abdominal Infections

Intra-abdominal infections (IAIs) are a common cause of sepsis, and frequently occur in intensive care unit (ICU) patients. IAIs include many diagnoses, including peritonitis, cholangitis, diverticulitis, pancreatitis, abdominal abscess, intestinal perforation, abdominal trauma, and pelvic inflammatory disease. IAIs are the second most common cause of infectious morbidity and mortality in the ICU after pneumonia. IAIs are also the second most common cause of sepsis in critically ill patients, and affect approximately 5% of ICU patients. Mortality with IAI in ICU patients ranges from 5 to 50%, with the wide variability related to the specific IAI present, associated patient comorbidities, severity of illness, and organ dysfunction and failures. It is important to have a comprehensive understanding of IAIs as potential causes of life-threatening infections in ICU patients to provide the best diagnostic and therapeutic care for optimal patient outcomes in the ICU.

Retrospective Cohort Analysis of the Effect of Antimicrobial Stewardship on Postoperative Antibiotic Therapy in Complicated Intra-Abdominal Infections: Short-Course Therapy Does Not Compromise Patients’ Safety

Background: Recent evidence suggests that short-course postoperative antibiotic therapy (PAT) of intra-abdominal infections is non-inferior considering clinical outcomes. The aim of this study was to compare the outcome of short vs. long PAT in complicated intra-abdominal infections (cIAIs) without sepsis. Methods: We performed a single center-quality improvement study at a 1500 bed sized university hospital in Bavaria, Germany, with evaluation of the length of antibiotic therapy after emergency surgery on cIAIs with adequate source control during 2016 to 2018. We reviewed a total of 260 cases (160 short duration vs. 100 long duration). The antibiotic prescribing quality was assessed by our in-house antimicrobial stewardship team (AMS). Results: No significant differences of patient characteristics were observed between short and long PAT. The frequency of long PAT declined during the observation period from 48.1% to 26.3%. Prolongation of PAT was not linked with any clinical benefits, on the contrary clinical outcome of patients receiving longer regimes were associated with higher postoperative morbidity. AMS identified additional educational targets to improve antibiotic prescribing quality on general wards like unnecessary postoperative switches of antibiotic regimes, e.g., unrequired switches to oral antibiotics as well as prolongation of PAT due to elevated CRP. Conclusion: Short-course antibiotic therapy after successful surgical source control in cIAIs is safe, and long-duration PAT has no beneficial effects.

Diagnostic challenges in postoperative intra-abdominal sepsis in critically ill patients: When to reoperate?

The present paper was done to review common diagnostic techniques used to help surgeons find the most suitable way to diagnose postoperative intra-abdominal sepsis (IAS). The topic was searched on MEDLINE, Embase, and Cochrane Library databases. Collected articles were classified and checked for their quality. Findings of selected research were included in this study and analyzed to find the best diagnostic method for intra-abdominal sepsis. IAS presents severe morbidity and mortality, and its early diagnosis can improve the outcome. Currently, there is no consensus among surgeons on a single diagnostic modality that should be used while deciding reoperation in patients with postoperative IAS. Though it has a high sensitivity for abdominal infections, computed tomography has limited applications due to mobility and time constraints. Diagnostic laparoscopy is a safe process that produces usable images, and can be used at the bedside. Diagnostic peritoneal lavage (DPL) has high sensitivity, and the patients testing positive through DPL can be subjected to exploratory laparotomy, depending on severity. Abdominal Reoperation Predictive Index (ARPI) is the only index reported as an aid for this purpose. Serial intra-abdominal pressure measurement has also emerged as a potential diagnostic tool. A proper selection of diagnostic modality is expected to improve the outcome in IAS, which presents high mortality risk and a limited time frame.

[Safety and efficacy of laparoscopic approach for widespread appendicular peritonitis]

OBJECTIVE

To analyze treatment outcomes in patients with acute appendicitis complicated by widespread peritonitis.

MATERIAL AND METHODS

The study included 165 patients acute appendicitis complicated by widespread peritonitis. Inclusion criteria: acute appendicitis complicated by widespread peritonitis MIP grade 1-2 in reactive or toxic phase (grading system by Simonyan K.S.), abdominal cavity index ≤16. Exclusion criteria: MIP grade 3, terminal phase, abdominal cavity index ≥17.

RESULTS

Analysis of postoperative data revealed no correlation between surgical approach and incidence of postoperative intra-abdominal abscesses and infiltrates. In the main group, intra-abdominal abscesses occurred in 4.9% of patients (n=5), infiltrates - 12.8% (n=13). In the control group, these parameters were 4.6% (n=2) and 18.2% (n=8), respectively. We have developed and introduced into clinical practice a differentiated approach to surgical treatment of widespread appendicular peritonitis based on laparoscopic data. Abdominal cavity was intraoperatively assessed. The proposed method included 5 criteria with establishment of appropriate points (min 3, max 14). In case of total score 3-8, laparoscopic approach was preferred. Overall score 9-11 required laparoscopic surgery with subsequent elective repeated laparoscopy, ≥12 scores - intraoperative conversion and open surgery. Thus, subject to the rules of surgical intervention, the number of intra-abdominal complications between laparoscopic and open methods is equalized.

CONCLUSION

The developed differentiated surgical strategy for patients with appendicular peritonitis is effective and reduces the incidence of wound infection, extra-abdominal complications, and hospital-stay, as well as contributes to early rehabilitation of patients.

Bacterial translocation in patients undergoing major gastrointestinal surgery and its role in postoperative sepsis

Bacteria of the human intestinal microflora have a dual role. They promote digestion and are part of a defense mechanism against pathogens. These bacteria could become potential pathogens under certain circumstances. The term "bacterial translocation" describes the passage of bacteria of the gastrointestinal tract through the intestinal mucosa barrier to mesenteric lymph nodes and other organs. In some cases, the passage of bacteria and endotoxins could result in blood stream infections and in multiple organ failure. Open elective abdominal surgery more frequently results in malfunction of the intestinal barrier and subsequent bacterial translocation and blood stream infections than laparoscopic surgery. Postoperative sepsis is a common finding in patients who have undergone non-elective abdominal surgeries, including trauma patients treated with laparotomy. Postoperative sepsis is an emerging issue, as it changes the treatment plan in surgical patients and prolongs hospital stay. The association between bacterial translocation and postoperative sepsis could provide novel treatment options.

Hydroxyethyl Starch for Fluid Management in Patients Undergoing Major Abdominal Surgery: A Systematic Review With Meta-analysis and Trial Sequential Analysis

BACKGROUND

In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement.

METHODS

In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome (P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P value <.01 was considered statistically significant).

RESULTS

Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94-1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10-2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57-1.02; P = .02).

CONCLUSIONS

In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function.

Rate of stoma formation following damage-control surgery for severe intra-abdominal sepsis: a single-centre consecutive case series

BACKGROUND

Severe intra-abdominal sepsis (IAS) is associated with high mortality and stoma rates. A two-stage approach with initial damage-control surgery (DCS) and subsequent reconstruction might decrease stoma and mortality rates but requires standardization.

METHODS

A standardized two-stage damage-control algorithm for IAS was implemented in April 2016 and applied systematically.

RESULTS

Some 203 consecutive patients (median age 70 years, 62 per cent ASA score greater than 3) had DCS for severe IAS. Median operation time was 82 minutes, 60 per cent performed during night-time. Median intraoperative noradrenaline doses were 20 (i.q.r. 26) µg/min and blood gas analysis (ABG) was abnormal (metabolic acidosis) in 90 per cent of patients. The second-stage operation allowed definitive surgery in 76 per cent of patients, 24 per cent had up to four re-DCSs until definitive surgery. The in-hospital mortality rate was 26 per cent. At hospital discharge, 65 per cent of patients were stoma free. Risk factors for in-hospital death were noradrenaline (odds ratio 4.25 (95 per cent c.i. 1.72 to 12.83)), abnormal ABG (pH: odds ratio 2.72 (1.24 to 6.65); lactate: odds ratio 6.77 (3.20 to 15.78)), male gender (odds ratio 2.40 (1.24 to 4.85)), ASA score greater than 3 (odds ratio 5.75 (2.58 to 14.68)), mesenteric ischaemia (odds ratio 3.27 (1.71 to 6.46)) and type of resection (odds ratio 2.95 (1.24 to 8.21)). Risk factors for stoma at discharge were ASA score greater than 3 (odds ratio 2.76 (95 per cent c.i. 1.38 to 5.73)), type of resection (odds ratio 30.91 (6.29 to 559.3)) and longer operation time (odds ratio 2.441 (1.22 to 5.06)).

CONCLUSION

Initial DCS followed by secondary reconstruction of bowel continuity for IAS within 48 hours in a tertiary teaching hospital was feasible and safe, following a clear algorithm.

The Essential Involvement of the Omentum in the Peritoneal Defensive Mechanisms During Intra-Abdominal Sepsis

Although the abilities of the omentum to alleviate inflammation and prevent infection have been revealed over the past decades, the underlying mechanisms remain largely unelucidated. Here, we demonstrated that the mortality of mice exposed to cecal ligation and puncture (CLP) and omentectomy was remarkably increased compared to those treated with CLP alone. Moreover, the efficacy of the omentum was associated with an impairment in intraperitoneal bacterial clearance together with an increase in the expression of proinflammatory cytokines. Besides, in response to peritoneal infections, the size and quantity of the omental milky spots (MSs) were increased tremendously and they also support innate-like B1 cell responses and local IgM production in the peritoneal cavity. Furthermore, not only the migration but also the functional activities of neutrophils were diminished in the absence of the omentum. These data collectively show that the omentum contributes more to peritoneal immune responses during septic peritonitis than has heretofore been recognized. Thus, harnessing the function of MS-containing omentum to increase its protective effectiveness may exert important biological and therapeutic implications for the control of intra-abdominal infections.

Superior primary fascial closure rate and lower mortality after open abdomen using negative pressure wound therapy with continuous fascial traction

BACKGROUND

Open abdomen (OA) is a useful option for treatment strategy in many acute abdominal catastrophes. A number of temporary abdominal closure (TAC) methods are used with limited number of comparative studies. The present study was done to examine risk factors for failed delayed primary fascial closure (DPFC) and risk factors for mortality in patients treated with OA.

METHODS

This study was a multicenter retrospective analysis of the hospital records of all consecutive patients treated with OA during the years 2009 to 2016 at five tertiary referral hospitals and three secondary referral centers in Finland.

RESULTS

Six hundred seventy-six patients treated with OA were included in the study. Vacuum-assisted closure with continuous mesh-mediated fascial traction (VACM) was the most popular TAC method used (N = 398, 59%) followed by VAC (N = 128, 19%), Bogota bag (N = 128, 19%), and self-designed methods (N = 22, 3%). In multivariate analysis, enteroatmospheric fistula and the number of needed TAC changes increased the risk for failed DPFC (odds ratio [OR], 8.9; 95% confidence interval [CI], 6.2-12.8; p < 0.001 and OR, 1.1; 95% CI, 1.0-1.3; p < 0.001, respectively). Instead, VACM and ruptured abdominal aortic aneurysm as cause for OA both decreased the risk for failed DPFC (OR, 0.1; 95% CI, 0.0-0.3; p < 0.001 and OR, 0.2; 95% CI, 0.1-0.7; p = 0.012). The overall mortality rate was 30%. In multivariate analysis for mortality, multiorgan dysfunction (OR, 2.4; 95% CI, 1.6-3.6; p < 0.001), and increasing age (OR, 4.5; 95% CI, 2.0-9.7; p < 0.001) predicted increased mortality. Institutional large annual patient volume (OR, 0.4; 95% CI, 0.3-0.6; p < 0.001) and ileus and postoperative peritonitis in comparison to severe acute pancreatitis associated with decreased mortality (OR, 0.2; 95% CI, 0.1-0.4; p < 0.001; OR, 0.5; 95% CI, 0.3-0.8; p = 0.009). Kaplan-Meier analysis showed increased survival in patients treated with VACM in comparison with other TAC methods (LogRank p = 0.019).

CONCLUSION

We report superior role for VACM methodology in terms of successful primary fascial closure and increased survival in patients with OA.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

SOFA Score, Hemodynamics and Body Temperature Allow Early Discrimination between Porcine Peritonitis-Induced Sepsis and Peritonitis-Induced Septic Shock

Porcine model of peritonitis-induced sepsis is a well-established clinically relevant model of human disease. Interindividual variability of the response often complicates the interpretation of findings. To better understand the biological basis of the disease variability, the progression of the disease was compared between animals with sepsis and septic shock. Peritonitis was induced by inoculation of autologous feces in fifteen anesthetized, mechanically ventilated and surgically instrumented pigs and continued for 24 h. Cardiovascular and biochemical parameters were collected at baseline (just before peritonitis induction), 12 h, 18 h and 24 h (end of the experiment) after induction of peritonitis. Analysis of multiple parameters revealed the earliest significant differences between sepsis and septic shock groups in the sequential organ failure assessment (SOFA) score, systemic vascular resistance, partial pressure of oxygen in mixed venous blood and body temperature. Other significant functional differences developed later in the course of the disease. The data indicate that SOFA score, hemodynamical parameters and body temperature discriminate early between sepsis and septic shock in a clinically relevant porcine model. Early pronounced alterations of these parameters may herald a progression of the disease toward irreversible septic shock.

Open Abdomen and Fluid Instillation in the Septic Abdomen: Results from the IROA Study

BACKGROUND

Open abdomen (OA) is a surgical option that can be used in patients with severe peritonitis. Few evidences exist to recommend the use of intraperitoneal fluid instillation associated with OA in managing septic abdomen.

MATERIALS AND METHODS

A prospective analysis of adult patients enrolled in the International Register of Open Abdomen (trial registration: NCT02382770) was performed.

RESULTS

A total of 387 patients were enrolled in two groups: 84 with peritoneal fluid instillation (FI) and 303 without (NFI). The groups were homogeneous for baseline characteristics. Overall complications were 92.9% in FI and 86.3% in NFI (p = 0.106). Complications during OA were 72.6% in FI and 59.9% in NFI (p = 0.034). Complications after definitive closure were 70.8% in FI and 61.1% in NFI (p = 0.133). Entero-atmospheric fistula was 13.1% in FI and 12% in NFI (p = 0.828). Fascial closure was 78.6% in FI and 63.7% in NFI (p = 0.02). Analysis of FI in negative pressure wound therapy (NPWT) showed: Overall morbidity in NPWT was 94% and in non-NPWT 91.2% (p = 0.622) and morbidity during OA was 68% and 79.4% (p = 0.25), respectively. Definitive fascial closure in NPWT was 87.8% and 96.8% in non-NPWT (p = 0.173). Overall mortality was 40% in NPWT and 29.4% in non-NPWT (p = 0.32) and morality during OA period was 18% and 8.8% (p = 0.238), respectively.

CONCLUSION

We found intraperitoneal fluid instillation during open abdomen in peritonitic patients to increase the complication rate during the open abdomen period, with no impact on mortality, entero-atmospheric fistula rate and opening time. Fascial closure rate is increased by instillation. Fluid instillation is feasible even when associated with nonnegative pressure temporary abdominal closure techniques.

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

BACKGROUND

Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.

MATERIALS AND METHODS

The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.

RESULTS

The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.

CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS

ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations

BACKGROUND

Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines.

METHODS

The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020.

RESULTS

The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible.

CONCLUSIONS

The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

Intra-Abdominal Infections by Carbapenemase-Producing Enterobacteriaceae in a Surgical Unit: Counting Mortality, Stay, and Costs

Background: Carbapenemase-producing Enterobacteriaceae (CPE)-related infections are a problem in public health at present, including intra-abdominal infections (IAI) and surgical populations. The aim of this study was to determine mortality and related risk factors, length of stay (LOS,) and costs for CPE-IAI in surgical patients. Patients and Methods: Review of CPE-related IAI acquired during admission in a general surgery department from January 2013 to December 2018. A mortality analysis was performed specifically in patients with CPE-IAI, and a global analysis of IAI including patients with CPE-IAI (cases) and matched patients with IAI by non-resistant bacteria (controls). Results: Forty patients with CPE-IAI were included, OXA-48-producing Klebsiella pneumoniae was present in 85%. Global mortality rate at 30 days for CPE-IAI was 17.5%; mortality-related factors were: solid tumor (p = 0.009), metastatic disease (p = 0.005), immunodeficiency (p = 0.039), blood transfusion (p = 0.009), and septic shock (p = 0.011). Predictors related to mortality for IAI in the global analysis included age (p = 0.046), Charlson index (p = 0.036), CPE isolation (p = 0.003), and septic shock (p < 0.001). Median global LOS was 43 days (IQR 27-64) in patients with CPE-IAI, and 27 days (IQR 18-35) in controls (p < 0.001). Median global cost of admission was $31,671 (IQR 14,006-55,745) for patients with CPE-IAI and $20,306 (IQR 11,974-27,947) for controls (p = 0.064). The most relevant locations of underlying disease for CPE-IAI were: colorectal (32.5%) with 57-day LOS (IQR 34-65) and cost of $42,877 (IQR 18,780-92,607), and pancreas (25%) with 60-day LOS (IQR 32-99) and cost of $56,371 (IQR 32,590-113,979). Conclusion: Carbapenemase-producing Enterobacteriaceae-related IAI is associated with substantial mortality, LOS, and costs. Factors related to CPE-IAI mortality are solid tumor, metastatic disease, immunodeficiency, blood transfusion, and septic shock. Carbapenemase-producing Enterobacteriaceae isolation in IAI implies higher risk of mortality.

Advantage of laparoscopic peritoneal toileting in acute peritonitis with unclear etiology: A case report with inspiring outcome (with video)

INTRODUCTION

Acute peritonitis is a surgical emergency and is conventionally managed with exploratory laparotomy in many centers, but laparoscopy is not contraindicated in such conditions. Operative management remains a cornerstone treatment in peritonitis irrespective of the primary pathology.

PRESENTATION OF CASE

A 32-years-old man was admitted with acute diffuse peritonitis. As he was clinically stable, we proceeded with conservative treatment and diagnostic workup. He did not respond by 24 h and CT imaging showed ascites, but no definite diagnosis could be made. Diagnostic laparoscopy was performed, thorough peritoneal toileting was done but surprisingly the etiology was unclear. Following laparoscopy, he responded well with an uneventful recovery.

DISCUSSION

Timely proper evaluation and correct intervention are a paramount concern for the positive outcome. Regarding the most effective operative approach (laparotomy or laparoscopy) in acute peritonitis remains controversial in the literature and laparoscopy has been considered as a relative contraindication. However, the laparoscopy is gaining wider acceptance as the limitations of laparoscopy are declining rapidly. We experienced a case of extensive peritonitis with unclear etiology which we managed successfully by laparoscopy.

CONCLUSION

Laparoscopic approach in peritonitis is effective and helpful for accurate diagnosis and to minimize the hazards of an unnecessary laparotomy. This case report might encourage many surgeons to consider laparoscopic approach in peritonitis with confidence and to perform further studies.

Perforated and bleeding peptic ulcer: WSES guidelines

BACKGROUND

Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.

METHODS

The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.

CONCLUSIONS

The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study: a WSES observational study

BACKGROUND

Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.

METHODS

This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.

RESULTS

A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO2) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8.

CONCLUSIONS

The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Vacuum-Assisted Wound Closure with Mesh-Mediated Fascial Traction Achieves Better Outcomes than Vacuum-Assisted Wound Closure Alone: A Comparative Study

Background

Open abdomen (OA) permits the application of damage control surgery principles when abdominal trauma, sepsis, severe acute peritonitis and abdominal compartmental syndrome (ACS) occur.

Methods

Non-traumatic patients treated with OA between January 2010 and December 2015 were identified in a prospective database, and the data collected were retrospectively reviewed. Patients’ records were collected from charts and the surgical and intensive care unit (ICU) registries. The Acosta “modified” technique was used to achieve fascial closure in vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) patients. Sex, age, simplified acute physiology score II (SAPS II), abdominal compartmental syndrome (ACS), cardiovascular disease (CVD) and surgical technique performed were evaluated in a multivariate analysis for mortality and fascial closure prediction.

Results

Ninety-six patients with a median age of 69 (40–78) years were included in the study. Sixty-nine patients (72%) underwent VAWCM. Forty-one patients (68%) achieved primary fascia closure: two patients (5%) were treated with VAWC (37 median days) versus 39 patients (95%) who were treated with VAWCM (10 median days) (p = 0.0003). Forty-eight patients underwent OA treatment due to ACS, and 24 patients (50%) survived compared to 36 patients (75%) from the “other reasons” group (p = 0.01). The ACS group required longer mechanical ventilator support (p = 0.006), length of stay in hospital (p = 0.005) and in ICU (p = 0.04) and had higher SAPS II scores (p = 0.0002).

Conclusions

The survival rate was 62%. ACS (p = 0.01), SAPS II (p = 0.004), sex (p = 0.01), pre-existing CVD (p = 0.0007) and surgical technique (VAWC vs VAWCM) (p = 0.0009) were determined to be predictors of mortality. Primary fascial closure was obtained in 68% of cases. VAWCM was found to grant higher survival and primary fascial closure rate.

Early Versus Delayed Source Control in Open Abdomen Management for Severe Intra-abdominal Infections: A Retrospective Analysis on 111 Cases

BACKGROUND

Time to source control plays a determinant prognostic role in patients having severe intra-abdominal infections (IAIs). Open abdomen (OA) management became an effective treatment option for peritonitis. Aim of this study was to analyze the correlation between time to source control and outcome in patients presenting with abdominal sepsis and treated by OA.

METHODS

We retrospectively analyzed 111 patients affected by abdominal sepsis and treated with OA from May 2007 to May 2015. Patients were classified according to time interval from first patient evaluation to source control. The end points were intra-hospital mortality and primary fascial closure rate.

RESULTS

The in-hospital mortality rate was 21.6% (24/111), and the primary fascial closure rate was 90.9% (101/111). A time to source control ≥6 h resulted significantly associated with a poor prognosis and a lower fascial closure rate (mortality 27.0 vs 9.0%, p = 0.04; primary fascial closure 86 vs 100%, p = 0.02). We observed a direct increase in mortality (and a reduction in closure rate) for each 6-h delay in surgery to source control.

CONCLUSION

Early source control using OA management significantly improves outcome of patients with severe IAIs. This damage control approach well fits to the treatment of time-related conditions, particularly in case of critically ill patients.

FTY720-Induced Lymphopenia Does Not Aggravate Mortality in a Murine Model of Polymicrobial Abdominal Sepsis

BACKGROUND

FTY720 is an immunosuppressive molecule licensed for the treatment of chronic relapsing multiple sclerosis (MS). It attenuates the adaptive immune response by sequestering T cells within secondary lymphoid organs via its action as functional antagonist of sphingosine-1-phasphate. To date, it is unknown whether FTY-induced lymphopenia puts MS patients at increased risk for severe forms of postoperative infectious complications such as abdominal sepsis.

OBJECTIVES

To determine the effect of FTY720-induced lymphopenia on survival to sepsis secondary to postoperative intraabdominal infections in a murine model of polymicrobial sepsis.

METHODS

Detailed analysis of cellular dynamics in secondary lymphoid organs and of cytokine profiles was performed in FTY720-treated or placebo-treated C57BL/6 mice after induction of colon ascendens stent peritonitis (CASP). Furthermore, survival analysis was performed in FTY720-treated and placebo-treated animals in severe CASP. Fifty percent of each group were treated with broad spectrum antibiotics.

RESULTS

FTY720 treatment resulted in remodeling of cell populations present in the peripheral blood, the peritoneal cavity, and the spleen after CASP induction. Both lymphoid and myeloid cell lines were affected. However, survival in lymphopenic FTY720-treated animals was similar to placebo-treated mice following CASP. Antibiotic treatment increases survival in untreated as well as FTY720-treated animals to a similar extent.

DISCUSSION

Our data demonstrate that inhibition of T-cell migration and induction of peripheral lymphopenia did not affect survival in a model of severe murine sepsis. The presence of reduced T- and B-cell numbers in the peripheral blood during a septic challenge did not negatively affect sepsis mortality in our model of severe abdominal sepsis. The absence of increased mortality under FTY720 treatment in the CASP model suggests that FTY720 treatment will probably not result in increased mortality in MS patients suffering from sepsis.

Raising concerns about the Sepsis-3 definitions

The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use of the Sepsis-3 definitions.

Assessment of hemodynamic response to fluid resuscitation of patients with intra-abdominal sepsis in low- and middle-income countries

BACKGROUND

Patients with intra-abdominal infections need to achieve adequate hemodynamic status before being taken to the operating room. Multiple parameters (urinary output [UOP], vital signs, inferior vena cava collapsibility index, and central venous pressure) may be used to assess hemodynamic response to fluid resuscitation, but the options are few in limited-resource settings. This study aimed at assessing if a bedside-performed ultrasound to assess the inferior vena cava collapsibility index is superior to UOP in assessing hemodynamic response to fluid resuscitation.

METHODS

All adult patients presenting to a tertiary referral hospital in the capital city of Rwanda with intra-abdominal infection requiring intravenous fluid (IVF) resuscitation before operation were included in this study. Before IVF administration, the baseline inferior vena cava collapsibility index (IVC-CI) and vital parameters were recorded. After initiation of IVF resuscitation, serial measurements of IVC-CI and UOP were recorded every 2 h until the decision was made to take the patient to the operating room.

RESULTS

Twenty-four patients were enrolled. The mean duration of symptoms was 4.7 days. Four patients (16%) had altered mental status as a presenting symptom. Half of all patients had generalized peritonitis due to gangrenous bowel as the primary diagnosis (n = 12). The mean difference between time of hemodynamic response based on IVC-CI versus UOP was 2 h (P < 0.001).

CONCLUSIONS

Measurement of the IVC-CI can provide early detection of hemodynamic response to fluid therapy in patients with intra-abdominal infection with spontaneous breathing compared to UOP. Future research should utilize this parameter in the preoperative management of hemodynamically unstable patients.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference

This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.

Heart-rate variability depression in porcine peritonitis-induced sepsis without organ failure

Depression of heart-rate variability (HRV) in conditions of systemic inflammation has been shown in both patients and experimental animal models and HRV has been suggested as an early indicator of sepsis. The sensitivity of HRV-derived parameters to the severity of sepsis, however, remains unclear. In this study we modified the clinically relevant porcine model of peritonitis-induced sepsis in order to avoid the development of organ failure and to test the sensitivity of HRV to such non-severe conditions. In 11 anesthetized, mechanically ventilated and instrumented domestic pigs of both sexes, sepsis was induced by fecal peritonitis. The dose of feces was adjusted and antibiotic therapy was administered to avoid multiorgan failure. Experimental subjects were screened for 40 h from the induction of sepsis. In all septic animals, sepsis with hyperdynamic circulation and increased plasma levels of inflammatory mediators developed within 12 h from the induction of peritonitis. The sepsis did not progress to multiorgan failure and there was no spontaneous death during the experiment despite a modest requirement for vasopressor therapy in most animals (9/11). A pronounced reduction of HRV and elevation of heart rate developed quickly (within 5 h, time constant of 1.97 ± 0.80 h for HRV parameter TINN) upon the induction of sepsis and were maintained throughout the experiment. The frequency domain analysis revealed a decrease in the high-frequency component. The reduction of HRV parameters and elevation of heart rate preceded sepsis-associated hemodynamic changes by several hours (time constant of 11.28 ± 2.07 h for systemic vascular resistance decline). A pronounced and fast reduction of HRV occurred in the setting of a moderate experimental porcine sepsis without organ failure. Inhibition of parasympathetic cardiac signaling probably represents the main mechanism of HRV reduction in sepsis. The sensitivity of HRV to systemic inflammation may allow early detection of a moderate sepsis without organ failure. Impact statement A pronounced and fast reduction of heart-rate variability occurred in the setting of a moderate experimental porcine sepsis without organ failure. Dominant reduction of heart-rate variability was found in the high-frequency band indicating inhibition of parasympathetic cardiac signaling as the main mechanism of heart-rate variability reduction. The sensitivity of heart-rate variability to systemic inflammation may contribute to an early detection of moderate sepsis without organ failure.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.