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327 Management of Secondary Peritonitis
Abstract and Figures
The authors review current definition, classification, scoring, microbiology, inflammatory response, and goals of management of secondary peritonitis. Despite improved diagnostic modalities, potent antibiotics, modern intensive care, and aggressive surgical treatment, up to one third of patients still die of severe secondary peritonitis. Against the background of current understanding of the local and systemic inflammatory response associated with peritonitis, there is growing controversy concerning the optimal antibiotic and operative therapy, intensified by lack of properly conducted randomized studies. In this overview the authors attempt to outline controversies, suggest a practical clinical approach, and highlight issues necessitating further research. The authors review the literature and report their experience. The emerging concepts concerning antibiotic treatment suggest that less-in terms of the number of drugs and the duration of treatment-is better. The classical single operation for peritonitis, which obliterates the source of infection and purges the peritoneal cavity, may be inadequate for severe forms of peritonitis; for the latter, more aggressive surgical techniques are necessary to decompress increased intra-abdominal pressure and prevent or treat persistent and recurrent infection. The widespread acceptance of the more aggressive and demanding surgical methods has been hampered by the lack of randomized trials and reportedly high associated morbidity rates.
Sepsis represents the host's systemic inflammatory response to bacterial peritonitis. To improve results, both the initiator and the biologic consequences of the peritoneal infective-inflammatory process should be addressed. The initiator may be better controlled in severe forms of peritonitis by aggressive surgical methods, whereas the search for methods to abort its systemic consequences is continuing.
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Supplementary resources (3)
... The main aim of treatment is to control sepsis and treat the underlying cause. Surgery plays important role in the management of perforations [16][17][18][19]. ...
Background: Peritonitis refers to an inflammatory response of the peritoneum in the abdominal cavity in terms of activation of local mediator cascades by different stimuli. Therefore, bacterial, viral and chemical agents may cause inflammation of the peritoneal layer. Secondary peritonitis is usually due to spillage of gastrointestinal or genitourinary microorganisms into the peritoneal cavity as a result of loss of integrity of the mucosal barrier. Methods: Cross sectional observational study was performed. All patients admitted and treated for perforation secondary to non-traumatic hollow viscus perforation in surgical units of Department of General Surgery, Government Medical College, Nalgonda, Telangana, India, during the period of October 2019 - September 2021. A detailed history was taken and all the patients were subjected to thorough clinical examination. Patients subjected to laparotomy are followed in post-operative period to know the complications, morbidity and mortality rates. General condition at the time of admission was monitored by noting presenting complaints, pulse, BP, respiratory rate, hydration status. Operative findings were recorded. Necessary surgical intervention done is recorded; post operatively patients will be followed up for any complications. Each case will be studied as per the proforma. Results: The most common age group was 40- 60yrs (53.3%) in the present study. Major etiological factor noted is gastric perforation and next is appendicular perforation& duodenal ulcer perforation. In this study pain abdomen was the predominant symptom and was presented in all cases (100%). In this study guarding/rigidity was seen in all cases (100%). Most of the cases had a mean duration of 10-19days of hospital stay. Mortality rate was found to be 16.6%. Conclusion: In our study, youngest age of small intestine perforation was 23years and oldest was 80 years. Most cases had a duration of hospital stay of 10- 19 days. Main presenting complaint was pain abdomen, vomiting, fever and distension of abdomen. Risk factors for perforations were smoking, tobacco, alcohol and NSAIDs.
... In one study, the 5 year survival rate following loop ileostomy in emergency surgeons was revealed as 39.2% in comparison to 64.7% in elective cases. 15 It was beyond scope of our study due to short duration of study period. ...
Background: Loop ileostomy is a temporary diversion of small intestinal contents towards exterior through anterior abdominal wall. Though it is a good procedure for a better outcome of primary surgery it has itself many complications. Objective: To determine the clinical spectrum of loop ileostomy complications. Materials and method: This prospective study was conducted from January, 2017 to December, 2017. Consecutive 30 patients requiring loop ileostomy were enrolled in the study by purposive sampling and were categorized into Group A requiring emergency surgery and Group B planned for elective surgery. Data regarding sociodemographic, clinical, surgical and outcome profile were recorded in a pre-structured, interview and observation based, peer reviewed data collection sheet. Data were compiled, edited and analyzed with SPSS version 23. Data were presented as mean and standard deviation, frequency percentage and median with range. Results: The mean age of the patients were 32.79±5.19 years (age range: 20-43 years) and 49.16±6.17 years (age range: 28-76 years) in Group A and Group B respectively with sex ratio of male to female of 4:1 and 3:1. Out of 10 patients in Group A, 4(40%) patients underwent resection anastomosis with ileostomy and primary repair with loop ileostomy whereas 2(20%) patients underwent exteriorization of multiple perforation site. In Group B among 20 patients, 9(45%) underwent low anterior resection with loop ileostomy and 5(25%) patients underwent left hemicolectomy with loop ileostomy. Out of 10 patients in Group A, 5(50%) patients each suffered from skin excoriation and major wound infection. On the contrary, among 20 patients in Group B, 11(55%) and 4(20%) patients suffered from skin excoriation and stomal obstruction. Only skin excoriation was evident as statistically significantly higher in Group B than in Group A (p 0.03). Among the general complications, electrolyte imbalance (60% vs 40% in Group A and B respectively) and respiratory tract infection (10% each in Group A and B) were evident. Conclusion: Skin discoloration, skin edema, major and minor wound infection, prolapse, skin excoriation and stomal obstruction are the different spectrum of loop ileostomy complications in our perspective. Among them skin excoriation is much higher in routine cases than emergency surgery. Delta Med Col J. Jan 2021;9(1):17-22
... The other sequelae to this may include decreased renal perfusion with progressive azotaemia and acute tubular necrosis, weight loss due to decreased diet intake and excessive protein catabolism, impaired thermoregulatory mechanism resulting into decreased core body temperature and other irreversible adverse changes which can cause death if not treated timely and efficiently. 7,8 However patients with poor prognostic factors including delayed or even missed diagnosis, advanced age, comorbidities, malignancy or advanced disease may Email: draheelahmed@gmail.com Open Access deteriorate rapidly and develop septic shock and organ failure. ...
Introduction: Despite latest development the diagnosis and prognosis of acute intraperitoneal infection is still offer a challenge. Different scoring algorithms have been formulated to grade the severity and decision making.Objective: To document reliability of Mannheim Peritonitis Index as a criterion for prediction of mortality after acute intraperitoneal infectionMethodology: This cross-sectional study was conducted at department of Surgery; Civil Hospital Karachi/Dow University of Health Sciences during December 2019 to June 2020. Total 200 patients aged 16 to 55 years from either gender, presenting with peritonitis were enrolled. Patients were evaluated using Mannheim Peritonitis Index (MPI) score for mortality taking real mortality within 7 days as gold standard.Results: The mean age was 37.3 ±9 years with male (71%) dominance, while mean MPI score was 27.12 ±7.1. The sensitivity was 91.8 %, specificity was 84.4 %, while positive predictive and negative predictive values and diagnostic accuracy values were 87.8 %, 89.4 % and 93% respectively.Conclusion: Several scoring systems are utilized to evaluate and stratify patients in overcrowded emergency department which is crucially important for selection of patients who need early clinical decisions. MPI scoring index is the specific and simply accessible in such condition to predict the mortality.Keywords: Mannheim Peritonitis Index, acute intraperitoneal infection, In-hospital mortality, Diagnostic accuracy.
... CT has an upper edge over other modalities as multidetector CT can detect free gas as well as determine the site of perforation with an accuracy of 86% [10,14]. The definitive treatment for gastrointestinal perforation comprises fluid resuscitation, antibiotic treatment, control of the source, support of the organ system, and nutritional support [15,16]. Diagnostic delay or inappropriate management of intestinal obstruction becomes a surgical emergency that is associated with high mortality. ...
Background
The aim of this retrospective study is to establish a correlation between clinical features, surgical diagnosis, and the final diagnosis of laparotomies, as well as to establish the relationship between preoperative delay on the outcomes of surgery in the form of mortality and morbidity. Emergency surgery is high-risk in patients with acute abdomen with uncertain diagnosis. The results of surgery are remarkable and provide quick relief to the suffering and agony of patients with the dreadful condition of acute generalized peritonitis.
Methodology
Patients presenting with complaints of acute abdomen who needed laparotomy based on clinical judgment and investigations were included in this study. The study data were reviewed from April 2007 to January 2011 and March 2014 to February 2016 in a government hospital.
Results
A total of 174 patients with acute abdomen in whom there was an indication of laparotomy based on clinical judgment and radiological investigations were selected. Most patients had gastrointestinal perforation (n = 115) and acute intestinal obstruction (n = 23). The most important clinical features analyzed were abdominal tenderness (n = 160), guarding (n = 153), distention (n = 75), and tachycardia (n = 63).
Conclusions
Among the total patients, 150 underwent surgery within 24 hours of the presentation in the emergency and the remaining after 24 hours. The most common cause of laparotomy was a duodenal perforation in 79 patients and gastric perforation in 24 patients. A total of 114 patients developed no complications postoperatively. Among patients who developed postoperative complications, wound sepsis and acute respiratory distress syndrome were the most common. Mortality was noted in three patients.
... Intra-abdominal infection (IAI) is defined as an inflammatory reaction to bacteria and their toxins in the peritoneum, resulting in a purulent exudate in the peritoneal cavity [5][6][7][8]. Among all the causes of sepsis, IAI is reportedly the second most common cause, with a relatively high mortality rate of nearly 30.0% ...
Background
Sepsis is the most common cause of death in hospitals, and intra-abdominal infection (IAI) accounts for a large portion of the causes of sepsis. We investigated the clinical outcomes and factors influencing mortality of patients with sepsis due to IAI.
Methods
This post-hoc analysis of a prospective cohort study included 2126 patients with sepsis who visited 16 tertiary care hospitals in Korea (September 2019–February 2020). The analysis included 219 patients aged > 19 years who were admitted to intensive care units owing to sepsis caused by IAI.
Results
The incidence of septic shock was 47% and was significantly higher in the non-survivor group (58.7% vs 42.3%, p = 0.028). The overall 28-day mortality was 28.8%. In multivariable logistic regression, after adjusting for age, sex, Charlson Comorbidity Index, and lactic acid, only coagulation dysfunction (odds ratio: 2.78 [1.47–5.23], p = 0.001) was independently associated, and after adjusting for each risk factor, only simplified acute physiology score III (SAPS 3) ( p < 0.001) and continuous renal replacement therapy (CRRT) ( p < 0.001) were independently associated with higher 28-day mortality.
Conclusions
The SAPS 3 score and acute kidney injury with CRRT were independently associated with increased 28-day mortality. Additional support may be needed in patients with coagulopathy than in those with other organ dysfunctions due to IAI because patients with coagulopathy had worse prognosis.
The open abdomen (OA) is a challenging surgical scenario necessitating meticulous management to mitigate complications and improve outcomes. This chapter provides a concise overview of contemporary strategies for OA management, encompassing indications, techniques, and complications. Emphasis is placed on evolving approaches such as negative pressure wound therapy, dynamic closure systems, and progressive closure techniques. Additionally, the author highlights the importance of multidisciplinary collaboration and adherence to evidence-based practices in optimizing outcomes for patients with an open abdomen.
Background
Emergency laparotomy is associated with a high morbidity and mortality rate. The decision on whether to perform an anastomosis or an enterostomy in emergency small bowel resection is guided by surgeon preference alone, and not evidence based. We examined the risks involved in small bowel resection and anastomosis in emergency surgery.
Methods
A retrospective study from 2016 to 2019 in a university hospital in Denmark, including all emergency laparotomies, where small‐bowel resections, ileocecal resections, right hemicolectomies and extended right hemicolectomies where performed. Demographics, operative data, anastomosis or enterostomy, as well as postoperative complications were recorded. Primary outcome was the rate of bowel anastomosis. Secondary outcomes were the anastomotic leak rate, mortality and complication rates.
Results
During the 3.5‐year period, 370 patients underwent emergency bowel resection. Of these 313 (84.6%) received an anastomosis and 57 (15.4%) an enterostomy. The 30‐day mortality rate was 12.7% (10.2% in patients with anastomosis and 26.3% in patients with enterostomy). The overall anastomotic leak rate was 1.6%, for small‐bowel to colon 3.0% and for small‐bowel to small‐bowel 0.6%.
Conclusion
A primary anastomosis is performed in more than eight out of 10 patients in emergency small bowel resections and is associated with a very low rate of anastomotic leak.
Background: Secondary peritonitis is a common emergency surgical condition with varying aetiologies managed by surgeons all over the world. One important morbidity associated with it is postoperative surgical site infection (SSI). A better prevention strategy can be instituted if this complication in patients can be correctly predicted. The study aimed to identify factors in patients with peritonitis that have a significant bearing on the development of postoperative SSI.
Method: A total of fifty patients operated on for peritonitis in a period of one year were studied. Factors including age, gender, comorbidities, presenting symptoms, time of presentation, time of intervention, intraoperative findings, duration of surgery, and postoperative SSI were noted. Chi-square, Fisher's exact test and Student's t-test were used to test for association where appropriate and a p-value of < 0.05 was considered statistically significant.
Results: Peritonitis was most commonly due to a ruptured appendix (46%) followed by perforated peptic ulcer disease (42%). The incidence of SSI was 44%. For the patients that developed SSI, the lowest rate was observed in cases of ruptured appendix (39.1%) and the highest in perforated gastric ulcer (64.3%) which was closely followed by perforated duodenal ulcer (57.1%). The association between the time of presentation and the occurrence of SSI was statistically significant (p = 0.028).
Conclusion: The SSI rate (44%) from peritonitis in our centre was quite high and the time of presentation played a crucial role. Prevention strategies focusing on predictors of SSI is necessary to reduce the rate of SSI in our setting.
Keywords: Peritonitis; Predictors of SSI; Surgical site infection; Time of presentation.
Background
Early recovery from shock improves prognosis in septic shock patients. We determined whether cytokine modulation by Continuous Renal Replacement Therapy (CRRT) following acute care surgery resulted in stable hemodynamics in them. To investigate our hypothesis, we measured proinflammatory cytokines IL-6, IL-1ra and the coagulation cascade activator plasminogen activator inhibitor-1 (PAI-1) following CRRT with polymyxin B immobilized fiber (PMX-DHP) which has been utilized as an adjuvant treatment option for patients with severe septic shock.
Methods
66 septic shock patients requiring 2 h direct hemoperfusion therapy PMX-DHP were included. 36 patients of them also received continuous hemodiafiltration (CHDF) after performing PMX-DHP. Circulatory dynamics and levels of inflammatory mediators, namely IL-6, IL-1ra, and PAI-1 were assessed before, immediately after, and 24 h initiation of PMX-DHP.
Results
Mean Arterial Pressure (MAP) rose intentionally by PMX-DHP just after enforcement 24 h later ( p < 0.01). Levels of IL-6, IL-1ra, and PAI-1 significantly decreased after PMX-DHP ( p < 0.05) and this trend was observed up to 24 h post initiation of PMX-DHP ( p < 0.05). IL-6 modulation by PMX-DHP was enhanced with using CHDF and there was a significant correlation between IL-6 and MAP ( p < 0.0001). In addition, levels of Il-6 and PAI-1 showed a significant correlation.
Conclusion
Our data showed employing CRRT as cytokine modulators could be an additional therapeutic strategy to improve septic shock outcomes via the crucial role of IL-6 signaling in endothelial dysfunction.
El peritoneo: descripción de un nuevo síndrome es el resultado de múltiples cuestionamientos surgidos durante la formación como médicos y cirujanos de los autores, referente a la función del peritoneo en el sentido orgánico específicamente en su aplicación práctica, sin perder de vista el beneficio para los pacientes y de sus familiares.
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COMPARTMENT SYNDROME is a condition in which increased pressure in a confined anatomical space adversely affects the circulation and threatens the function and viability of the tissues therein. Although compartment syndrome is best known to occur within the fascial spaces of the extremities, it also may develop within the non-yielding envelopes of the orbital globe (as in glaucoma), the intracranial cavity, and the kidney (post ischemic oliguria) (1).
The concept that the abdominal cavity can also be considered as a single compartment and that any change in the volume of any of its contents will elevate intra-abdominal pressure is not new. However, the notion that elevated intra-abdominal pressure may impair organ and physiologic function by producing an abdominal compartment syndrome (ACS) has received relatively little attention. This is the first comprehensive presentation all aspects of the abdominal compartment syndrome.
Overview of the Planned Open Abdomen in general and Staged Abdominal Repair (STAR) in particular based on four operative principles; to close the source of infection, to eliminate infectious material, to kill bacteria, and the decompress abdominal hypertension (Abdominal compartment syndrome). Indications and operative technique for various forms of open abdomen are shown. Special focus is direct at staged abdominal repair (STAR) regarding definition, indications, detailed operative technique, results and unsolved issues.
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases.When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
A mail survey of 283 members of the Israeli Association of Surgeons was conducted to document their current attitudes concerning the duration of antibiotic therapy following emergency operations for abdominal contamination and infection. The response rate to the questionnaire was 26.5%. Evaluation of responses demonstrated that about half of the answers supported an excessive use of postoperative antibiotics. It appears that failure to distinguish between contamination - requiring no or minimal postoperative administration - and infection - requiring a proper postoperative course - is currently the main reason for the unnecessarily prolonged use of antibiotics.
• This prospective, open, consecutive, nonrandomized trial examined management techniques and outcome in severe peritonitis. A total of 239 patients with surgical infection in the abdomen and an APACHE (acute physiology and chronic health evaluation) II score greater than 10 were studied. Seventy-seven patients (32%) died. Reoperation had a 42% mortality rate (35 of 83 patients died) compared with a 27% mortality rate (42 of 156 died ) in patients who did not undergo reoperation. Forty-six patients underwent one reoperation; 15, two reoperations; 10, three reoperations; five, four reoperations; and seven, five reoperations, with mortality rates of 43%, 40%, 30%, 40%, and 57%, respectively. There was no significant difference in mortality between patients treated with a "closed-abdomen technique" (31% mortality) and those treated with variations of the "open-abdomen" technique (44% mortality). Logistic regression analysis showed that a high APACHE II score, low serum albumin level, and high New York Heart Association cardiac function status were significantly and independently associated with death. Low serum albumin level, youth, and high APACHE II score were significantly and independently associated with reoperation.(Arch Surg. 1993;128:193-199)
• As multiple-organ failure (MOF) has been generally associated with sepsis, the importance of bacterial sepsis was evaluated retrospectively in 55 trauma and 37 intra-abdominal—sepsis patients with MOF. The severity of MOF was graded, and an analysis was made of day of onset, incidence, severity, sequence, and mortality of organ failures. No difference was found between groups in sequence, severity, or mortality of organ failures. In contrast, bacterial sepsis was found in 65% of intra-abdominal—sepsis patients but only in 33% of trauma patients. It is concluded that sepsis is probably not the essential cause of MOF. Instead, an alternative hypothesis is presented involving massive activation of inflammatory mediators by severe tissue trauma or intra-abdominal sepsis, resulting in systemic damage to vascular endothelia, permeability edema, and impaired oxygen availability to the mitochondria despite adequate arterial oxygen transport. (Arch Surg 1985;120:1109-1115)
The introduction of several new antibiotics, including cephalosporins and ureido-penicillins, has been a stimulus for clinical trials with these agents for intra-abdominal infection. Despite marked differences in antibacterial spectra, substantial differences in treatment results have not been documented. We reviewed published trials of antibiotic therapy for intra-abdominal infection to determine factors in study design that might impair identification of clinically important differences between regimens. Sixteen articles were identified that provided sufficient numbers of cases and data for analysis. Eight were prospective comparative trials, the remainder "single-armed" studies. The mortality rate was 3.5%, and the overall success rate was 84% for aminoglycoside plus clindamycin (range 52%-96%), 89% (range 83%-93%) for aminoglycoside plus metronidazole, and 93% (range 61%-9S%) for cephalosporin-based regimens. Several defects in study design were identified. (1) Exclusionary criteria employed generally prevented enrollment of seriously ill patients or infections associated with high failure rates: Patients were excluded if even mild renal impairment was present or if antibiotic therapy had been recently administered, thereby excluding patients with postoperative or recurrent infections. Several studies allowed entry of contaminated but not infected patients. (2) Criteria used for reporting infectious diagnosis, premorbid health status, severity of infection, and outcome were nonuniform, and few studies provided such information. (3) Despite the small number of treatment failures, data reported did not allow determination of the basis for failure. For example, only four studies provided information on the operations performed upon treatment failures. Whether treatment failures were due to inadequate antibiotic therapy could therefore not be determined. Enrollment of a variety of low mortality infections precluded demonstration of any differences in regimens. Use of stratified randomization, stratifying for site of infection and severity of infection, and inclusion of greater numbers of patients would increase the likelihood of identifying differences between regimens. Such study design would likely require a multicenter trial to enroll sufficient numbers of cases for statistical analysis.