Diffuse postoperative peritonitis -- value of diagnostic parameters and impact of early indication for relaparotomy

The mesenteric entry site as a potential weak point in gastrointestinal anastomoses - findings from an ex-vivo biomechanical analysis

PURPOSE

Gastrointestinal disorders frequently necessitate surgery involving intestinal resection and anastomosis formation, potentially leading to severe complications like anastomotic leakage (AL) which is associated with increased morbidity, mortality, and adverse oncologic outcomes. While extensive research has explored the biology of anastomotic healing, there is limited understanding of the biomechanical properties of gastrointestinal anastomoses, which was aimed to be unraveled in this study.

METHODS

An ex-vivo model was developed for the biomechanical analysis of 32 handsewn porcine end-to-end anastomoses, using interrupted and continuous suture techniques subjected to different flow models. While multiple cameras captured different angles of the anastomosis, comprehensive data recording of pressure, time, and temperature was performed simultaneously. Special focus was laid on monitoring time, location and pressure of anastomotic leakage (LP) and bursting pressures (BP) depending on suture techniques and flow models.

RESULTS

Significant differences in LP, BP, and time intervals were observed based on the flow model but not on the suture techniques applied. Interestingly, anastomoses at the insertion site of the mesentery exhibited significantly higher rates of leakage and bursting compared to other sections of the anastomosis.

CONCLUSION

The developed ex-vivo model facilitated comparable, reproducible, and user-independent biomechanical analyses. Assessing biomechanical properties of anastomoses offers an advantage in identifying technical weak points to refine surgical techniques, potentially reducing complications like AL. The results indicate that mesenteric insertion serves as a potential weak spot for AL, warranting further investigations and refinements in surgical techniques to optimize outcomes in this critical area of anastomotic procedures.

Associated Factors of Leaked Repair Following Omentopexy for Perforated Peptic Ulcer Disease; a Cross-sectional Study

Introduction

Previous studies have reported numerous clinico-pathologic risk factors associated with increased risk of leaked repair following omental patch for perforated peptic ulcer disease (PPUD). This study aimed to analyze the risk factors associated with leaked repair of omental patch and document the management and outcome of established cases of leaked repair in a resource-poor setting.

Methods

This is a multicenter cross-sectional study of leaked repair after omental patch of PPUD between January 2016 to December 2022. Following primary repair of PPUD with omental pedicle reinforcement, associated factors of leaked repair were evaluated using univariate and multivariate analyses.

Results

Overall, 360 cases were evaluated (62.8% male). Leaked repair rate was 11.7% (42 cases). Those without immunosuppression were 3 times less likely to have leaked repair (aOR= 0.34; 95% CI: 0.16 - 0.72; p = 0.003) while those with sepsis were 4 times more likely to have leaked repair (aOR=4.16; 95% CI: 1.06 - 12.36; p = 0.018). Patients with delayed presentation (>48 hours) were 2.5 times more likely to have leaked repair than those who presented in 0 - 24 hours (aOR=2.51; 95% CI: 3.62 - 10.57; p = 0.044). Those with Perforation diameter 2.1-3.0 cm were 8 times (aOR=7.98; 95% CI: 2.63-24.21; p<0.0001), and those with perforation diameter > 3.0cm were 33 times (aOR=33.04; 95% CI: 10.98-100.25; p<0.0001) more likely to have leaked repair than those with perforation diameter of 0-1.0 cm. Similarly, in those with no perioperative shock, leaked repair was 4 times less likely to develop than those with perioperative shock (aOR= 0.42; 95% CI: 0.41-0.92; p = 0.041). There was significant statistical difference in morbidity (p = 0.003) and mortality (p < 0.0001) rates for cases of leaked repairs and successful repairs.

Conclusion

Leaked repair following omentopexy for peptic ulcer perforation was significantly associated with large perforation diameter, delayed presentation, sepsis, immunosuppressive therapy, and perioperative shock.

[Surgical wound closure in advanced peritonitis]

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

Clinical importance and characteristic features of secondary culture-negative sepsis after surgery due to abdominal infection: A retrospective study

PURPOSE

Herein, we identified whether the clinical outcomes differ according to secondary culture results in postoperative sepsis patients and determined the predictors of culture-negative sepsis after abdominal surgery based on the secondary culture results.

METHODS

Patients who admitted to the intensive care unit(ICU) after surgery due to abdominal infection and diagnosed with postoperative sepsis were included. Culture tests were obtained from body fluids and drains. Primary culture test was performed immediately after surgery, and secondary culture test was performed within 48 h to 7days after surgery. The participants were divided into the culture-positive sepsis(CPSS) and the culture-negative sepsis group(CNSS) according to culture positivity, and the clinical outcomes were compared. The predisposing factors of secondary CNSS were determined using multiple logistic regression analysis.

RESULTS

Among 83 participants, 51 patients (61.4%) showed secondary culture-positivity(2'CPSS) and 32 patients (38.6%) showed secondary culture-negativity(2'CNSS). ICU mortality and in-hospital mortality were not different between two groups, but the length of ICU and hospital stay were significantly longer in 2'CPSS. In multivariate analysis, non-bowel surgery [odds ratio(OR) = 6.934, 95% confidence interval(CI):1.609-29.884, p=0.009], no diabetes (OR = 4.027,95%CI:1.161-13.973, p=0.028), and the prolonged administration of preoperative antibiotics (OR = 1.187,95%CI:1.023-1.377, p=0.024) were revealed as significant predisposing factors of 2'CNSS.

CONCLUSION

Mortality showed no difference according to secondary culture positivity in postoperative sepsis patients after abdominal surgery. If a patient underwent non-bowel surgery or had no diabetes or administered preoperative antibiotics for more than 3 days, the physician should pay more attention to clinical deterioration, even if the seconday culture results are negative.

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.

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.

Diagnostic Challenges in Sepsis

Purpose of Review

Sepsis is a leading cause of death worldwide. Groundbreaking international collaborative efforts have culminated in the widely accepted surviving sepsis guidelines, with iterative improvements in management strategies and definitions providing important advances in care for patients. Key to the diagnosis of sepsis is identification of infection, and whilst the diagnostic criteria for sepsis is now clear, the diagnosis of infection remains a challenge and there is often discordance between clinician assessments for infection.

Recent Findings

We review the utility of common biochemical, microbiological and radiological tools employed by clinicians to diagnose infection and explore the difficulty of making a diagnosis of infection in severe inflammatory states through illustrative case reports. Finally, we discuss some of the novel and emerging approaches in diagnosis of infection and sepsis.

Summary

While prompt diagnosis and treatment of sepsis is essential to improve outcomes in sepsis, there remains no single tool to reliably identify or exclude infection. This contributes to unnecessary antimicrobial use that is harmful to individuals and populations. There is therefore a pressing need for novel solutions. Machine learning approaches using multiple diagnostic and clinical inputs may offer a potential solution but as yet these approaches remain experimental.

Calculated parenteral initial treatment of bacterial infections: Intra-abdominal infections

This is the seventh chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter deals with the empirical and targeted antimicrobial therapy of complicated intra-abdominal infections. It includes recommendations for antibacterial and antifungal treatment.

Findings requiring immediate surgery in blunt abdominal trauma patients with isolated free fluid without solid organ injury on abdominal computed tomography: Retrospective laboratory, clinical and radiologic analysis. A case control study

BACKGROUND

Determining surgical treatment is difficult in blunt abdominal trauma (BAT) patients with isolated free fluid without solid organ injury (IFFWSOI) on abdominal computed tomography (CT). We investigated the laboratory, clinical, and radiologic features of BAT patients with IFFWSOI on abdominal CT requiring surgery.

METHODS

A retrospective medical record review was performed for patients treated at our government-established regional tertiary trauma center from March 2014 to August 2018. A total of 501 patients were identified and reviewed. Patients were divided into Surgery and No Surgery groups for analysis. The Surgery group included patients who underwent surgery during the index admission, while the No Surgery group included patients who did not undergo surgery.

RESULTS

There were significantly more cases of severe fluid collection (61.5% vs. 11.8%; p < 0.001), car accidents (69.2% vs. 35.3%; p = 0.018), and abdominal pain (87.2% vs. 58.8%; p = 0.031) at the emergency department in the Surgery group. Regarding laboratory studies performed at the emergency department, only the median amylase level was significantly higher in the No Surgery group (54.5 U/L vs. 62.5 U/L; p = 0.048). On multivariate logistic regression analysis with adjustments for age and sex, the odds ratio (OR) for severe fluid collection on abdominal CT to predict surgery was 13.52 (p = 0.006), while the OR for abdominal pain was 7.34 (p = 0.036) and the OR for car accident was 2.14 (p = 0.329). In addition, a multivariate logistic regression with adjustment for age, sex, delta neutrophil index, and C-reactive protein, showed the same propensity as the other model, although statistical significance was retained only for severe fluid collection.

CONCLUSION

Surgical treatment should be actively considered in the presence of a large volume of intra-abdominal free fluid, especially when concomitant with abdominal pain or after car accidents in BAT patients without solid organ injury.

Predictors of 30-Day In-Hospital Mortality in Patients Undergoing Urgent Abdominal Surgery Due to Acute Peritonitis Complicated with Sepsis

Background

Sepsis is a life-threatening condition with high morbidity and mortality rate. Identifying early prediction factors of critical situations in intra-abdominal sepsis patients can help reduce mortality rates. This prospective study was carried out to evaluate the association of technically available factors with 30-day in-hospital mortality.

Material/Methods

There were 67 intra-abdominal sepsis patients included in the study; patients were observed for 30 days postoperatively. The data was processed using SPSS24.0 statistical analysis package. All tests that had a significance level of 0.05 were selected.

Results

Septic shock in association with increase in age per year showed increase the odds of mortality and prognosed 30-days in hospital mortality correctly in 79% of cases. The observed OR was 12.24 (P<0.001). Multiple logistic regression model 2 for the 30-day mortality identified a combination of septic shock, age (≥70 years), time from peritonitis symptoms to surgery prognose mortality with accuracy of 82%. The most accurate model to prognose 30-day in-hospital mortality included the presents of septic shock, age, time from peritonitis symptoms to surgery, drop of MAP <65 mmHg) post-induction, the odds of mortality 8.86 (P=0.001). Severe hypotension post-induction was more frequent in patients who were not diagnosed with sepsis (P=0.035).

Conclusions

The present study revealed a simple indicator for the risk for death under diffuse peritonitis patients complicated with sepsis. Septic shock, increase in age per year, peritonitis symptoms lasting more than 30 hours, and severe hypotension post-induction had a negative prognostic value for mortality in patients with intra-abdominal sepsis, and might be a high risk for 30-day mortality.

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.

Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome

PURPOSE

Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery.

METHODS

Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed.

RESULTS

Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p = 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p = 0.001), and increased operation time (105 vs. 84 min., p = 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p < 0.001). Complication rate (44 vs. 24%, p = 0.092), mortality (12 vs. 0%, p = 0.061), overall number of surgeries (3.4 vs. 2.4, p = 0.017), enterostomy rate (76 vs. 36%, p = 0.001), and length of hospital stay (25 vs. 18.8 days, p = 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p = 0.005) and with fungal infection (100 vs. 49%, p = 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p < 0.001), enterostomy rate (81 vs. 48%, p = 0.017), and anastomotic leakage (29 vs. 6%, p = 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p = 0.014).

CONCLUSION

Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

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.

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

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

The Role of Planned and On-Demand Relaparotomy in the Developing World

INTRODUCTION/BACKGROUND

This study compares planned repeat laparotomy (PR) with on-demand repeat laparotomy (OD) in a developing world setting.

MATERIALS AND METHODS

This study was conducted over a 30-month study period (December 2012-May 2015) at Greys Hospital, Pietermaritzburg, South Africa. All trauma and general surgery adult patients requiring a single relaparotomy were included in this study. Prospectively gathered data entered into an established electronic registry were retrospectively analysed. Full ethical approval for the registry and this study was granted by the University of KwaZulu-Natal Biomedical Ethics Committee.

RESULTS

A total of 162 patients were included, with an average age of 36 years (standard deviation 17) and 69 % male predominance. Appendicitis and stab abdomen were the most common underlying diagnoses. PR strategy was used in 46 % and an OD approach in 54 %. Patients selected for the PR strategy had higher admission pulse rates, higher Modified Early Warning System (MEWS) scores and significantly higher rates of diffuse intra-abdominal sepsis at initial laparotomy. However, findings at relaparotomy were similar in both groups. The PR group had a much shorter time between operations, but much higher need for intensive care unit (ICU) admission. There was no difference between the groups in terms of open abdomen at discharge, length of hospital stay, morbidity or mortality.

CONCLUSION

In our environment, a planned approach to relaparotomy shows no major outcome advantages over an on-demand approach. There is however increased need for ICU admission with the PR approach. This is in keeping with international literature. Of concern is the much longer time delay between index procedure and repeat operation in the OD group. Improved post-operative decision making may help address this.

Risk factors for mortality in postoperative peritonitis in critically ill patients

AIM

To identify the risk factors for mortality in intensive care patients with postoperative peritonitis (POP).

METHODS

This was a retrospective analysis using a prospective database that includes all patients hospitalized in a surgical intensive care unit for POP from September 2006 to August 2011. The data collected included demographics, comorbidities, postoperative severity parameters, bacteriological findings, adequacy of antimicrobial therapy and surgical treatments. Adequate source control was defined based on a midline laparotomy, infection source control and intraoperative peritoneal lavage. The number of reoperations needed was also recorded.

RESULTS

A total of 201 patients were included. The overall mortality rate was 31%. Three independent risk factors for mortality were identified: The Simplified Acute Physiological II Score (OR = 1.03; 95%CI: 1.02-1.05, P < 0.001), postoperative medical complications (OR = 6.02; 95%CI: 1.95-18.55, P < 0.001) and the number of reoperations (OR = 2.45; 95%CI: 1.16-5.17, P = 0.015). Surgery was considered as optimal in 69% of the cases, but without any significant effect on mortality.

CONCLUSION

The results from the large cohort in this study emphasize the role of the initial postoperative severity parameters in the prognosis of POP. No predefined criteria for optimal surgery were significantly associated with increased mortality, although the number of reoperations appeared as an independent risk factor of mortality.

Association between source control and mortality in 258 patients with intra-abdominal candidiasis: a retrospective multi-centric analysis comparing intensive care versus surgical wards in Spain

Early empiric therapy and adequate resuscitation have been identified as main predictors of outcome in patients with candidemia or bacteremia. Moreover, source control is a major determinant in infectious sites when feasible, as a main technique to reduce microbiological burden. A retrospective, multicenter, cohort study was performed at surgical wards and intensive care units (ICU) of three University Hospitals in Spain between 2010 and 2014, with the aim of improving understanding of the interaction between source control, early antifungal therapy, and use of vasoactives in patients with intra-abdominal candidiasis (IAC). Source control was defined as all physical actions taken to control a focus of infection and reduce the favorable conditions that promote microorganism growth or that maintain the impairment of host defenses. Two hundred and fifty-eight patients with IAC were identified. Sixty-one patients were at ICU for diagnosis. Mortality was higher in the ICU group compared to what was documented for the non-ICU group (35 % vs 19.5 %, p = 0011). Adequate source control within 48 h of diagnosis was achieved in 60 % of the cohort. In multivariate analysis, inadequate source control was identified as the only common risk factor for 30-day mortality in both groups (ICU group OR: 13.78 (95% CI: 2.60-72.9, p = 0.002) and non-ICU group OR: 6.53 (95% CI: 2.56-16.61, p = <0.001). The population receiving both adequate source control and adequate antifungal treatment was the one associated with a higher survival rate, in both the ICU and surgical groups. Source control remains a key element in IAC, inside and outside the intensive care unit. Early antifungal treatment among ICU patients was associated with lower mortality.

Current understanding in source control management in septic shock patients: a review

Sepsis and septic shock is one of the leading causes of death worldwide. Antibiotics, fluid resuscitation support of vital organ function and source control are the cornerstones for the treatment of these patients. Source control measures include all those actions taken in the process of care to control the foci of infection and to restore optimal function of the site of infection. Source control represents the multidisciplinary team required in order to optimize critical care for septic shock patients. In the last decade an increase interest on fluids, vasopressors, antibiotics, and organ support techniques in all aspects whether time, dose and type of any of those have been described. However information of source control measures involving minimal invasion and new techniques, time of action and outcome without it, is scarce. In this review the authors resumes new information, recommendations and future directions on this matter when facing the more common types of infections.

Surgical risk model for acute diffuse peritonitis based on a Japanese nationwide database: an initial report on the surgical and 30-day mortality

PURPOSE

Acute diffuse peritonitis (ADP) is an important surgical complication associated with high morbidity and mortality; however, the risk factors associated with a poor outcome have remained controversial. This study aimed in collecting integrated data using a web-based national database system to build a risk model for mortality after surgery for ADP.

METHODS

We included cases registered in the National Clinical Database in Japan. After data cleanup, 8,482 surgical cases of ADP from 1,285 hospitals treated between January 1 and December 31, 2011 were analyzed.

RESULTS

The raw 30-day and surgical mortality rates were 9.0 and 14.1 %, respectively. The odds ratios (>2.0) for 30-day mortality were as follows: American Society of Anesthesiologists (ASA) class 3, 2.69; ASA class 4, 4.28; ASA class 5, 8.65; previous percutaneous coronary intervention (PCI), 2.05; previous surgery for peripheral vascular disease (PVD), 2.45 and disseminated cancer, 2.16. The odds ratios (>2.0) for surgical mortality were as follows: ASA class 3, 2.27; ASA class 4, 4.67; ASA class 5, 6.54, and disseminated cancer, 2.09. The C-indices of 30-day and surgical mortality were 0.851 and 0.852, respectively.

CONCLUSION

This is the first report of risk stratification after surgery for ADP using a nationwide surgical database. This system could be useful to predict the outcome of surgery for ADP and for evaluations and benchmark performance studies.

Repeat laparotomy in a developing world tertiary level surgical service

BACKGROUND

Repeat laparotomy is associated with significant morbidity and mortality; however, developing world data are scarce. This study reviews the spectrum and outcomes of relaparotomy in a developing world setting.

METHODS

Prospectively collected data from adult patients needing repeat laparotomy over an 18-month period were analyzed.

RESULTS

Relaparotomy rate was 24% and average age was 38 years with a male predominance (70%). Appendicitis and trauma were the most common diagnoses. Planned relaparotomy rate was high (41%); however, negative relaparotomy rate was only 9%. Need for intensive care unit admission (51%) and morbidity rate (64%) were both high, but overall mortality rate was 14%. Patients requiring multiple relaparotomies had further worsened outcomes.

CONCLUSIONS

The need for repeat laparotomy in the developing world is high and it is associated with significant morbidity and need for intensive care unit admission. However, mortality rates and negative repeat laparotomy rates were low.

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.

Diagnostics, therapy and outcome prediction in abdominal sepsis: current standards and future perspectives

PURPOSE

In the perioperative phase, sepsis and sepsis-associated death are the most important problems for both the surgeon and the intensivist. Critically ill patients profit from an early identification and implementation of an interdisciplinary therapy. The purpose of this review on septic peritonitis is to give an update on the diagnosis and its evidence-based treatment.

RESULTS

Rapid diagnosis of sepsis is essential for patient´s survival. A bundle of studies was performed on early recognition and on new diagnostic tools for abdominal sepsis. Although surgical intervention is considered as an essential therapeutic step in sepsis therapy the time-point of source control is still controversially discussed in the literature. Furthermore, the Surviving Sepsis Campaign (SSC) guidelines were updated in 2012 to facilitate evidence-based medicine for septic patients.

CONCLUSION

Despite many efforts, the mortality of surgical septic patients remains unacceptably high. Permanent clinical education and further surgical trials are necessary to improve the outcome of critically ill patients.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

Postoperative peritonitis without an underlying digestive fistula after complete cytoreductive surgery plus HIPEC

BACKGROUND/AIM

Peritoneal carcinomatosis (PC) is a pernicious event associated with a dismal prognosis. Complete cytoreductive surgery (CCRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is able to yield an important survival benefit but at the price of a risky procedure inducing potentially severe complications. Postoperative peritonitis after abdominal surgery occurs mostly when the digestive lumen and the peritoneum communicate but in rare situation, no underlying digestive fistula can be found. The aim of this study was to report this situation after CCRS plus HIPEC, which has not been described yet and for which the treatment is not yet well defined.

PATIENTS AND METHODS

Between 1994 and 2012, 607 patients underwent CCRS plus HIPEC in our tertiary care center and were retrospectively analyzed.

RESULTS

Among 52 patients (9%) reoperated for postoperative peritonitis, no digestive fistula was found in seven (1%). All had a malignant peritoneal pseudomyxoma with an extensive disease (median Peritoneal Cancer Index: 27). The median interval between surgery and reoperation was 8 days [range: 3-25]. Postoperative mortality was 14%. Five different bacteriological species were identified in intraoperative samples, most frequently Escherichia coli (71%). The infection was monobacterial in 71%, with multidrug resistant germs in 78%.

CONCLUSIONS

Postoperative peritonitis without underlying fistula after CCRS plus HIPEC is a rare entity probably related to bacterial translocation, which occurs in patients with extensive peritoneal disease requiring aggressive surgeries. The principles of treatment do not differ from that of other types of postoperative peritonitis.

Antimicrobial treatment of "complicated" intra-abdominal infections and the new IDSA guidelines ? a commentary and an alternative European approach according to clinical definitions

Recently, an update of the IDSA guidelines for the treatment of complicated intraabdominal infections has been published. No guideline can cater for all variations in ecology, antimicrobial resistance patterns, patient characteristics and presentation, health care and reimbursement systems in many different countries. In the short time the IDSA guidelines have been available, a number of practical clinical issues have been raised by physicians regarding interpretation of the guidelines. The main debatable issues of the new IDSA guidelines are described as follows: The authors of the IDSA guidelines present recommendations for the following subgroups of "complicated" IAI: community-acquired intra-abdominal infections of mild-to-moderate and high severity and health care-associated intra-abdominal infections (no general treatment recommendations, only information about antimicrobial therapy of specific resistant bacterial isolates). From a clinical point of view, "complicated" IAI are better differentiated into primary, secondary (community-acquired and postoperative) and tertiary peritonitis. Those are the clinical presentations of IAI as seen in the emergency room, the general ward and on ICU. Future antibiotic treatment studies of IAI would be more clinically relevant if they included patients in studies for the efficacy and safety of antibiotics for the treatment of the above mentioned forms of IAI, rather than conducting studies based on the vague term "complicated" intra-abdominal infections. - The new IDSA guidelines for the treatment of resistant bacteria fail to mention many of new available drugs, although clinical data for the treatment of "complicated IAI" with new substances exist. Furthermore, treatment recommendations for cIAI caused by VRE are not included. This group of diseases comprises enough patients (i.e. the entire group of postoperative and tertiary peritonitis, recurrent interventions in bile duct surgery or necrotizing pancreatitis) to provide specific recommendations for such antimicrobial treatment. - A panel of European colleagues from surgery, intensive care, clinical microbiology and infectious diseases has developed recommendations based on the above mentioned clinical entities with the aim of providing clear therapeutic recommendations for specific clinical diagnoses. An individual patient-centered approach for this very important group of diseases with a substantial morbidity and mortality is essential for optimal antimicrobial treatment.