Costs of relaparotomy on-demand versus planned relaparotomy in patients with severe peritonitis: an economic evaluation within a randomized controlled trial

Damage Control Surgery and Transfer in Emergency General Surgery

Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.

Damage control surgery in emergency general surgery: What you need to know

ABSTRACT

Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.

The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

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.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Transverse vs. median laparotomy in peritonitis and staged lavage: a single center case series

Background: Staged lavage was first introduced in the 1970s and now serves as a therapeutic option for septic patients with peritonitis. A central aspect of this treatment concept is leaving the abdomen open after a wide incision. To evaluate the influence of transverse vs. median access to the abdomen in staged lavage, data from the authors’ patients were analyzed.

Methods: To evaluate patients with peritonitis, prospective intensive care data were examined together with data on the surgical details. The main aspects covered here were the surgical details of the lavage (namely, transverse vs. median laparotomy), number of lavages, fascia closure, wound-healing disorders, and observed lethality, in combination with the preoperatively evaluated SAPS-II score, expected hospital lethality, patient age, and the Mannheim Peritonitis Index.

Results: Between January 2008 and December 2018, 522 patients were treated with open abdomen and staged lavage. The mean age of the patients was 66.0 years (standard deviation (SD) 15.9 years). A median incision was used in 140 cases, and transverse laparotomy was performed in 382. The mean SAPS-II score was 46.5 (SD 15.7), expected lethality was 39.6% (SD 26.3%), and observed lethality was 19.9%. On average, two lavages were performed after the index operation. Transverse incision was significantly less likely to cause wound-healing disorder (p=0.03), and fascial dehiscence was observed less frequently in the transverse laparotomies group than in median incisions in the statistical trend (p=0.06).

Conclusion: In summary, staged lavage reduced expected lethality in patients with peritonitis. Transverse incision caused wound-healing disorders and fascial dehiscence less often. Therefore, the indication for transverse laparotomy should be generous, as this form of treatment is advantageous in case of peritonitis.

Patient's characteristics, management practices and outcome of re-laparotomies in a tertiary hospital in Tanzania

BACKGROUND

Relaparotomy is an important indicator of the safety and quality of laparotomy in any surgical setting. Despite this, its measure in many low- and middle-income countries is scarce, Tanzania included. Understanding its existence will help curb it and mitigate its adverse outcomes by systematic improvement strategies. This study, therefore, aimed to examine characteristics of patients undergoing on-demand relaparotomy and their management outcomes at a tertiary level hospital in Tanzania.

METHODS

A cross-sectional descriptive study was carried out in the department of surgery of Muhimbili National Hospital for one year in 2017-2018. All patients (of all ages and sex) who required an on-demand relaparotomy within 60 days of their index laparotomy were identified for inclusion into the study. Data were collected regarding patient's demography, clinical characteristics, index surgical procedure, indication for relaparotomy, number of re-laparotomies, complications during re-laparotomy, ICU admission, and mortality. Data were entered into SPSS version 23 for analysis where continuous variables were summarized as means with standard deviations and categorical variables summarized as the frequency with proportions. Ethical approval for the audit was obtained from the Muhimbili University of Health IRB.

RESULTS

A total of 101 patients had undergone relaparotomy, with a relaparotomy rate among those primarily operated at our hospital of 7.6%. Their mean age was 37 years with equal sex distribution. The leading primary procedure had involved bowel resection and anastomosis (47.5%) with anastomotic leak being the leading reason for relaparotomy (37.6%) followed by intra-abdominal collection (29.7%), bowel fistula (19.8%) and wound dehiscence (18.8%). Electrolyte imbalance was the leading complication among the patients (22.9%) followed by anemia (21.5%), wound infection (18.9%) and Septicemia (11%). The overall mortality of rate was 39.6%.

CONCLUSION

On-demand relaparotomy carries a high mortality and morbidity at Muhimbili National Hospital in Tanzania. Addressing predictors and improving post-operative services are urgently needed.

Protocol for a parallel economic evaluation of a trial comparing two surgical strategies in severe complicated intra-abdominal sepsis: the COOL-cost study

BACKGROUND

The risk of death in severe complicated intra-abdominal sepsis (SCIAS) remains high despite decades of surgical and antimicrobial research. New management strategies are required to improve outcomes. The Closed Or Open after Laparotomy (COOL) trial investigates an open-abdomen (OA) approach with active negative pressure peritoneal therapy. This therapy is hypothesized to better manage peritoneal bacterial contamination, drain inflammatory ascites, and reduce the risk of intra-abdominal hypertension leading to improved survival and decreased complications. The total costs and cost-effectiveness of this therapy (as compared with standard fascial closure) are unknown.

METHODS

We propose a parallel cost-utility analysis of this intervention to be conducted alongside the 1-year trial, extrapolating beyond that using decision analysis. Using resource use metrics (e.g., length of stay, re-admissions) from patients at all study sites and microcosting data from patients enrolled in Calgary, Alberta, the mean cost difference between treatment arms will be established from a publicly-funded health care payer perspective. Quality of life will be measured at 6 months and 1 year postoperatively with the Euroqol EQ-5D-5 L and SF-36 surveys. A within-trial analysis will establish cost and utility at 1 year, using a bootstrapping approach to provide confidence intervals around an estimated incremental cost-effectiveness ratio. If neither operative strategy is economically dominant, Markov modeling will be used to extrapolate the cost per quality-adjusted life years gained to 2-, 5-, 10-year, and lifetime horizons. Future costs and benefits will be discounted at 1.5% per annum. A cost-effectiveness acceptability curve will be generated using Monte Carlo simulation. If all trial outcomes are similar, the primary analysis will default to a cost-minimization approach. Subgroup analysis will be carried out for patients with and without septic shock at presentation, and for patients whose initial APACHE II scores are > 20 versus ≤ 20.

DISCUSSION

In addition to an estimate of the clinical effectiveness of an OA approach for SCIAS, an understanding of its cost effectiveness will be required prior to its adoption in any resource-constrained environment. We will estimate this key parameter for use by clinicians and policymakers.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03163095, registered May 22, 2017.

Closed Or Open after Source Control Laparotomy for Severe Complicated Intra-Abdominal Sepsis (the COOL trial): study protocol for a randomized controlled trial

Background

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise.

Methods

The Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score ≥ 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score ≥ 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources.

Discussion

Although facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only.

Trial registration

ClinicalTrials.gov, NCT03163095.

Open abdomen in liver transplantation

INTRODUCTION

Damage control laparotomy with vacuum assisted closure (VAC) is used for selective cases in trauma. In liver transplantation, VAC has also been applied for management of intra-operative hemorrhage. The primary objective was to evaluate peri-operative blood loss and blood product utilization in VAC compared to primary abdominal closure (PAC) at the index transplant operation.

METHODS

Retrospective review of all adults undergoing deceased donor liver transplantation (2007-2011) at a single center tertiary care institution.

RESULTS

201 deceased donor liver transplantations were performed, with 167 PAC and 34 VAC cases. Intra-operative blood loss (4.4L vs 10.7L), cell saver return (1399 ml vs 3998 ml), FFP (7.6U vs 15.9U) and PLT requirements (8.5U vs 18.3U), were all significantly elevated in VAC compared to PAC. VAC patients had significantly increased RBC, FFP, PLT, and total volume requirements during initial ICU admission. 30 PAC cases required on demand laparotomy and most commonly for post-operative bleeding.

CONCLUSION

In liver transplantation, application of VAC secondary to massive intra-operative exsanguination was safely utilized. Further evaluation is required to identify long-term morbidity and mortality.

A systematic review and overview of health economic evaluations of emergency laparotomy

Background

Little is known about the economic impact of emergency laparotomy (EL) surgery in healthcare systems around the world. The aim of this systematic review is to describe the primary resource utilisation, healthcare economic and societal costs of EL in adults in different countries.

Methods

MEDLINE, EMBASE, ISI Web of Knowledge, Cochrane Central Register Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were searched for full and partial economic analyses of EL published between 1 January 1991 and 31 December 2015. Quality of studies was assessed using the Consensus on Health Economic Criteria (CHEC) checklist.

Results

Sixteen studies were included from a range of countries. One study was a full economic analysis. Fifteen studies were partial economic evaluations. These studies revealed that emergency abdominal surgery is expensive compared to similar elective surgery when comparing primary resource utilisation costs, with an important societal impact. Most contemporaneous studies indicate that in-hospital costs for EL are in excess of US$10,000 per patient episode, rising substantially when societal costs are considered.

Discussion

EL is a high-risk and costly procedure with a disproportionate financial burden for healthcare providers, relative to national funding provisions and wider societal cost impact. There is substantial heterogeneity in the methodologies and quality of published economic evaluations of EL; therefore, the true economic costs of EL are yet to be fully defined. Future research should focus on developing strategies to embed health economic evaluations within national programmes aiming to improve EL care, including developing the required measures and infrastructure.

Conclusions

Emergency laparotomy is expensive, with a significant cost burden to healthcare and systems and society worldwide. Novel strategies for reducing this econmic burden should urgently be explored if greater access to this type of surgery is to be pursued as a global health target.

Trial registration

PROSPERO registration no. 42015027210.

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.

Surgical treatment of secondary peritonitis : A continuing problem

Secondary peritonitis remains associated with high mortality and morbidity rates. Treatment of secondary peritonitis is challenging even in modern medicine. Surgical intervention for source control remains the cornerstone of treatment, beside adequate antimicrobial therapy and resuscitation. A randomized clinical trial showed that relaparotomy on demand (ROD) after initial emergency surgery is the preferred treatment strategy, irrespective of the severity and extent of peritonitis. The effective and safe use of ROD requires intensive monitoring of the patient in a setting where diagnostic tests and decision making about relaparotomy are guaranteed round the clock. The lack of knowledge on timely and adequate patient selection, together with the lack of use of easy but reliable monitoring tools, seems to hamper full implementation of ROD. The accuracy of the relap decision tool is reasonable for prediction of ongoing peritonitis and selection for computer tomography (CT). The value of CT in an early postoperative phase is unclear. Future research and innovative technologies should focus on the additive value of CT in cases of operated secondary peritonitis and on the further optimization of bedside prediction tools to enhance adequate patient selection for intervention in a multidisciplinary setting.

Open abdomen with negative pressure device vs primary abdominal closure for the management of surgical abdominal sepsis: a retrospective review

BACKGROUND

Open abdomen with temporary abdominal closure remains a controversial management strategy for surgical abdominal sepsis compared with primary abdominal closure (PAC) and on-demand laparotomy. The primary objective was to compare mortality between PAC and open abdomen with vacuum assisted closure (VAC).

METHODS

Retrospective review of a tertiary center intensive care unit database (2006 to 2010) including suspected/diagnosed severe abdominal sepsis/septic shock requiring source control laparotomy. Groups were categorized according to closure method at index source control laparotomy. APACHE-IV was used as a measure of disease severity.

RESULTS

Of 211 patients, 75 PAC and 136 VAC cases were included. Controlling for disease severity, adjusted odds ratio of mortality for VAC was .41 95% confidence interval (.21, .81; P = .01) compared with PAC. PAC and VAC APACHE-1V predicted mortality rate were both 45%. VAC mortality was lower than PAC (22.8% vs 38.6%; P = .012).

CONCLUSIONS

Open abdomen with VAC is associated with significantly improved survival compared with PAC in abdominal sepsis requiring laparotomy.

[Surgical treatment of secondary peritonitis: A continuing problem. German version]

BACKGROUND

Secondary peritonitis remains associated with high mortality and morbidity rates. Treatment of secondary peritonitis is still challenging even in the era of modern medicine. Surgical intervention for source control remains the cornerstone of treatment besides adequate antimicrobial therapy and when necessary intensive medical care measures and resuscitation. A randomized clinical trial showed that relaparotomy on demand (ROD) after initial emergency surgery was the preferred treatment strategy, irrespective of the severity and extent of peritonitis.

RESULTS AND DISCUSSION

The effective and safe use of ROD requires intensive monitoring of the patient in a setting where diagnostic tests and decision making about relaparotomy are guaranteed round the clock. The lack of knowledge on timely and adequate patient selection, together with the lack of use of easy but reliable monitoring tools seem to hamper full implementation of ROD. The accuracy of the relaparotomy decision tool is reasonable for prediction of the formation of peritonitis and necessary selection of patients for computed tomography (CT). The value of CT in the early postoperative phase is unclear. Future research and innovative technologies should focus on the additive value of CT after surgical treatment for secondary peritonitis and on the further optimization of bedside prediction tools to enhance adequate patient selection for interventions in a multidisciplinary setting.

Procalcitonin ratio and on-demand relaparotomy for septic peritonitis: validation of the focus index (FI)

PURPOSE

Secondary peritonitis remains challenging to manage and some recent evidence suggests that on-demand relaparotomy is more appropriate than planned relaparotomy. This study was designed to validate the predictive power of postoperative procalcitonin (PCT) changes in relation to elimination of the septic abdominal focus.

METHODS

In this prospective trial, postoperative PCT serum levels were monitored in 234 surgical patients with secondary peritonitis. The PCT ratio on postoperative days (PODs) 1 and 2 (focus index; FI) was calculated and correlated with the success of the operation.

RESULTS

A cutoff value of 1.1 was calculated for the FI. Values below 1.1 indicated insufficient elimination of the focus and values above 1.1 correlated with effective treatment. The optimal time for first PCT sampling was found to be 12-24 h after the index operation. After the respective data cleanup, successful elimination of the intraabdominal focus could be confirmed, with a sensitivity of 93 % and a specificity of 71 %.

CONCLUSIONS

The FI is a single parameter-based reliable predictor of successful surgical eradication and strengthens the on-demand relaparotomy concept as the method of choice to treat secondary peritonitis.

Intra-abdominal sepsis--epidemiology, aetiology and management

Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease, the nature of which varies around the world. In rich countries, appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited, the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources, radiological investigation, ultrasound, CT scan or MRI may be used to select patients for non-operative management. For patients with appendicitis, laparoscopic surgery has achieved results comparable to open operation; however, in many centres open operation remains the standard. In complicated peritonitis "damage control surgery" may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient's general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups, such as steroid-dependent nephrotic syndrome patients, whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery.

Long-term outcome study in patients with abdominal wound dehiscence: a comparative study on quality of life, body image, and incisional hernia

OBJECTIVE

Long-term quality of life and body image of patients with abdominal wound dehiscence were assessed.

METHODS

Thirty-seven patients with abdominal wound dehiscence from a prospectively followed cohort of 967 patients (2007-2009) were reviewed. Patients completed the Short Form 36 quality of life questionnaire and Body Image Questionnaire and participated in semi-structured telephone interviews. For each patient, four controls were matched by age and gender. Analyses were adjusted for age, gender, comorbidity, and follow-up length.

RESULTS

Of the 37 patients with abdominal wound dehiscence, 23 were alive after a mean follow-up of 40 months (range 33-49 months). Nineteen patients developed incisional hernias (83 %). Patients with abdominal wound dehiscence reported significantly lower scores for physical and mental component summaries (p = 0.038, p = 0.013), general health (p = 0.003), mental health (p = 0.011), social functioning (p = 0.002), and change (p = 0.034). No differences were found for physical functioning (p = 0.072), role physical (p = 0.361), bodily pain (p = 0.133), vitality (p = 0.150), and role emotional (p = 0.138). Patients with abdominal wound dehiscence reported lower body image scores (median 16.5 vs. 18, p = 0.087), cosmetic scores (median 13 vs. 16, p = 0.047), and total body image scores (median 30 vs. 34, p = 0.042).

CONCLUSIONS

At long-term follow-up, patients with abdominal wound dehiscence demonstrated a high incidence of incisional hernia, low body image, and low quality of life.

Efficacy and safety of active negative pressure peritoneal therapy for reducing the systemic inflammatory response after damage control laparotomy (the Intra-peritoneal Vacuum Trial): study protocol for a randomized controlled trial

Background

Damage control laparotomy, or abbreviated initial laparotomy followed by temporary abdominal closure (TAC), intensive care unit resuscitation, and planned re-laparotomy, is frequently used to manage intra-abdominal bleeding and contamination among critically ill or injured adults. Animal data suggest that TAC techniques that employ negative pressure to the peritoneal cavity may reduce the systemic inflammatory response and associated organ injury. The primary objective of this study is to determine if use of a TAC dressing that affords active negative pressure peritoneal therapy, the ABThera Open Abdomen Negative Pressure Therapy System, reduces the extent of the systemic inflammatory response after damage control laparotomy for intra-abdominal sepsis or injury as compared to a commonly used TAC method that provides potentially less efficient peritoneal negative pressure, the Barker’s vacuum pack.

Methods/Design

The Intra-peritoneal Vacuum Trial will be a single-center, randomized controlled trial. Adults will be intraoperatively allocated to TAC with either the ABThera or Barker’s vacuum pack after the decision has been made by the attending surgeon to perform a damage control laparotomy. The study will use variable block size randomization. On study days 1, 2, 3, 7, and 28, blood will be collected. Whenever possible, peritoneal fluid will also be collected at these time points from the patient’s abdomen or TAC device. Luminex technology will be used to quantify the concentrations of 65 mediators relevant to the inflammatory response in peritoneal fluid and plasma. The primary endpoint is the difference in the plasma concentration of the pro-inflammatory cytokine IL-6 at 24 and 48 h after TAC dressing application. Secondary endpoints include the differential effects of these dressings on the systemic concentration of other pro-inflammatory cytokines, collective peritoneal and systemic inflammatory mediator profiles, postoperative fluid balance, intra-abdominal pressure, and several patient-important outcomes, including organ dysfunction measures and mortality.

Discussion

Results from this study will improve understanding of the effect of active negative pressure peritoneal therapy after damage control laparotomy on the inflammatory response. It will also gather necessary pilot information needed to inform design of a multicenter trial comparing clinical outcomes among patients randomized to TAC with the ABThera versus Barker’s vacuum pack.

Trial registration

ClinicalTrials.gov identifier http://www.clicaltrials.gov/ct2/show/NCT01355094

[Update: studies in intensive care medicine. Results of the last 12 months]

Die Intensivmedizin spielt eine bedeutende Rolle sowohl für den medizinischen als auch den ökonomischen Erfolg eines Krankenhauses. Eine qualitativ hochwertige Intensivmedizin setzt die Kenntnis und die Umsetzung relevanter neuer klinischer Studien voraus. Die vorliegende Arbeit gibt einen Überblick über die wichtigsten intensivmedizinischen Publikationen des Jahres 2010 und der ersten Jahreshälfte von 2011 und ordnet diese im Hinblick auf die jeweilige klinische Relevanz ein. In den Jahren 2010 und 2011 sind zahlreiche randomisierte Studien veröffentlicht worden. Schwerpunkte waren die Therapie des Lungenversagens, die Analgosedierung und die Sepsistherapie.

Bending the cost curve in the United States: the role of comparative effectiveness research

Owing to an increasing focus on the rising cost of medical care in the United States, bending the cost curve has become the central tenet of healthcare reform. The exact definition of this phrase, however, remains elusive. In order to affect change in the cost and quality of healthcare, the importance of comparative effectiveness research must be recognized.