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Radical Surgical Debridement in the Treatment of Advanced Generalized Bacterial Peritonitis
Abstract
The continued high mortality in patients with generalized peritonitis, treated by conventional means, led the author, in 1963, to a study of the effects of radical surgical debridement in those patients in whom the source of contamination could be eliminated. Ninety two patients have been treated with the described regimen. They varied from 3 to 69 years of age, and a variety of contamination sources were encountered. All were critically ill and over 90% had mechanical intestinal obstruction. Although these operations were tedious and often prolonged (average operating time, three hours), all patients survived and postoperative complications were surprisingly minimal. It is believed that the success of this method results from stopping further contamination and restoring the peritoneum to a state that allows normal host defense mechanisms to clear any residual infection.
... Inside the clot, bacteria are able to proliferate, leading to the formation of abscesses. 14,133,134 S. aureus can directly activate prothrombin through the action of two secreted coagulases, coagulase (Coa) and von Willebrand factor binding protein (vWbp). 135,136 Coa and vWbp share sequence and structural homology, particularly in their N-terminal regions. ...
Fibrinogen, one of the most abundant plasma proteins playing a key role in hemostasis, is an important modulator of wound healing and host defense against microbes. In the current review, we address the role of fibrin(ogen) throughout the process of wound healing and subsequent tissue repair. Initially fibrin(ogen) acts as a provisional matrix supporting incoming leukocytes and acting as reservoir for growth factors. It later goes on to support re-epithelialization, angiogenesis, and fibroplasia. Importantly, removal of fibrin(ogen) from the wound is essential for wound healing to progress. We also discuss how fibrin(ogen) functions through several mechanisms to protect the host against bacterial infection by providing a physical barrier, entrapment of bacteria in fibrin(ogen) networks, and by directing immune cell function. The central role of fibrin(ogen) in defense against bacterial infection has made it a target of bacterial proteins, evolved to interact with fibrin(ogen) to manipulate clot formation and degradation for the purpose of promoting microbial virulence and survival. Further understanding of the dual roles of fibrin(ogen) in wound healing and infection could provide novel means of therapy to improve recovery from surgical or chronic wounds and help to prevent infection from highly virulent bacterial strains, including those resistant to antibiotics.
... Históricamente desde 1905, Price, y en 1906 Torek, utilizaron su técnica de desbridamiento y lavado de la cavidad (3,4) , en Doi: 10.18004/sopaci.2021.abril.9 1960 Artz propuso la irrigación con antibióticos en el transoperatorio (5) y Schumer la irrigación continua posoperatoria (6,7) , en 1975 Huspeth inició la técnica del desbridamiento radical peritoneal (8). Solamente en el año 1979 Steimberg manejó la cavidadabdominal como un absceso, abierto (9) y en 1980 Teichmann y Wittmann utilizando el principio anterior del abdomen abierto, utilizaron una malla con cremallera para abordar la cavidad abdominal drenando y lavándola periódicamente (10) . ...
The open abdomen is a surgical technique in which we leave the cavity open, covering the organs for the management of different clinicopathological entities. Materials and methods: 14 patients were prospectively evaluated between February 2018 and February 2020, treated with an open abdomen technique contained with Bogotá Bag in the Surgery Service of the Central Military Hospital. Results: The average age was 49 years, and 79% were male. Indications for open abdomen management were: abdominal sepsis, damage control, abdominal hypertension and second look. In patients with open abdomen due to damage control, the most frequently injured organs were: splenic injury with perforation of the transverse colon and liver injury with duodenal perforation. The average number of reoperations was 2.4 per patient. All patients were in the Intensive Care Unit, with an average of 15 days. Complications found: patients with intestinal fistula 21.4% and deaths 21.4%. In 7 patients, the vacuum aspiration system was used concomitantly. Conclusions: The management of the open abdomen contained with Bogota Bag is a simple technique for our environment due to its use with low-cost material such as polyethylene, obtaining satisfactory results.
... The microbiological analysis is especially important for patients who were previously exposed to antibiotics or who are at a high risk of infection with resistant organisms. Gram staining provides early guidance that aids in the choice of antibiotics and may be the only source of information if cultures do not achieve satisfactory growth [33] . Indication for surgical treatment should be aggressive and aims to eliminate the source of infection, to reduce the peritoneal contaminants, and to avoid a continued peritonitis. ...
Intra-abdominal infections can be classified into uncomplicated or complicated (peritonitis). Peritonitis is divided into primary, secondary, and tertiary. Tertiary peritonitis is the less common but the most severe among peritonitis stratifications, being defined as a recurrent intra-abdominal infection that occurs 48 h after a well-succeeded control of a secondary peritonitis. This disease has a complex pathogenesis that is closely related to the capacity of the peritoneal cavity to activate immunological processes. Patients who progress to persistent peritonitis are at an increased risk of developing several infectious complications such as sepsis and multiple organ failure syndrome. Moreover, tertiary peritonitis remains an important cause of hospital death mainly among patients with associated risk factors. The microbiological profile of organisms causing tertiary peritonitis is often different from that observed in other types of peritonitis. In addition, there is a high prevalence of multidrug-resistant pathogens causing this condition, and an appropriate and successful clinical management depends on an early diagnosis, which can be made easier with the use of clinical scores presenting a good prediction value during the intensive care unit admission. Complementarily, immediate therapy should be performed to control the infectious focus and to prevent new recurrences. In this sense, the treatment is based on initial antimicrobial therapy and well-performed peritoneal drainage.
... Several studies [31,32] have evaluated different therapeutic options for IAS. The transfer of therapeutic options from one institution to another and the comparison between studies about the same illness has been difficult, because of the impossibility to compare analogous populations and similar illnesses. ...
Background:
The grading systems for intra-abdominal sepsis (IAS) are not employed commonly in clinical practice because they are too complicated or too specific. We propose to grade IAS with a simple grading system: the TNM system, which is an acronym borrowed from cancer staging, where T indicates Temperature, N indicates Neutrophils, and M indicates Multiple organ failure (MOF). The aim of this prospective observational study is to assess the predictive value of the TNM score on deaths of patients with complicated IAS.
Patients and Methods:
We considered 147 patients with complicated IAS. Three classes of attribute were chosen: Temperature (T), Neutrophil count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3), and M (M0-M2), they were grouped in stages (0-IV). We analyzed specific variables for their possible relation to death: Age, gender, blood transfusion, causes of IAS, T, N, pre-operative organ failure, immunocompromised status, stage 0, I, II, III, and IV. Odds ratios were calculated in a uni-variable and multi-variable analysis.
Results:
This was the distribution in classes, based on TNM stages: One patient was in stage 0; 15 patients in stage I; 47 patients in stage II; 56 patients in stage III; 28 patients in stage IV. Death occurred in 45 (30.6%) patients. The N, pre-operative organ failure, immunocompromised status, stage III-IV were potential predictors of post-operative death in uni-variable analysis. Only pre-operative organ failure and stage IV were significant independent predictors of post-operative death in multi-variable analysis.
Conclusions:
The TNM classification is an easy system that could be considered to define the death risk of patients with IAS and to compare patients with sepsis.
... Soon thereafter, I began using aggressive laparoscopic lysis of adhesions to treat abscesses and pelvic inflammatory disease [5−19]. Laparoscopic lysis of adhesions is much easier if the adhesions are acute rather than chronic and well vascularized [20]. Many of these women retain their ability to conceive without in vitro fertilization. ...
... Bacterial intestinal translocation occurs when the gastrointestinal microflora passes through the lamina propria into the local mesenteric lymph nodes and then into other organs (liver, spleen, etc.). [2] The enteric bacteria can then spread throughout the body through the systemic circulation and cause death as a result of sepsis, shock, and multi-organ failure. Therefore, surgical treatment of secondary peritonitis should be based on the control of the infection site, reduc- ...
BACKGROUND: Currently, all progress in diagnostic techniques, surgical techniques, antibiotherapy, and intensive care units is accompanied by a decrease in the mortality due to severe secondary peritonitis; however, the rate is still unacceptably high. To remove the source of peritonitis, a surgeon has several options, such as closure, exclusion, and resection, depending on the preference of the surgeon and the condition of the patient. The aim of this study is to determine the rates of bacterial translocation by comparing the dry cleaning method (gauze squeezed with saline) and peritoneal lavage method (cleaning with saline), which are among the peritoneal cleaning methods. METHODS: A total of 64 rats were studied as sham, control, dry cleaning, and saline cleaning groups. Only laparotomy was performed in the sham group, and cecal ligation puncture was performed in the control group. After ligation puncture operations in the other two groups, one of them was subjected to dry cleaning and the other to isotonic cleaning. The samples obtained from the liver, spleen, and mesothelium were sacrificed and cultured under aerobic and anaerobic environments. RESULTS: There was no significant difference in the anaerobic bacterial counts, although there was a significant difference in the results of the aerobic bacterial counts in liver, spleen, and mesothelium samples on comparing the dry cleaning and saline cleaning groups. CONCLUSION: According to our study, the cleaning of intraabdominal infections with dry gauze is more effective than the cleaning with physiological saline for the elimination of aerobic bacteria. There is no difference observed with respect to the anaerobic bacterial counts.
... Additionally radical débridement carries the danger of creating new iatrogenic bowel leaks. These drawbacks of radical debridement may be some of the reasons that the comparison of this technique with other techniques involving less radical debridement did not reveal any significant advantage (77,120,141). ...
... Additionally radical débridement carries the danger of creating new iatrogenic bowel leaks. These drawbacks of radical debridement may be some of the reasons that the comparison of this technique with other techniques involving less radical debridement did not reveal any significant advantage (77,120,141). ...
se Pages in Portugais and English
... There appears to be some controversy regarding the relative benefits of debridement of the fibrinous exudate. Hudspeth [10] advocates "radical peritoneal debridement," defining it as complete abdominal exploration ...
English
Surgical principles in the management of intraabdominal infection have remained constant. Rather, it is the application of these principles in selected cases that has varied. Judgement, therefore, becomes paramount for the surgeon. In selected cases. Multiple planned relaparotomies may be the most effective means of closing the infectious source and eliminating toxic infectious materials. The Artificial Burr (Wittmann Patch) has proven to be an effective yet safe means of permitting abdominal entry and closure of the abdominal fascia.
German
Operative Behandlung der intraabdominellen Infektion. Die Prinzipien der Behandlung intraabdomineller Infektionen sind unverändert geblieben. Was veränderlich ist, sind die Anwendungen dieser Prinzipien in ausgewahlten Fällen. Die Beurteilung des jeweiligen Falles ist daher für den Chirurgen von herausragender Bedeutung. In ausgewählten Fällen kann die vorher geplante
mehrfache Eröffnung des Bauchraumes die effektivste Methode sein, den Infektionsherd zu verschließen und toxisches, infektioses Material zu entfernen. Der Klettverschluß (Burr) hat sich als eine wirkungsvolle und sichere Methode erwiesen, die Bauchhöhle zu eröffnen und zu verschließen.
... Otro procedimiento usado en conjun:o con el lavado peritoneal intraoperatorio es el debridamiento de adhereócias y tejido necrótico. Este procedimiento se fundamenta en que la eliminación de las condiciones anaeróbicas y la reducción de bacterias previenen la formación de abscesos residuales ( 20). Existen controversias al respecto, Polk ( 3 5 ) trató 22 pacientes con debridam~ento peritoneal radical y 24 pacientes con tratamiento conservador, no encontrando beneficio alguno en cuanto a la sobrevida; sin embargo sugiere que la diferencia pudo ser debida .al ...
RESUMEN La sepsis intraabdominal continúa siendo uno de los grandes retos en cirugía ya que su mortali-dad sigue siendo elevada. En el afán de buscar métodos más eficaces para el manejo de esta entidad surge nuevamente el llamado ((Manejo Abierto de la Cavidad Abdominal". El propósito de nuestro traba-jo es hacer una revisión amplia en cuanto al manejo quirúrgico de la sepsis intraabdominal y presentar el primer caso manejado en el Hospital Vargas de Caracas según la técnica abierta con malla de Marlex y cierre tipo cremallera. INTRODUCCION La sepsis intraabdominal continúa siendo uno de los grandes retos de la terapéutica quirúrgica. El trata-miento específico ha sido tradicionalmente conservador y expectante. Pes~ a la administración de potentes antibióticos y medidas de sostén en modernas unidades de cuidados intensivos la mortalidad de la peritonitis bac-teriana severa en general es elevada (Tabla 1) . La razón se debe fundamentalmente a la persistencia de sep-sis intraabdominal y a la sepsis recurrente oculta.
... The approach suggested in damage control surgery, used originally in trauma surgery, was subsequently extended to general abdominal surgery in every setting in which a ''second look'' at the abdominal cavity was needed [14,15]. Lately, many efforts have been undertaken to define and outline recommendations for management of the OA [16][17][18], but definitive evidence for an optimal means of its management is still needed [1,19]. ...
Background:
Macrolide-based treatment has been associated with survival benefit in patients hospitalized with community-acquired pneumonia (CAP). However, the influence of macrolide therapy in all patients hospitalized with pneumonia, including healthcare-associated pneumonia (HCAP), is unclear.
Methods:
Analysis of a retrospective single-center cohort.
Results:
Community-acquired pneumonia was present in 220 (22.5%) of all patients with pneumonia admitted through the emergency department of Barnes-Jewish Hospital, and HCAP was present in 757. Macrolide-based treatment was administered to 411 patients (42.1%). These patients were more likely to have CAP than were patients not receiving macrolide-based therapy (35.3% vs. 13.3%; p<0.001) and had lower scores on the CURB-65 tool, a measure of the severity of illness (2.4±1.5 vs. 3.1±1.3; p<0.001). Patients receiving macrolides also had a lower hospital mortality rate in univariable analysis (12.7% vs. 27.2%; p<0.001). A propensity score analysis showed that macrolide-based treatment was associated with a lower in-hospital mortality rate (adjusted odds ratio [AOR] 0.67; 95% confidence interval [CI] 0.54-0.81; p=0.043). Separate propensity score analyses of patients with CAP (AOR 0.20; 95% CI 0.11-0.34; p=0.003) and HCAP (AOR 0.81; 95% CI 0.65-1.01; p=0.337) produced discordant findings.
Conclusions:
Macrolide-based treatment was associated with better survival in patients hospitalized with pneumonia. The survival advantage appeared predominantly among patients with CAP.
... There appears to be some controversy regarding the relative benefits of debridement of the fibrinous exudate. Hudspeth [10] advocates "radical peritoneal debridement," defining it as complete abdominal exploration ...
El abdomen abierto es una técnica quirúrgica empleada en el tratamiento de los pacientes con procesos infecciosos peritoneales severos, en el trauma abdominal grave en pacientes que requieren cirugía de control de daños y en el manejo del síndrome de hipertensión abdominal. El tratamiento con abdomen abierto ocasiona riesgos trascendentales para el paciente tales como alteraciones hidroelectrolíticas, contaminación externa de órganos abdominales, desarrollo de fístulas intestinales, adherencias obstructivas, defectos herniarios gigantes de la pared abdominal y la presencia de grandes heridas cruentas con cicatrización lenta, con consecuencias estéticas y funcionales importantes. Existen técnicas que además de manejar el abdomen abierto tratan de evitar la retracción aponeurótica y el desarrollo de hernias ventrales gigantes que requieren de una compleja reconstrucción tardía de la pared abdominal. El Cierre Secuencial de la Pared Abdominal es una técnica desarrollada en el Centenario Hospital Miguel Hidalgo en la que se emplean materiales y métodos utilizados en diversas técnicas del manejo de abdomen abierto, adecuados a la infraestructura del hospital y a la disponibilidad de materiales. Los beneficios del procedimiento propuesto son reparar, drenar, descomprimir y ofrecer control de la pared abdominal en aquellos pacientes que requieren tratamiento con abdomen abierto. La técnica tiene la ventaja de que el paciente puede permanecer en su cama, sin necesidad de reiterados ingresos a quirófano y debido a que se trata de una técnica sencilla y fácil de realizar así como por el uso de materiales inertes se asocia a un bajo índice de complicaciones y resultados iniciales alentadores.
Muitas tentativas t6m sido feitas para definir a peritonite e as infeccöes intra-abdominais, que incluem uma grande variedade de diferentes condicöes patologicas, variando, em gravidade, de um pequeno problema local a uma doenca devastadora de todos os orgäos sistemicos. Nenhuma dessas classificacöes 6 satisfat6ria e mesmo os sistemas atuais endossados pela Surgical Infection Society (SIS) tem desvantagens.18,110,162 O sistema de classificaqäo apropriado atualmente usado estä relacionado no Quadro 29-1. Definicao Infecäo intra-abdominal (IIA) e peritonite näo säo sinönimos, embora ambos os termos sejam utilizados clinicamente. Peritonite significa in-flamagäo do peritönio ou de parte dele. Teori-camente, pode incluir estados isolados de infla-maqäo peritoneal, tal qual peritonite quimica, vista ap6s perfuraqäo de rilcera p6ptica, ou Pan-creatite. Clinicamente, entretanto, inflamagäo näo-bacteriana do peritönio 6 muito dificil de ser diferenciada de infecqäo. A resposta inflamatoria inicial do peritönio 6 uniforme. Desta forma, o termo peritonite 6 preferido nosologi-camente e o termo infecqäo 6 usado quando os microrganismos infectantes podem modificar a resposta inflamat6ria. Este capitulo descreve a peritonite secundäria ou peritonite aguda supurativa, que resulta em uma peritonite supurativa difusa ou infecqäo intra-abdominal difusa. Tanto a Sociedade de Infecqöes Cinirgicas da Europa como a da Am6rica do Norte (SIS) concordam em excluir da definiqäo de infecqäo abdominal os pri-meiros estägios de perfuraqäo de rilcera pepti-387 Pub # 375 Bookchapter in Portugese about Intra-abdominal Infections
The open abdomen is used when the abdominal incision cannot be closed, when an early reoperation is necessary, to prevent an abdominal compartment syndrome, for the treatment of secondary or tertiary peritonitis, for the treatment of omphaloceles in neonates, and for the treatment of missing portions of the abdominal wall. The unique contribution of Oswaldo A. Borraez Gaona, MD, of Bogota, Colombia, was the application of a plastic bag over the open abdomen in injured patients. The bag allows for rapid access for a relaparotomy and covers and protects the viscera until edema and/or infection resolves.
Die Zahl der jährlich neu erscheinenden Publikationen zum Thema „Behandlung der diffusen Peritonitis“ steigt ständig. Immer wieder werden neue Antibiotika mit breiterem Spektrum und besserer Wirksamkeit für die Therapie der diffusen Peritonitis empfohlen. So fällt es dem Chirurgen immer schwerer, seine Wahl zu treffen. Gewisse Faktoren machen die diffuse Bauchfellentzündung hinsichtlich der Therapie und der Prognose zu einer schwer abwägbaren Erkrankung:
Unterschiedliche Ursachen der Peritonitis,
verschiedene Grade der Beteiligung von Keimen,
das Resistenzverhalten der Keime,
das Vorhandensein von Mischinfektionen,
unterschiedliche Zeiträume bis zum Beginn der Therapie,
die patienteneigene Abwehrlage.
Laparoscopy has come to dominate the management of endometriosis because it allows easy access to the dependent aspects of the pelvis, where endometriosis is most frequently found, and because it provides magnification, which allows subtle lesions to be detected. Pain management dominates fertility concerns during that portion of adolescence prior to the childbearing years and after the patient’s family is complete or the issue of childbearing has been resolved. During the latter period, the patient is more likely to want definitive therapy for endometriosis, whereas in the former, the patient wants to preserve reproductive potential and prevent progression of her endometriosis. In either case surgical intervention is usually required for pain relief.
Purpose:
Colorectal perforations are a serious condition associated with a high mortality. The aim of this study was to describe the clinical characteristics and identify predictors for the surgical mortality in adult patients with colorectal perforation, thereby achieving better outcomes.
Methods:
A retrospective study of adult patients diagnosed with colorectal perforation operated was performed. The clinical variables that might influence the surgical mortality were first analyzed, and the significant variables were then analyzed using a logistic regression model.
Results:
A total of 423 patients were identified, and the surgical mortality rate was 36.9 %. The most common etiology was diverticulitis (38.2 %). The highest etiology-specific mortality was for colorectal cancer (61.5 %) and ischemic proctocolitis (59.8 %). In a logistic analysis, the significant predictors for the surgical mortality were ≥3 comorbidities (p = 0.034), preoperation American Society of Anesthesiologists score ≥4 (p = 0.025), preoperative sepsis or septic shock (p < 0.001), colorectal cancer or ischemic proctocolitis (p = 0.035), reoperation (p = 0.041), and Hinchey classification grade IV (p = 0.024).
Conclusion:
We demonstrated that ≥3 comorbidities, a preoperation American Society of Anesthesiologists score ≥4, preoperative sepsis or septic shock, colorectal cancer or ischemic proctocolitis, reoperation, and Hinchey classification grade IV are predictors for the surgical mortality in the adult cases of colorectal perforation. These predictors should be taken into consideration to prevent surgical mortality and to reduce potentially unnecessary medical expenses.
Antisepsis: Vernichtung oder Beeinträchtigung pathogener Keime auf mechanischem, physikalischem oder chemischem Wege.
Approximately one million women in the United States are diagnosed with acute pelvic inflammatory disease (PID) annually.1 By the year 2000 the projected direct and indirect costs of PID and its sequelae will approach $9 billion. 2 Risk factors include a sexually active adolescence, multiple sexual partners (especially a new partner within the last 2 months), failure to use a barrier contraceptive method, use of an intrauterine contraceptive device (increased risk the first months after insertion), intrauterine manipulative procedures, immunosuppression, and frequent douching. Bacterial vaginosis has now also been implicated as a risk factor.
Peritonitis continues to be a complex illness that requires the coordinated efforts of timely surgical intervention, systemic antibiotic therapy, and supportive critical care management. Peritonitis and its accompanying sequela of intraabdominal abscess are frequently associated with activation of the systemic inflammatory response syndrome (SIRS) and is commonly associated with the development of the multiple organ dysfunction syndrome (MODS). Many authors consider peritonitis to be the prototypical infection associated with MODS, although there is general consensus at the present time that any infectious source could potentially activate SIRS and lead to MODS.1 The general perception is that effective intervention in the initial management of patients with peritonitis can avoid subsequent evolution of the multiple organ failure cascade. Some have reported reversal of organ failure with surgical intervention in intraabdominal infection.2–4 This chapter summarizes the significant aspects of the treatment of the complex constellation of diseases called peritonitis.
Das durch Kirschner 1926 standardisierte Behandlungskonzept der Peritonitis gilt auch heute noch als weitgehend akzeptierte Grundlage für die Therapie dieser schweren und mit hoher Letalität einhergehenden Erkrankung [48]. Durch bedeutende Fortschritte in der Intensivmedizin, welche die postoperative Beatmung, die kardiale und periphere Kreislaufsubstitution, die peridurale Analgesie, die Hämodialyse und die breitspektrale Antibiotikatherapie umfaßt, sowie durch neue adjuvante chirurgische Maßnahmen wie die intraoperative Spülung mit Antiseptika, die geschlossene postoperative Dauerspülung [59, 64], die offene kontinuierliche Dauerspülung [66] und die offene Spülung mit programmierter Relaparotomie oder bei primär offengelassenem Abdomen, wurde dieses Grundkonzept in der Behandlung der Peritonitis in den letzten Jahren erweitert. Das therapeutische Ziel der chirurgischen Methoden ist in erster Linie die rasche und anhaltende Säuberung der Bauchhöhle von bakterien-, toxin- und fremdstoffreichem Inhalt. Die prognostische Bedeutung der Quantität von lokal verbleibenden Bakterien für die Letalität und Morbidität der Peritonitispatienten wurde immer wieder unterschiedlich bewertet. Experimentelle und klinische Studien haben zeigen können [4, 19, 21, 44, 50], daß die Eliminierung von Bakterien im eitrigen Peritonealexsudat durch pharmakologische oder manuelle Maßnahmen die Überlebensrate verbessert. Kochsalzlösungen, antibiotische Lösungen und zunehmend häufiger antiseptische Lösungen wurden zu diesem Zwecke eingesetzt.
A pelvic abscess is a localized collection of a large number of organisms, inflammatory exudate, and necrotic debris often separated from surrounding tissue by a fibrous pseudocapsule. A tubo-ovarian complex is a tubo-ovarian abscess (TOA) that lacks a classic pseudocapsule and is made up of the agglutination of tube and ovary to adjacent pelvic and abdominal structures following reaction to purulent exudate from the inflamed tube. A true pelvic abscess with a classic pseudocapsule can occur in the ovary and after rupture of a diverticulum. Whatever the terminology, purulent material exists in a collection within the pelvis.
In 1988 there were 281,982 hospitalizations during which adhesiolysis was performed, accounting for 948,727 days of inpatient care. Of these admissions, 54,100 were precipitated by adhesions. These hospitalizations were responsible for an estimated $1,179.9 million in expenditures.1 Nor do these figures take into account outpatient surgical procedures for adhesiolysis.
Diffuse peritonitis remains a surgical disease where history and physical diagnosis are sufficient for the critical decision of whether to proceed with laparotomy. For patients with peritonitis due to a perforated viscus, intra-operative decisions regarding such items as extent of resection, anastamosis vs ostomy, and fascial closure or open management determine morbidity and mortality.
Inflammatory bowel disease (IBD) is a common, serious gastrointestinal disorder that frequently afflicts women of childbearing age. Thus there is concern about the effects of the disease on fertility and pregnancy and, conversely, about the effects of pregnancy on the course of the disease. It is incumbent on the obstetrician to recognize this disorder and to be prepared, with the help of appropriate consultants, to provide the pregnant IBD patient with counseling and any medical and surgical treatment that may be required.
A pelvic abscess is a localized collection of many organisms, inflammatory exudate, and necrotic debris often separated from surrounding tissue by a fibrous pseudocapsule. A tubo-ovarian complex is a tubo-ovarian abscess (TOA) that lacks a classic pseudocapsule and is made up of the agglutination of tube and ovary to adjacent pelvic and abdominal structures after reaction to purulent exudate from the inflamed tube. A true pelvic abscess with a classic pseudocapsule can occur in the ovary and after rupture of a diverticulum. Whatever the terminology, purulent material exists in a collection within the pelvis.
Of the four pathologic processes—inflammation, hemorrhage, torsion, and colic—responsible for an acute abdomen, inflammation is by far the most common. Specific conditions such as acute appendicitis, acute cholecystitis, and perforated duodenal ulcer are associated with peritoneal inflammation, the extent and severity of which varies. Regardless of the underlying conditions responsible for peritonitis, the features of peritoneal irritation remain the same: pain, tenderness, rebound tenderness, and muscle spasm. Identifying the area of peritoneal irritation provides a clue to the probable structure involved in the inflammatory process. For example, inflammation resulting from causes as diverse as acute appendicitis, cecal diverticulitis, perforation of cecal carcinoma, Meckel’s diverticulitis, and acute regional enteritis of the terminal ileum is associated with pain, tenderness, rebound tenderness, and muscle spasm in the right lower quadrant. Signs of inflammation in the right upper quadrant should lead one to suspect that the problem arises from the gallbladder, liver, duodenum, head of the pancreas, hepatic flexure of the colon, or right kidney—structures normally present in that area.
Das klinische Syndrom „Akutes Abdomen“ umfaßt alle akut einsetzenden, zunehmend schweren Erkrankungen der Bauchhöhle, die ohne entsprechende Therapie zu einer vitalen Gefährdung des Patienten führen. Ätiologisch handelt es sich um eine der folgenden Krankheitserscheinungen, die im fortgeschrittenen, unbehandelten Stadium nicht selten kombiniert vorliegen:
Perforation von Hohlorganen
Organinfektion bzw. intraabdomineller Abszeß
Peritonitis, regional oder diffus
Darmverschluß, mechanisch oder paralytisch
intraperitoneale Blutungen
Durchblutungsstörungen, Torsion innerer Organe.
Enterolysis is indicated in acute cases of complete small bowel obstruction.
Abdominal surgical wound infections cause significant morbidity and expenses and double the length of postoperative hospital stays. The role of antimicrobial therapy in the outcome of infection of the abdominal cavity is difficult to assess. This is primarily because of the often dramatic response to surgical drainage when there is localized infection. Nevertheless, appropriate antimicrobial therapy has been shown to reduce the mortality significantly [11,72]. Antimicrobial drugs are expected to control bacteremia and to reduce suppurative complications if given early. Once suppuration has occurred it may be difficult to cure infection if antimicrobial drugs are used without drainage. Cultures of peritoneal fluid or abscess pus often yield the responsible organisms. However, antimicrobial therapy should be started immediately, and this means that it has to be initiated before the completion of in vitro antimicrobial sensitivity testing of any specific
Die Enterolyse bzw. Adhäsiolyse ist in akuten Fällen von vollständig ausgeprägtem Dünndarmileus angezeigt.
Drainagen ermöglichen die Entfernung von Pus, Blut, Serum, Lymphe, Galle, Pankreassaft oder Intestinalinhalt aus dem Körper. Sie formen einen abgegrenzten Passageweg von der Ansammlung des Eiters oder anderen Ansammlungen nach außen. Der Drainageweg muß lange genug und sicher offengehalten werden, damit eine vollständige Entleerung der Ansammlung gewährleistet ist.
The indications for an operative procedure have remained much the same for a number of years but there are now several new indications for considering an operation particularly for considering a reoperation. The usual indications for an elective operation must consider the risks versus the benefits. For emergency operations the consideration must be whether or not the procedure is life-saving and again risks versus benefits related to the procedure. What is the risk for the patient what are the potential benefits do they balance out as a win-win situation for the patient his or her family?
Treatment of infertility is glamorous gynecology. Treatment of pelvic inflammatory disease (PID), the most important preventable cause of infertility, afflicting an estimated 1 million American women yearly, is not glamorous gynecology . . . [and] must be one of the most neglected areas of American medicine.1
Background: A systematic and effective treatment of peritonitis could only be achieved in the context of the development of modern medicine. Methods: A systematic historic review of the decisive developments in the field is given. Results: The prerequisite for the surgical treatment of peritonits and for abdominal surgery in general was the foundation of experimental physiology and medicine by Francois Magendy and Claude Bernard, the development of cellular pathology by Virchow, the advent of the germ theory connected with the names of Pasteur and Koch, the introduction of antisepsis and asepsis by Lister and Semmelweis, the introduction of the systemic physical examination and the correlation between clinical and pathological findings by the Paris clinical school, and the introduction of general anesthesia by Wells and Morton. With this background the knowledge of pathophysiology and bacteriology of peritonitis as well as the surgical treatment of the disease developed rapidly around the turn of the century. The principles of the latter were summarized by Kirschner in 1926. The most important are mandatory surgical exploration, secure elimination of the focus of infection, and an effective peritoneal toilet. Conclusions: Advances in the treatment of peritonitis during the last five decades were due to the advent of antibiotics and intensive care medicine, the better understanding of the synergism of bacteria in the peritoneal cavity, the systemic inflammatory response due to intraperitoneal infections, and the development of scoring systems and their application to patients with peritonitis.
• The degree of peritoneal contamination correlates with the severity of infection and outcome. • The host responds to peritoneal infection by absorbing pathogens into the bloodstream and by mounting a local peritoneal inflammatory reaction; both responses kill bacteria but affect the host adversely. • The goal of peritoneal toilet is to remove mechanically as many contaminants as possible to reduce the severity of infection and limit adverse host responses. • Surgically aggressive forms of peritoneal debridement may remove more contaminating material, but at the cost of increased resources and adverse effects. Their value is controversial.
This chapter reviews types and usual applications of surgical drains. The indications for “routine” drainage are under continuous review, and with the availability of percutaneous drainage techniques, fewer and fewer drains are used in surgery. Nonetheless, it is important to know what options are available when surgical drainage is required.
Secondary bacterial peritonitis arises as a consequence of injury to an intraabdominal viscus from intrinsic disease or extrinsic trauma. The resulting infection is typically polymicrobial, with aerobic Gram negatives such as Escherichia coli and anaerobes such as Bacteroides fragilis playing an important role in its evolution. The first priority in management is resuscitation and hemodynamic stabilization of the patient. Definitive therapy is primarily surgical, through the drainage of localized collections or abscesses, the debridement of necrotic tissue and other adjuvants, and the definitive management of loci of ongoing microbial contamination. Antibiotics provide adjunctive therapy; a variety of regimens have shown clinical efficacy. Prognosis is determined primarily by the severity of the resultant physiologic derangement and the adequacy of surgical therapy; treatment failure is reflected in progressive organ dysfunction.
Interval appendectomy (IA) is a controversial subject, with little consensus on its use in patients undergoing treatment for malignancy. We sought to determine the frequency of recurrent appendicitis in cancer patients managed nonoperatively (NOM) during index hospitalization (IHA) for acute appendicitis (AA). Clinical presentation, cancer treatment, and follow-up were collected from electronic medical records of patients with CT scan-confirmed AA treated at a single institution between August 1999 and August 2009. Seventy-two of 109 AA patients underwent appendectomy during IHA; 34 of these 109 were NOM during IHA. Median index length of NOM patients' stay was six days (0-55), median age was 59 (18-80) years. Indications for NOM were presence of abscess or phlegmon (14), mild symptoms (13), high surgical risk (3), end-stage cancer (3), and patient declining surgery (1). Eight NOM patients underwent percutaneous drainage of abdominal abscess (median total duration of intravenous + oral antibiotics = 12 days [0-55]). There were six deaths (1 IHA, 5 NOM): four sepsis and two cancer progression. At a median of 19-month follow-up (range 1-103), four NOM patients surviving IHA had recurrent AA (11.7%) at two (n = 2) and three months (n = 2) after the first episode. Overall, six had IA (17.6%) one to seven months post AA; 25 remained asymptomatic, without IA. In conclusion, among NOM patients at a cancer center at IHA for AA, recurrent AA was early (<4 months) but uncommon. IA should be offered to those with recurrent symptoms, but appears to have a very limited role after several months of asymptomatic follow-up.
An open, randomised study was carried out to compare the efficacy and tolerability of pefloxacin plus metronidazole with gentamicin plus metronidazole in the coadjuvant treatment of generalised purulent peritonitis. The study was conducted on 100 patients of both sexes aged 18 to 93 years who had a diagnosis of diffuse purulent peritoneal infection. The antibiotics were administered up to a period of 4 days after all clinical or microbiological signs of infection had disappeared, with total treatment not exceeding 4 weeks. At the end of treatment, 6 of the 48 patients (12.5%) receiving pefloxacin plus metronidazole (PM group) and 21 of the 52 patients (40.4%) receiving gentamicin plus metronidazole (GM group) had localised infections. When the clinical efficacy of treatment was evaluated 15 days after discharge from the hospital, 39 patients in the PM group were found to be cured (81.2%), and there were 3 deaths (6.25%). In the GM group, 29 patients were found to be cured (55.7%), and there were 8 deaths (15.4%). Thus, the cure rate was significantly higher in the PM group than in the GM group (χ2 = 6.323; p < 0.05). We conclude that both antibiotic regimens utilised were effective as coadjuvants in the surgical treatment of diffuse purulent peritonitis, although the pefloxacin/metronidazole combination led to a better cure rate.
Septic peritonitis is caused by an intra-abdominal lesion. It is one of the most common causes of death in the postoperative period following abdominal surgery. Together with neoplastic diseases and cerebrovascular accidents, septic peritonitis is one of the three most common causes of prolonged hospitalization. Treatment includes examination of the abdominal cavity, elimination of the cause of the infection, thorough cleansing of the abdominal cavity, and appropriate use of antibiotics. Cefotaxime and metronidazole are a good combination for eradicating polybacterial infections that include anaerobic organisms. The use of parenteral feeding together with antibiotic therapy can improve the prognosis for many patients with septic peritonitis.
Despite the progress made in the intensive treatment of operated patients, the introduction of new antimicrobials and the betterment of surgical techniques, mortality rates from diffuse peritonitis are still alarmingly elevated. A better understanding of physiopathological phenomena which accompany an infective peritoneal process and knowledge of the chemical inflammatory mediators have not yet led to a substantial improvement in the survival rate of these patients. The diagnosis is mainly based on a clinical assessment aided by supplementary methods and predictive indexes. Early surgical managment in any form is a basic foundation for a successful treatment backed up by an effective general support. The treatment fails due to a persistent peritoneal infection and dehiscence in intestinal sutures. The first causes of death are fistulae, multiple organ failure and high digestive bleeding.
Background:
No conclusive results on the efficacy and timing of open abdomen (OA) are available, particularly in the setting of intra-abdominal infections. We analyzed outcomes and risk factors retrospectively in a large series of patients managed with an OA during the past 20 y in an effort to clarify this issue.
Methods:
We reviewed the records of 133 patients who underwent treatment with an OA, considering factors related to patient, disease, medical management, and surgical treatment. The end points of the bi-variable analysis were 1-y mortality, calculated from the time of an initial OA procedure, and definitive fascial closure.
Results:
Most patients (112/133) managed with an OA had one of several types of peritonitis. Many patients had severe clinical conditions (mean Acute Physiology and Chronic Health Evaluation [APACHE] II score was almost 9 points for the study population). With regard to surgical management, the mean (+SD) number of abdominal revisions was 5.9+9.3 during a mean duration of treatment with an OA of 14.3+11.6 d. The overall mortality in the study was 26% (35/133). Bi-variable analysis revealed factors associated with overall mortality to be age, renal and respiratory co-morbidities, edema on an initial chest radiograph, blood pressure, blood glucose and creatinine concentrations; and APACHE II score. The rate of definitive fascial closure was 75% (100/133). Factors associated negatively with fascial closure were respiratory co-morbidity, edema on a first chest radiograph, post-operative mesenteric ischemia as an indication for OA, blood glucose and creatinine concentrations, and duration of an OA.
Conclusions:
Patients' pre-operative clinical status influences strongly their response to surgical treatment. The management of OA does not affect adversely the survival of patients with intra-abdominal infections, but factors related to the management of OA (duration of OA) seem to affect the possibility of definitive fascial closure.
Introduction
Perforating lesions of the colon affect a heterogeneous group of patients, often elderly, and usually present as abdominal emergencies with high morbidity and mortality. The aims of this study were to assess the prognostic value of specific factors in patients with left colonic peritonitis and to evaluate the utility of a scoring method that defines groups of patients with different mortality risks.
Study design
Between January 1994 and December 1999, 156 patients (77 men and 79 women), with a mean (SD) age of 63.2 years (± 15.5 years) (range: 22 to 87 years), underwent emergency surgery for distal colonic perforation. Resection and primary anastomosis of the colon was the first choice operation and was performed in 69 patients (47.4%), subtotal colectomy was performed in 9 and colostomy in 4 patients.We analyzed specific variables for their possible relationship to death including gender, age, American Society of Anesthesiologists (ASA) score, immunocompromised status, etiology and degree of peritonitis, preoperative organ failure, time (hours) between hospital admission and surgical intervention, and degree of temperature elevation (38 °C). Univariate relationships between predictors and outcomes (death) were analyzed using logistic regression. Multivariate logistic regression analysis was used to assess the prognostic value of combinations of the variables. Significant factors identified in univariate and multivariate logistic regression analyses were used to define a left colonic peritonitis severity score (PSS). Factors that were significant only in the univariate analysis scored 2 points if present and 1 if not. Variables that were significant in the multivariate analysis were scored from 1 to 3 points. Patients were randomly split into two groups, one to calculate the scoring system and the other to validate it.
Results
The overall postoperative mortality rate was 22.4%. Septic-related mortality was observed in 24 patients (15.4%). Age, peritonitis grade, ASA score, immunocompromised status, and ischemic colitis were significant for postoperative death in the univariate analysis. However, only ASA score and preoperative organ failure were significantly associated with postoperative mortality in the multivariate logistic regression analysis. The PSS, as defined in this study, was related to patient outcome. The mortality rate increased from 0%, when the PSS was 6 points (minimum possible score = 5) to 100% in patients with a PSS of 13 (maximum possible score = 14).
Conclusions
Left colonic peritonitis continues to have persistently high mortality in patients with septic complications. ASA score and preoperative organ failure were the only factors that were significantly associated with mortality in the multivariate analysis. The PSS classification may help to uniformly define the mortality risk of patients with distal large bowel peritonitis, and may help to increase the comparability of studies carried out at different centers. Key words: Left colonic peritonitis. Prognostic factors for mortality. New scoring system.
Zusammenfassung Die sekundäre Peritonitis ist trotz Verbesserungen in antibiotischer Therapie, Intensivmanagement und chirurgischen Verfahren mit einer erheblichen Morbidität und einer anhaltend hohen Mortalität verbunden. Die bezüglich der chirurgischen Vorgehensweise bei sekundärer Peritonitis verfügbare Literatur wurde aus Pub-Med (1966 bis Januar 2005) sowie aus einigen ausgewählten Referenzen der erfassten Literatur recherchiert. Definitionen, Pathophysiologie, die Klassifikation der sekundären Peritonitis und die wissenschaftlichen Grundprinzipien für das chirurgische Vorgehen bei sekundärer Peritonitis werden diskutiert. Ebenso werden historische Entwicklungen sowie die wissenschaftliche Grundlage heute gültiger Relaparotomiestrategien bei sekundärer Peritonitis evaluiert: die programmierte Relaparotomie und die Relaparotomie „on demand“. Es werden Kriterien für die Relaparotomie nach der initialen Laparotomie und mögliche zukünftige Forschungsfelder hinsichtlich der Reduktion sowohl der Morbidität als auch der Mortalität diskutiert. Die Behandlung von Patienten mit sekundärer Peritonitis entwickelt sich von einer chirurgischen Disziplin zu einer multidisziplinären Aufgabe, welche sowohl Chirurgen, Intensivmediziner als auch Radiologen und Mikrobiologen gleichermaßen einbezieht. Die Forschung muss auf neue Bereiche ausgeweitet werden, um Morbidität und Mortalität weiter senken zu können.
The efficacy of topical 10 and 1.5% povidone-iodine was assessed in a rat fecal peritonitis model. Both solutions were bactericidal in vitro. An LD90 preparation of fecal peritonitis in the rat was then assessed and rats were assigned to control or four treatment groups consisting of lavage with saline, 10% povidone-iodine (2.5 ml/kg), povidone-iodine plus saline (600 ml/kg), or 1% cephalothin (600 ml/kg). Twenty-four-hour mortality rates were recorded. Quantitative peritoneal cultures were obtained before and 3 and 6 hr after lavage. Lavage was effective only with 1.5% povidone-iodine or when cephalothin was added. Each of these lavage solutions significantly reduced mortality (P < 0.05). Delayed intravenous cephalothin (200 mg/kg) reduced mortality significantly following 10 or 1.5% povidone-iodine. Failure of povidone irrigation is due to uncontrolled infection rather than to drug toxicity.
Residual abscess following peritonitis still remains a real problem at present. The worse the appendicular pathology at the time of operation, the more likely is such an abscess. This experiment has shown that postoperative intraperitoneal lavage may be a way of overcoming this problem The objections to lavage have been discussed, and it would seem that the benefits which accrue in the way of lessened morbidity and mortality far outweigh any disadvantages.
Invasive infection of major surgical wounds continues as a serious problem. In spite of good surgical technics, proper wound draping, irrigation, local and systemic antibiotics, etc, the incidence of wound infections remains unacceptably high, in an attempt to solve this problem, a technic was developed wherein primary closure of the wound is delayed for five to seven days after the initial surgery. This method has been applied to 300 consecutive wound-infection-prone patients, and there has been no incidence of invasive infection in any of these patients. The method does not increase hospitalization time and patient acceptance is excellent. There has been no associated morbidity with the technic and wound healing is not delayed. The cosmetic result of delayed primary wound closure is no different from that obtained from primary closure.