Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study)

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association between postoperative fluid balance and mortality and morbidity in critically ill patients with complicated intra-abdominal infections: a retrospective study

Background

Postoperative fluid overload may increase the risk of developing pulmonary complications and other adverse outcomes. We evaluated the impact of excessive fluid administration on postoperative outcomes in critically ill patients.

Methods

We reviewed the medical records of 320 patients admitted to intensive care unit (ICU) after emergency abdominal surgery for complicated intra-abdominal infection (cIAI) between January 2013 and December 2018. The fluid balance data of the patients were reviewed for a maximum of 7 days. The patients were grouped based on average daily fluid balance with a cutoff value of 20 ml/kg/day. Propensity score matching was performed to reduce the underlying differences between the groups.

Results

Patients with an average daily fluid balance of ≥20 ml/kg/day were associated with higher rates of 30-day mortality (11.8% vs. 2.4%; P=0.036) than those with lower fluid balance (<20 ml/kg/day). Kaplan-Meier survival curves for 30-day mortality in these groups also showed a better survival rate in the lower fluid balance group with a statistical significance (P=0.020). The percentage of patients who developed pulmonary consolidation during ICU stay (47.1% vs. 24.7%; P=0.004) was higher in the fluid-overloaded group. Percentages of newly developed pleural effusion (61.2% vs. 57.7%; P=0.755), reintubation (18.8% vs. 10.6%; P=0.194), and infectious complications (55.3% vs. 49.4%; P=0.539) showed no significant differences between the two groups.

Conclusions

Postoperative fluid overload in patients who underwent emergency surgery for cIAI was associated with higher 30-day mortality and more frequent occurrence of pulmonary consolidation. Postoperative fluid balance should be adjusted carefully to avoid adverse clinical outcomes.

TNM: a simple classification system for complicated intra-abdominal sepsis after acute appendicitis

BACKGROUND

Delayed diagnosis in case of acute appendicitis (AA) could lead to complicated intra-abdominal sepsis (IAS). Grading systems are not commonly employed in the clinical practice, because they are too complicated or too specific. Therefore, we suggest grading the severity of complicated IAS after AA with a simple system: TNM, an acronym borrowed by cancer staging where T indicates temperature, N neutrophils, and M multiple organ failure (MOF). This prospective observational study evaluates the predictive value of the TNM score on mortality of patients with complicated IAS after AA.

METHODS

Sixty-eight patients with complicated IAS after AA were treated. Three classes of attributes were chosen: temperature (T), neutrophils count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3) and M (M0-M2), these were grouped in stages (0-IV). Variables analyzed for their possible relation to death were age, sex, temperature, neutrophils count, preoperative organ failure, immunocompromised status, stage (0-IV). Odds ratios were calculated in a univariate and multivariate analysis.

RESULTS

TNM staging was: one patient stage 0; 16 patients at stage I; 26 patients at stage II; 16 patients at stage III; nine patients at stage IV. Death occurred in 15 patients (22%). Neutrophil count, preoperative organ failure, immunocompromised status, stages III-IV were potential predictors of postoperative death in univariate analysis; only stage IV was significant independent predictor of postoperative mortality in multivariate analysis.

CONCLUSIONS

TNM classification is very easy to use; it helps to define the mortality risk and is useful to objectively compare patients with sepsis.

Effectiveness of intraoperative peritoneal lavage (IOPL) with saline in patient with intra-abdominal infections: a systematic review and meta-analysis protocol

INTRODUCTION

Intra-abdominal infections (IAIs) are common surgical emergencies and cause a significant worldwide burden per year. Since the concept of intraoperative peritoneal lavage (IOPL) was proposed in 1905, it has been widely used in the surgery practice. However, the effectiveness of IOPL in patients with IAIs has always been controversial. Our objective is to identify whether it is beneficial to flush the abdominal cavity with saline in IAIs surgery through a comprehensive systematic review and meta-analysis.

METHODS AND ANALYSIS

This protocol is reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Electronic databases (including the Cochrane library, MEDLINE, EMBASE, Web of Science, etc) and clinical trial registry platforms will be searched from inception to 8 September 2019. Randomised controlled trials, quasi-randomised clinical trials and cohort studies comparing IOPL and suction alone in IAIs will be included. The primary outcomes are mortality and abscess rate. Two independent reviewers will screen literature, collect data and assess risk of bias of included studies. Discussion or a third reviewer will be referred for any disagreements. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to assess the quality of the evidence. We will perform meta-analysis using random-effects model. Subgroup analysis, sensitivity analysis and publication bias will be conducted if data are enough.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review and meta-analysis protocol. Results of this study will be published in a peer-reviewed journal, presented at relevant conferences and disseminated to local and international policy makers.

PROSPERO REGISTRATION NUMBER

CRD42019145109.

Serum level of visfatin can reflect the severity of inflammation in patients with acute cholecystitis

Purpose

Visfatin is a key cytokine released from the pe ripheral blood mononuclear cells (PBMCs) as well as adipose tissue, and it is involved in immune response as well as inflammation. In this study, we investigated whether the serum visfatin level could be a prognostic factor for predicting the severity of inflammation in patients with acute cholecystitis.

Methods

We examined the blood samples and gallbladder specimens from patients who underwent laparoscopic cholecystectomy for either acute (n = 18) or chronic cholecystitis (n = 18). We determined the visfatin levels of these samples using various procedures such as real-time polymerase chain reaction, enzyme-linked immunosorbent assay, western blotting, and immunohistochemistry.

Results

The patients with acute cholecystitis exhibited higher mRNA expression of visfatin in PBMCs, higher serum levels of visfatin, and increased protein expression of visfatin in the gallbladder specimens than in patients with chronic cholecystitis. In the in vitro model of acute cholecystitis, the mRNA expression of visfatin showed the fastest increase among the other pro-inflammatory mediators studied, including interleukin (IL)-10, tumor necrosis factor-α, IL-6, intracellular adhesion molecule-1, and ascular cell adhesion molecule-1. Inhibition of visfatin using siRNA abrogated the inhibitory effects of lipopolysaccharide (LPS) on the expression of ABCG1 in GBECs, suggesting that visfatin is significantly involved in the LPS-driven suppression of ABCG1.

Conclusion

Taken together, we concluded that visfatin is a pro-inflammatory mediators that is upregulated during acute cholecystitis and is expected to be increased within a short time after inflammation. Therefore, measuring the serum level of visfatin would be helpful in predicting the inflammatory severity in the patients with acute cholecystitis.

[Laparoscopic surgery for advanced appendicular peritonitis]

OBJECTIVE

To evaluate the results of laparoscopic treatment of patients with advanced appendicular peritonitis.

MATERIAL AND METHODS

There were 271 patients with acute appendicitis complicated by peritonitis. The main group consisted of patients who underwent laparoscopic appendectomy after diagnostic laparoscopy (n=231), the control group - diagnostic laparoscopy followed by conversion to median laparotomy (n=36). Four extremely ill patients were operated through laparotomy and excluded from the further analysis.

RESULTS

Diagnostic laparoscopy was performed in 267 patients with advanced appendicular peritonitis. Laparoscopic appendectomy, debridement and abdominal drainage were performed in 231 (85.2%) patients. Mean age of patients was 44±18.5 years, duration of disease - 36.2±20.3 hours. Diffuse peritonitis was diagnosed in 219 (82%) patients, advanced peritonitis - in 48 (16.5%) cases. Incidence of conversion was 13.5%. Mortality was absent in both groups. Postoperative morbidity was significantly higher in the conversion group (72.2% vs. 29.4%, p<0.0001).

CONCLUSION

Laparoscopic interventions for common appendicular peritonitis are feasible, effective and reduce postoperative morbidity.

Mucus-filled lesion of a distal viable remnant tip of an appendix that developed 23 years after appendectomy

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Appendectomy is currently the most common surgical operation worldwide.

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Post-appendectomy mucus-filled lesions are a rare clinical phenomenon.

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It is vital to perform appendectomy completely, without leaving appendiceal tissue.

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This prevents late complication of mucus-filled lesion formation.

Introduction

Post-appendectomy mucus-filled lesions, arising from appendiceal remnant tissue, are an exclusively rare clinical entity. We report a rare case of a mucus-filled lesion rising from a distal viable remnant appendiceal tip as a late complication of appendectomy.

Presentation of case

A 48-year-old man presented with a 2-week history of right buttock and right lower quadrant abdominal pain. He had previously undergone appendectomy 23 years ago. Radiological examination showed a cystic lesion lateral to the colon with a prominent tubular structure. According to the past operative note, the appendiceal tip was lost accidentally. Surgical resection was performed. Pathologic examination revealed a mucus-filled lesion lateral to the cecum, with no communication between them. There was no evidence of malignancy. The prominent structure had muscular layer, suggestive of distal appendiceal remnant.

Discussion

Surgical resection of appendiceal mucus-filled lesion is recommended, because there are no reliable criteria to exclude malignant lesions. Although appendiceal mucus-filled lesion is rare, it is extremely rare in patients with previous appendectomy. In our case, the mucinous material secreted from the remnant appendix might be enclosed by the surrounding tissue.

Conclusion

In patient with previous appendectomy who show a cystic mass close to the cecum, the possibility of lesion derived from the appendiceal stump or distal appendiceal remnant should be considered. In such cases, it is important to review the medical records for a definitive diagnosis. Complete appendectomy, without leaving appendiceal tissue, remains mandatory to prevent the development of late complications of mucus-filled lesions.

Risk factors for intra-abdominal abscess following laparoscopic appendectomy for acute appendicitis: a retrospective cohort study on 2076 patients

BACKGROUND

Intra-abdominal abscesses (IAA) may develop after laparoscopic appendectomies (LA) for acute appendicitis. The identification of risk factors for postoperative IAA could lead to a decrease in the readmission rate and surgery redoes after LA for acute appendicitis.

MATERIALS AND METHODS

The present study retrospectively analyzed patients undergone LA for acute appendicitis during the period 2001-2017. Clinical, intraoperative, and postoperative outcomes were described. Comparison between groups was made via univariate and multivariate analyses.

RESULTS

The charts of 2076 patients undergone LA were reviewed. Thirty-seven patients (1.8%) developed a postoperative IAA. Male gender (p < 0.05), ASA score ≥ 2 (p < 0.05), a gangrenous or perforated appendicitis (p < 0.0001), abscess or pelvic peritonitis (p < 0.0001), clipping the mesoappendix (p < 0.0001), appendix division by mechanical stapler (p < 0.05), prolonged antibiotic therapy (p < 0.05), and piperacillin/tazocin regimen (p < 0.0001) were significantly more frequent in the group of patients with IAA. In terms of multivariate analysis, only pelvic peritonitis (p = 0.010), perforated appendicitis (p = 0.0002), and clipping the mesoappendix (p = 0.0002) were independent predictive factors for postoperative IAA.

CONCLUSION

Patients with peritonitis or a perforated appendicitis, and those who had their mesoappendix clipped showed a higher likelihood of developing an IAA. At risk patients should be provided with careful follow-up for the early detection and management of this complication.

The impact of age and comorbidity on the postoperative outcomes after emergency surgical management of complicated intra-abdominal infections

Age-adjusted Charlson Comorbidity Index (a-CCI) score has been used to weight comorbid conditions in predicting adverse outcomes. A retrospective cohort study on adult patients diagnosed with complicated intra-abdominal infections (cIAI) requiring emergency surgery was conducted in order to elucidate the role of age and comorbidity in this scenario. Two main outcomes were evaluated: 90-day severe postoperative complications (grade ≥ 3 of Dindo-Clavien Classification), and 90-day all-cause mortality. 358 patients were analyzed. a-CCI score for each patient was calculated and then divided in two comorbid categories whether they were ≤ or > to percentile 75 ( = 4): Grade-A (0-4) and Grade-B ( ≥ 5). Univariate and multivariate regression analyses were performed, and the predictive validity of the models was evaluated by the area under the receiver operating characteristics (AUROC) curve. Independent predictors of 90-day severe postoperative complications were Charlson Grade-B (Odds Ratio [OR] = 3.49, 95% confidence interval [95%CI]: 1.86-6.52; p < 0.0001), healthcare-related infections (OR = 7.84, 95%CI: 3.99-15.39; p < 0.0001), diffuse peritonitis (OR = 2.64, 95%CI: 1.45-4.80; p < 0.01), and delay of surgery > 24 hours (OR = 2.28, 95%CI: 1.18-4.68; p < 0.02). The AUROC was 0.815 (95%CI: 0.758-0.872). Independent predictors of 90-day mortality were Charlson Grade-B (OR = 8.30, 95%CI: 3.58-19.21; p < 0.0001), healthcare-related infections (OR = 6.38, 95%CI: 2.72-14.95; p < 0.0001), sepsis status (OR = 3.98, 95%CI: 1.04-15.21; p < 0.04) and diffuse peritonitis (OR = 3.06, 95%CI: 1.29-7.27; p < 0.01). The AUROC for mortality was 0.887 (95%CI: 0.83-0.93). Post-hoc sensitivity analyses confirmed that the degree of comorbidity, estimated by using an age-adjusted score, has a critical impact on the postoperative course following emergency surgery for cIAI. Early assessment and management of patient's comorbidity is mandatory at emergency setting.

[Prediction and differentiated approach in the treatment of patients with secondary peritonitis and abdominal sepsis]

OBJECTIVE

To identify the most important high risk criteria for predicting course of disease, as well as optimal preoperative preparation and surgical strategy in patients with secondary peritonitis.

MATERIAL AND METHODS

A prospective study enrolled 43 patients with diffuse secondary peritonitis.

RESULTS

Significant predictors were Charlson's comorbidity index (p=0.001) and SOFA score of organ dysfunction within 3 days after admission. Rapid regression of organ dysfunction (SOFA1 - p=0.0001, SOFA2 - p=0.012, SOFA3 - p=0.017) and reduced time of examination and preoperative preparation (threshold value - 520 min after admission) are predictors of favorable outcome in patients with diffuse secondary peritonitis. There was no reliable correlation between the treatment outcome and preoperative preparation (infusion volume p=0.23, duration p=0.37, absence/presence of antibacterial therapy p=0.26). Elimination or control of infection is the fundamental principle of the management of patients with diffuse secondary peritonitis.

Evaluation of Amikacin Pharmacokinetics in Critically Ill Patients with Intra-abdominal Sepsis

Purpose: Although the current widespread use of amikacin is in intra-abdominal sepsis treatment, its pharmacokinetic changes in the present setting are not yet well known. This study was aimed to evaluate the amikacin pharmacokinetic profile in critically ill patients with intraabdominal sepsis compared to pneumosepsis.

Methods: Adult septic patients received amikacin therapy were studied. Patients with intraabdominal sepsis were enrolled in group 1 (n=16), and patients with pneumosepsis were enrolled in group 2 (n=13). The amikacin serum concentrations were evaluated in the first, second, fourth and sixth hours after initiating 30-minute infusion. The pharmacokinetic parameters were calculated for each patient.

Results: There was no significant difference in the volume of distribution between the two groups (0.33±0.08 vs. 0.28±0.10 L/kg, P=0.193). The amikacin clearance was significantly lower in group 1 compared to group 2 (58.5±21.7 vs. 83.9±37.0 mL/min, P=0.029). There was no significant correlation between amikacin clearance and creatinine clearance estimated by Cockcroft-Gault formula in all patients (P=0.206). The half-life was significantly longer in group 1 compared to group 2 (5.3±2.8 vs. 3.4±3.2 hours, P=0.015).

Conclusion: Pathophysiologic changes following intra-abdominal sepsis can affect amikacin pharmacokinetics behavior. The clearance and half-life may change, but the alteration of the volume of distribution is not significantly different in comparison with pneumosepsis. Further studies are required to evaluate the pharmacokinetic variables of amikacin in critically ill patients with intra-abdominal sepsis.

Clinical implications of multidrug-resistant microorganisms and fungi isolated from patients with intra-abdominal infections in the Republic of Korea: a multicenter study

The purpose of this study was to evaluate the clinical significance of fungi and multidrug-resistant organisms (MDROs) isolated from patients with intra-abdominal infections (IAIs). This multicenter study included consecutive patients admitted for microbiologically proven IAIs at 6 university-affiliated hospitals in South Korea between 2016 and 2018. A total of 1571 patients were enrolled. Multivariable logistic regression analysis revealed that the isolation of MDROs, isolation of Candida spp., underlying renal diseases, Charlson comorbidity score ≥ 3, septic shock, failure to receive a required surgery or invasive intervention, secondary bacteremia due to IAIs, and lower body mass index were found to be independent predictors for 28-day mortality. However, the isolation of Enterococcus spp. was not identified as a significant risk factor. MDROs and Candida spp. were found in 42 (2.7%) and 395 (25.1%), patients respectively. The isolation of MDROs or Candida spp. was a surrogate marker of 28-day mortality.

Post-operative abdominal infections: epidemiology, operational definitions, and outcomes

Postoperative abdominal infections are an important and heterogeneous health challenge in intensive care units (ICU) and encompass postoperative infectious processes developing within the abdominal cavity that may be caused by either bacterial or fungal pathogens. In this narrative review, we discuss postoperative bacterial and fungal abdominal infections, covering also multidrug-resistant (MDR) pathogens. We also cover clinically preeminent aspects such as the definition of postoperative abdominal infections, which still remains difficult owing to their heterogeneity in patient characteristics, clinical presentation, ecology and antimicrobial treatment. With regard to treatment, modifiable factors such as source control and antimicrobial therapy play a key role in influencing the prognosis of postoperative abdominal infections, but several conditions may hamper their correct application; thus efforts should necessarily be devoted towards improving their appropriateness and timing. Hot topics regarding the characteristics and management of postoperative abdominal infections are discussed in this narrative review.

Serum Interleukin-8 in Patients with Different Origin of Intra-Abdominal Infections in Perioperative Period

Intra-abdominal infections (IAI) are associated with high levels of pro-inflammatory serum IL-8 and poor outcomes, but data on IL-8 levels in various inflammatory reactions are contradictory. A better understanding of the diagnostic role of IL-8 is important, since the clinical relevance remains unclear. Methods: That was a single-center observational longitudinal cross-sectional study included 56 patients with various origins of intra-abdominal infections: 24 patients with postoperative abscesses, 12 patients with primary intra-abdominal abscesses, and 20 patients with diffuse peritoneal collection. Perioperative serum concentrations of interleukin-8 IL-8 were investigated at the day before surgery, on the 2nd–3rd day, and on the 5th–7th day after surgery. The hypothesis suggested that there was a difference in serum IL-8 in patients with IAI of different origin in the perioperative period. Results: The study showed that the level of serum IL-8 in patients with intra-abdominal infections of different origins is lower in comparison with healthy individuals. Despite the fact that we did not detect any statistically significant differences in the level of IL-8 in serum in IAI of different origin in the perioperative period, its lowest index was observed in the patients with postoperative abscesses on the 5th–7th days after surgical intervention. The levels of serum IL-8 ≤49.71 pg/mL and ≤48.88 pg/mL may serve as diagnostic markers for primary and postoperative abscesses with significant sensitivity and specificity. Conclusions: Our results differ from previous studies that showed high serum IL-8. High-quality clinical trials are needed to better comprehend the role of inflammatory mediators in IAI with different origin.

Poor Outcome Could Be Predicted by Lower Monocyte Human Leukocyte Antigen-DR Expression in Patients with Complicated Intra-Abdominal Infections: A Review

Complicated intra-abdominal infections (cIAIs) are still associated with high morbidity and mortality levels. Early prognostic evaluation is a great challenge, and a serious amount of resources have been used to find the perfect mortality predictor. Monocyte human leukocyte antigen-DR (mHLA-DR) expression has been studied as a biomarker in patients with sepsis and other infections. Our aim was to evaluate the potential prognostic performance of mHLA-DR in patients with cIAIs. Methods: We performed an electronic search of Google Scholar and PubMed databases for articles published before January 2019. The search terms were "HLA-DR," "monocyte HLA-DR," "intra-abdominal infections," "sepsis," "outcome," and "mortality." Results: A total of 12 studies with 761 patients met our inclusion criteria. In 10 studies, poor outcome was predicted by lower mHLA-DR expression, and two studies showed no prognostic value. Conclusion: This review found association between lower mHLA-DR expression and mortality. We concluded that mHLA-DR could be a reliable and meaningful predictor of poor outcome in patients with cIAIs. Nevertheless, more large prospective studies with surgical patients exclusively are needed before using this biomarker in a clinical setting.

Temperature-Neutrophils-Multiple Organ Failure Grading for Complicated Intra-Abdominal Infections

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.

Ethical considerations in conducting surgical research in severe complicated intra-abdominal sepsis

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has been hypothesized to mitigate MOF and death, although clinical equipoise for this operative approach exists. The Closed or Open after Laparotomy (COOL) study (https://clinicaltrials.gov/ct2/show/NCT03163095) will prospectively randomize eligible patients intra-operatively to formal abdominal closure or OA with NPTT. We review the ethical basis for conducting research in SCIAS.

MAIN BODY

Research in critically ill incapacitated patients is important to advance care. Conducting research among SCIAS is complicated due to the severity of illness including delirium, need for emergent interventions, diagnostic criteria confirmed only at laparotomy, and obtundation from anaesthesia. In other circumstances involving critically ill patients, clinical experts have worked closely with ethicists to apply principles that balance the rights of patients whilst simultaneously permitting inclusion in research. In Canada, the Tri-Council Policy Statement-2 (TCPS-2) describes six criteria that permit study enrollment and randomization in such situations: (a) serious threat to the prospective participant requires immediate intervention; (b) either no standard efficacious care exists or the research offers realistic possibility of direct benefit; (c) risks are not greater than that involved in standard care or are clearly justified by prospect for direct benefits; (d) prospective participant is unconscious or lacks capacity to understand the complexities of the research; (e) third-party authorization cannot be secured in sufficient time; and (f) no relevant prior directives are known to exist that preclude participation. TCPS-2 criteria are in principle not dissimilar to other (inter)national criteria. The COOL study will use waiver of consent to initiate enrollment and randomization, followed by surrogate or proxy consent, and finally delayed informed consent in subjects that survive and regain capacity.

CONCLUSIONS

A delayed consent mechanism is a practical and ethical solution to challenges in research in SCIAS. The ultimate goal of consent is to balance respect for patient participants and to permit participation in new trials with a reasonable opportunity for improved outcome and minimal risk of harm.

The Association Between Intra-abdominal View and Systemic Cytokine Response in Complicated Intra-abdominal Infections

BACKGROUND

There is a wide variety of disease severity in patients with complicated intraabdominal infection (cIAI). The prognostic role of intraabdominal view (IAV) was recently studied, and an IAV score was introduced. The aim of this study was to analyze the associations between the preoperative levels of eight relevant circulating cytokines and IAV components, the IAV score, as well as outcome.

MATERIALS AND METHODS

This was a single-center prospective study. The study cohort consisted of operatively managed adult patients with a cIAI. Preoperative plasma levels of eight cytokines were determined. The operating surgeon filled a form describing IAV. Outcomes analyzed were 30-day mortality and the development of organ dysfunctions requiring intensive care unit admission.

RESULTS

A total of 131 patients with cIAI were analyzed, 30-day mortality was 9.9% (n = 13), and 28 (21.4%) patients had postoperative organ dysfunctions. All components of IAV, the IAV score, and outcomes were associated with various cytokine levels. Interleukin-8 was the most competent marker associating with all the variables assessed in this study: diffuse peritonitis (P < 0.001), substantial diffuse redness (P = 0.012), substantial diffuse fibrin (P = 0.003), fecal or bile as exudate (P = 0.001), nonappendiceal source of infection (P < 0.001), IAV Score groups (P < 0.001), organ dysfunctions (P < 0.001), and 30-day mortality (P = 0.035).

CONCLUSIONS

Various cytokines associate with the IAV and outcome. IL-8 showed the best overall performance. The results emphasize the role of the surgeons' perception of the IAV. IAV provides an approximation of the magnitude of the systemic inflammatory response.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pre-surgery age-adjusted Charlson Comorbidity Index is associated with worse outcomes in acute cholecystitis

BACKGROUND

Beneficial effects of cholecystectomy in acute cholecystitis (AC) might be weakened by complications. The age-adjusted Charlson Comorbidity Index (CCI) assesses disease relevance in the prediction of one-year mortality.

AIMS

To evaluate whether age-adjusted CCI predicted complications (including surgical complications, intensive care unit [ICU] admission, and in-hospital death) among patients undergoing cholecystectomy for AC. Associations between age-adjusted CCI and the length of hospital stay have been also evaluated.

METHODS

271 patients were enrolled at Ospedale Policlinico San Martino (Genoa, Italy) between 2005 and 2013. Clinical data and blood samples were collected.

RESULTS

Patients' median age was 67 years. They underwent more frequently video-laparoscopic cholecystectomy with a limited rate of conversion to open cholecystectomy. Surgical complications occurred in 23 patients (8.5%). 6 patients (2.2%) needed ICU admission, while death occurred in 4 patients (1.5%). According to the cut-off point identified by ROC curve, an age-adjusted CCI cut-off value of 5 was found predictive for in-hospital complications also when confounders were considered (OR 1.35, 95% CI 1.02-1.79, p = 0.035). No association between adjusted CCI and the length of hospital stay was found.

CONCLUSIONS

In patients surgically treated for AC, age-adjusted CCI could represent an additional tool, along with available risk scores, to help surgeons in choosing the best therapeutic option.

The role of the intra-abdominal view in complicated intra-abdominal infections

Background

The prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality.

Methods

The study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission.

Results

A total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05–3.73), diffuse peritonitis (OR 2.15, 1.02–4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12–15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11–30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions.

Conclusions

The extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems.

Trial registration

The study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932).

Electronic supplementary material

The online version of this article (10.1186/s13017-019-0232-7) contains supplementary material, which is available to authorized users.

Nationwide observational study of mortality from complicated intra-abdominal infections and the role of bacterial cultures

BACKGROUND

The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI.

METHODS

The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI.

RESULTS

Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI.

CONCLUSIONS

Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.

Blurring the boundary between open abdomen treatment and ventral hernia repair

PURPOSE

Therapeutic approaches for septic open abdomen treatment remain a major challenge with many uncertainties. The most convincing method is vacuum-assisted wound closure with mesh-mediated fascia traction with a protective plastic sheet placed on the viscera. As this plastic sheet and the mesh must be removed before final fascial closure, such a technique only allows temporary abdominal closure. This retrospective study analyzes the results of a modification of this technique allowing final abdominal closure using an anti-adhesive permeable polyvinylidene fluoride (PVDF) mesh.

METHODS

The outcome of all consecutive patients with septic open abdomen treatment at one academic surgical department from January 2013 to June 2015 was retrospectively analyzed.

RESULTS

Retrospectively, 57 severely ill consecutive patients with septic open abdomen treatment with a 30-day mortality of 26% and a 2-year mortality of 51% were included in the study. In 26 patients, no mesh was implanted; in 31 patients, mesh implantation was done at median third-look laparotomy, median 5 days postoperative. Re-laparotomies after mesh implantation (median n = 2) revealed anastomotic leakage in 16% but no new bowel fistula. In 40% of those patients who had mesh implantation, fascia closure was not achieved and the mesh was left in place in a bridging position avoiding planned ventral hernia.

CONCLUSION

The application of an anti-adhesive PVDF mesh for fascia traction in vacuum-assisted wound closure of septic open abdomen is novel, versatile, and seems to be safe. It offers the highly relevant possibility for provisional and final abdominal closure.

Complicated intra-abdominal infections: a prospective validation study of the WSES Sepsis Severity Score

INTRODUCTION

The World Society of Emergency Surgery (WSES) recently developed and validated a sepsis severity score for complicated intra-abdominal infections (cIAIs). We aimed to prospectively study the validity of this score in our local setting and compare it with global findings.

METHODS

In a prospective study of 100 consecutive adult patients with cIAIs treated at Al-Ain Hospital, United Arab Emirates, from October 2014 to January 2016, we studied patients' demographics, disease, risk factors, WSES Sepsis Severity Score, management, hospital stay and mortality. Our findings were compared with those from a recent global multicentre prospective study from 53 countries (n = 4,496).

RESULTS

Compared with global data, our patients were more likely to be male (p < 0.0001) and younger (p < 0.0001), with more appendicitis and perforated peptic ulcers (p < 0.0001), significantly lower sepsis severity score (p < 0.0001) and more delays in surgical intervention (p = 0.001). Nevertheless, they had similar adequate source control (p = 0.54) and surgical reinterventions (p = 0.63). Overall, our patients had a significantly lower mortality rate (1.0% vs. 9.3% in global data; p = 0.001). A direct logistic regression model showed that the WSES Sepsis Severity Score significantly predicted mortality (p < 0.0001), but our hospital's setting was not predictive of mortality compared with other hospitals (p = 0.18).

CONCLUSION

Although our patient demographics and hospital's setting significantly differed from those of other international hospitals, the WSES Sepsis Severity Score was very accurate in predicting mortality among our patients, which supports its generalisability for all patient populations worldwide.

Abdominal Sepsis: An Update

Despite the significant development and advancement in antibiotic therapy, life-threatening complication of infective diseases cause hundreds of thousands of deaths world. This paper updates some of the issues regarding the etiology and treatment of abdominal sepsis and summaries the latest guidelines as recommended by the Intra-abdominal Infection (IAI) Consensus (2017). Prognostic scores are currently used to assess the course of peritonitis. Irrespective of the initial cause, there are several measures universally accepted as contributing to an improved survival rate, with the early recognition of IAI being the critical matter in this respect. Immediate correction of fluid balance should be undertaken with the use of vasoactive agents being prescribed, if necessary, to augment and assist fluid resuscitation. The WISS study showed that mortality was significantly affected by sepsis irrespective of any medical and surgical measures. A significant issue is the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in the clinical setting, and the reported prevalence of ESBLs intra-abdominal infections has steadily increased in Asia. Europe, Latin America, Middle East, North America, and South Pacific. Abdominal cavity pathology is second only to sepsis occurring in a pulmonary site. Following IAI (2017) guidelines, antibiotic therapy should be initiated as soon as possible after a diagnosis has been verified.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

METHODS

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

RESULTS

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann's procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

CONCLUSIONS

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

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.

[Management of Acute Cholecystitis]

Acute cholecystitis is a common serious complication of gallstones. The reported mortality of acute cholecystitis is approximately 3%, but the rate increases with age or comorbidity of the patient. If appropriate treatment is delayed, complications can develop as a consequence with a grave prognosis. The current standard of care in acute cholecystitis is an early laparoscopic cholecystectomy with the appropriate administration of fluid, electrolyte, and antibiotics. On the other hand, the severity of the disease and patient's operational risk must be considered. In those with high operational risks, gall bladder drainage can be performed as an alternative. Currently percutaneous and endoscopic drainage are available and show clinical success in most cases. After recovering from acute cholecystitis, the patients who have undergone drainage should be considered for cholecystectomy as a definitive treatment. However, in elderly patients or patients with significant comorbidity, operational risks may still be high, making cholecystectomy inappropriate. In these patients, gallstone removal using the percutaneous tract or endoscopy may be considered.

Getting the invite list right: a discussion of sepsis severity scoring systems in severe complicated intra-abdominal sepsis and randomized trial inclusion criteria

Background

Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database.

Methods

All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality.

Results

Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality).

Conclusions

No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission.

Trial registration

https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.

Gas-forming pyogenic liver abscess: A world review

BACKGROUNDS/AIMS

Gas-forming pyogenic liver abscess (GFPLA) has an incidence of up to 30% of all pyogenic liver abscesses (PLA). GFPLA has higher mortality compared to non-GFPLA. Mere presence of gas within abscess may not determine clinical outcome. Hence it is important to study biologic characteristics that make GFPLA a distinct clinical entity. The aim of this study was to conduct a world review on GFPLA.

METHODS

We conducted literature searches in PubMed using the following MeSH terms: "gas forming" AND "Liver abscess, pyogenic", "gas" AND "Liver abscess, pyogenic", "gas" AND "Liver abscess", "gas forming" AND "Liver abscess". Thirteen case series including 313 GFPLA patients were included. Age, gender, diabetes mellitus (DM), bacteriology, underlying etiology, symptoms, investigations, operative indications, and mortality rates were tabulated.

RESULTS

GFPLA is often cryptogenic. There was no difference in age, gender, or symptomatology between GFPLA and non-GFPLA patients. DM was more common in patients with GFPLA compared to that in non-GFPLA patients (mean: 83.5% vs. 38.3%). Klebsiella pneumoniae is the most common causative pathogen. GFPLA has higher mortality compared to non-GFPLA (mean: 30.3% vs. 9%).

CONCLUSIONS

GFPLA is associated with DM and monomicrobial Klebsiella pneumoniae infection. GFPLA has high mortality. It needs to be recognized as a distinct clinical entity.

Raising concerns about the Sepsis-3 definitions

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

Epidemiology and Risk Factors for Isolation of Multi-Drug-Resistant Organisms in Patients with Complicated Intra-Abdominal Infections

BACKGROUND

Patients with complicated intra-abdominal infections (cIAIs) caused by multi-drug-resistant organisms (MDROs) have been identified as being at increased risk for adverse outcomes. Prompt identification and stratification of these patients is essential in the clinical management, allowing the physician timely optimization of empiric antimicrobial therapy while awaiting results of intra-operative cultures to streamline antibiotic treatment.

METHODS

The study is a secondary analysis from two prospective multi-center color surveillance studies. It included all consecutively hospitalized adult patients undergoing surgical procedures, interventional drainage, or conservative treatment with cIAIs, with positive cultures performer on intra-operative samples of peritoneal fluid or purulent exudate/discrete abscesses. Patients with pancreatitis and primary peritonitis were excluded. A case-control approach has been used to evaluate the factors associated with the isolation of a MDRO in enrolled patients.

RESULTS

Among 1986 patients included in the study, a total of 3534 micro-organisms were isolated from intra-peritoneal fluid samples; in 46.5% of cultures, two or more pathogens were identified. The MDROs represented 9.8% of the total of isolated micro-organisms. The overall incidence rate of MDROs was 13.9%. The MDROs were more frequently isolated in patients with health-care-associated cIAIs (25.4%). Multi-nomial logistic regression analysis of risk factors demonstrated that statistically significant risk factors independently associated with the occurrence of MDROs were previous antimicrobial therapy administered within seven days before operation, presence of severe cardiovascular disease, white blood cell count <4000/mL or >12,000/mL, cIAI acquired in a healthcare setting, and inadequate source control.

CONCLUSIONS

The study showed that knowledge of five easily recognizable variables-assessable on hospital admission or as soon as the surgical intervention is concluded-might guide the surgeon to identify patients with cIAIs caused by MDROs, and therefore to choose the most adequate empiric antimicrobial therapy for them.

2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.

Mannheim Peritonitis Index (MPI) and elderly population: prognostic evaluation in acute secondary peritonitis

INTRODUCTION

Acute Secondary Peritonitis due to abdominal visceral perforation is characterized by high mortality and morbidity risk. Risk stratification allows prognosis prediction to adopt the best surgical treatment and clinical care support therapy. In Western countries elderly people represent a significant percentage of population Aim. Evaluation of Mannheim Peritonitis Index (MPI) and consideration upon old people.

PATIENTS AND METHODS

Retrospective study on 104 patients admitted and operated for "Acute Secondary Peritonitis due to visceral perforation". MPI was scored. In our study we want to demonstrate efficacy of MPI and the possibility to consider older age an independent prognostic factor.

RESULTS

Mortality was 25.96%. Greatest sensitivity and specificity for the MPI score as a predictor of mortality was at the score of 20. MPI score of <16 had 0.15 times lower risk of mortality compared to patients with MPI score 17 - 21 and 0.61 lower than patients with MPI >22. Patients with MPI score 17-21 had 0.46 times lower risk of mortality compared to patients with MPI score >21. In the group of patients with MPI score of >20 the mortality rate was 48.5% for patients older than 80 years old and 12.1% for younger patients (p < 0.005); in the group with MPI score of < 20 mortality rate was respectively 8.4% and 1.4% (p < 0.005).

DISCUSSION AND CONCLUSIONS

Data confirm the accuracy of the test. MPI score and age over 80 years old resulted independent predictors of mortality at multivariate analysis.

Neuroendocrine tumor of the common bile duct: case report

Neuroendocrine tumors (NET) are a very heterogeneous group of neoplasms; in recent years we have seen an increase in their incidence (3.65 /100.000/year). They can be associated with hereditary endocrine syndromes (MEN, Von Hippel Lindau); they can occur at any age and the incidence is slightly higher in men than women. The aetiology of the neuroendocrine tumors is unclear; in most cases, inflammation of the bile ducts may be the underlying cause and for this reason, the initial patient's evaluation should be focused on the different aspects concerning the oncological one and the possible sequelae of the biliary obstructions that can evolve in biliary sepsis. All neuroendocrine tumors have malignant potential. The most frequent sites of extrahepatic biliary NETs are the common hepatic duct and the distal common bile duct (19.2%), followed by the middle of the common bile duct (17.9%), the cystic duct (16.7%), and the proximal common bile duct (11.5%). We can divide them into: well-differentiated and poorly differentiated. Considering the clinical features, neuroendocrine tumors can be divided into functional and non-functional. As regards the staging, we distinguish localized, regional and metastatic tumors. Tumors derived from the bile duct are difficult to diagnose preoperatively, mainly because of its low incidence and difficult diagnostic process. However since cholangiocarcinomas account for about 80% of all primary biliary tumors, it is important to think about other options despite their low frequency when a patient presents with abnormal characteristics. The most sensitive immunohistochemical markers are expressing neuron-specific enolase, synaptophisin and chromogranin A. Liver function tests, alkaline phosphatase and bilirubin are often high. Sometimes an anemia can appear in the presence of a chronic disease or in patients with more advanced disease. It is known that the measurement of chromogranin A is useful for the preoperative diagnosis of neuroendocrine tumors. Chromogranin A is elevated in 90% of neuroendocrine tumors of the intestine, and the levels correlate with tumor burden and the possibility of recurrence and, therefore, chromogranin A can be an effective biological marker for preoperative diagnosis of neuroendocrine tumors. Bile endocrine tumors remain silent until metastasizing or growing into neighboring organs, because of its uncommon diagnosis in early stages due to its low incidence, absence of serum markers and lack of symptoms related to the hormonal pattern. Preoperative diagnosis of common bile duct carcinoma is extremely difficult, because it is foretold by non-specific symptoms that include pain or discomfort in the right upper quadrant level and weight loss. A 51- year-old woman presented a jaundice and severe bile duct dilatation. The enhanced CT scan showed a mass, approximately 15 mm in diameter, in the distal common biliary duct. The MRI and ERCP confirmed the mass. Cromogranin A value was negative. The diagnosis of well differentiated endocrine tumor of the biliary tract was done after its surgical resection was performed. The postoperative period was uneventful. Extrahepatic biliary NETs are rare, and extrahepatic bile ducts reportedly account for only 0.32% of primary NET sites. The prognosis for NET of the bile duct appears to be poor.

Open abdomen with vacuum-assisted wound closure and mesh-mediated fascial traction in patients with complicated diffuse secondary peritonitis: A single-center 8-year experience

BACKGROUND

Open abdomen (OA) treatment in patients with peritonitis is increasing worldwide. Various temporary abdominal closure devices are being used. This study included patients with complicated diffuse secondary peritonitis, OA, and vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). The aim of this study was to describe mortality and major morbidity in terms of delayed primary fascial closure and enteroatmospheric fistula rates.

METHODS

This was a single-academic-center retrospective study of consecutive patients with diffuse peritonitis, OA, and VAWCM between years 2008 and 2016. Descriptive and univariate analyses were performed.

RESULTS

Forty-one patients were identified and analyzed. Median age was 59 years, preoperative septic shock was diagnosed in 54% (n = 22), and 59% (n = 24) had a postoperative peritonitis. Mortality was 29% (n = 12), and 76% (n = 31) of patients were admitted in the intensive care unit. The median duration of OA was 7 days with a median of two dressing changes. Delayed primary fascial closure rate among survivors was 92% (n = 33), and enteroatmospheric fistulas developed in 7% (n = 3). In a subgroup analysis, patients with OA in the primary laparotomy for peritonitis (n = 27) were compared with patients with OA in the subsequent laparotomies (n = 14). There were no significant differences between groups.

CONCLUSIONS

The VAWCM technique in patients with complicated secondary diffuse peritonitis and OA yields excellent results in terms of delayed primary fascial closure rate and a low number of enteroatmospheric fistulas. It seems to be safe to close the abdomen at the index laparotomy, if possible, even if there is a risk of a need of OA later.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Clinical and epidemiological characteristics of pyogenic liver abscess in people 65 years or older versus people under 65: a retrospective study

BACKGROUND

To analyse the clinical, epidemiological, microbiological and prognostic differences of pyogenic liver abscess (PLA) in older (≥ 65 years of age) versus younger patients (< 65 years).

METHODS

Multicentre, retrospective cohort study in all patients with PLA admitted to two Spanish hospitals from January 2000 to January 2014. Cases were divided into two age groups (< 65 years and ≥65 years) for comparison of clinical, epidemiological and microbiological characteristics as well as treatment.

RESULTS

Of 98 patients analysed, 40 patients were younger than 65, and 58 were aged 65 or older. Significant associations in the older group were found with female sex (adjusted odds ratio [ORa] 9.0; 95% CI 1.4, 56), non-cryptogenic origin (ORa 14.5; 95% CI 1.6, 129), absence of chronic liver disease (ORa 14; 95% CI 1.3, 155), Escherichia coli infection (ORa 7.7; 95% CI 1.03, 58), and incidence of complications (ORa 2.3; 95% CI 1.04, 5.4). Mortality was 8.2% overall, although all deaths occurred in the older group (8/58; 13.8%) (p = 0.02).

DISCUSSION

Our results are in consonance with other published studies. Older patients with PLA tend to present more anomalies in the biliary tract (Kai et. al, World J Gastroenterol 18: 2948-295, 2012, Rahimian et. al, Clin Infect Dis 39:1654-9, 2004, Seeto, Medicine (Baltimore) 75:99-113, 1996, Kao et.al, Aliment Pharmacol Ther 36:467-76, 2012, Lai et. al, Gastroenterology 146:129-37, 2014), while younger patients are more often male and present more commonly with previous liver disease (especially related to alcohol) and cryptogenic PLA.

CONCLUSION

In patients aged 65 or older, PLA was more common in women and in those with a history of biliary disease, and E. coli was the most frequent bacterium. Mortality was also higher in the older group.

Laparoscopic ileocecal resection in acute and chronic presentations of Crohn's disease. A single center experience

INTRODUCTION

The terminal ileum is the most involved tract in Crohn's disease. The obstruction in this location is the most frequent complication. Acute or chronic presentations can occur. Surgery finds a role in the management of chronic strictures and in acute clinical presentations with complications not improving with conservative therapy.

PATIENTS AND METHODS

We investigate the outcome of patients with obstruction of the ileo-cecal bowel tract laparoscopically managed. It was analyzed the average operative time (OT), the conversion rate and the occurrence of re-operation due to surgical complications.

RESULTS

21 patients underwent an ileocecal resection for complicated Crohn's disease between January 2013 and December 2014. The admissions were performed in emergency in 42% of patients. The preintervention hospital stay was 5.8 (Sd 6.23). The mean operative time was 154 min (Sd 41). 28% of the procedures were converted to open surgery. The average hospital stay was 10 days (Sd 5) in uncomplicated patients. The morbidity rate was 28%. In 19% of cases a re-intervention was needed due to anastomotic leakage (3pts) and one hemoperitoneum for bleeding from the suture line.

DISCUSSION

Laparoscopy seems an affordable technique in the management of obstructive pattern of Crohn's disease. It should be the preferable approach in young patients that probably will be submitted to subsequent surgery for the same disease; in fact, the reduced adhesions formation provided by the less bowel manipulation make easy the subsequent access. Older patients had usually more post-operative morbidity and mortality mostly due to pre-existing conditions; if possible in these patients the treatment should be medical.

Acute appendicitis: should the laparoscopic approach be proposed as the gold standard? Six-year experience in an Emergency Surgery Unit

Acute appendicitis is common in an Emergency Surgery Unit. Although the laparoscopic approach is a method accepted for its treatment, no strong data are available for determining how many procedures must an experienced surgeon carry out for obtaining all the advantages of this technique and if this approach can become the gold standard in the activity of a general emergency unit with senior surgeons variously skilled on the basic laparoscopy. 142 patients that underwent appendectomy (90 laparoscopic, 52 conventional) for acute appendicitis were enrolled in this institutional retrospective cohort study. The surgeons were classified with a descriptor-based grading and divided in two groups regarding the skill. The only relevant result of our study was the significant reduction of conversion rate in case of laparoscopic approach. No strong differences were found concerning the duration of the procedure and the hospital stay between the two groups. The rate of complications were very low in both groups. In conclusion, the experienced surgeons can easily perform a laparoscopic approach independently from the specific skill in this approach.

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

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

Early goal-directed treatment versus standard care in management of early septic shock: Meta-analysis of randomized trials

BACKGROUND

Since the incorporation of the early hemodynamic resuscitation in septic shock according to the early goal-directed therapy (EGDT) protocol among the 6-hour resuscitation bundle of the Surviving Sepsis Campaign guidelines, a great debate has been raised about the issue. The present meta-analysis aims to determine whether the resuscitative phase really takes advantages by being performed with EGDT.

METHODS

A systematic review with meta-analysis of randomized controlled trials (RCTs) of EGDT versus usual care in patients with early septic shock was performed.

RESULTS

Four high-quality RCTs have been included with 4,464 patients (1990 in EGDT and 2013 in usual care arm). ICU admission and cardiovascular support necessity increased in the EGDT group (OR = 2.00, 95% CI 1.55-2.57 and OR = 1.33, 95% CI 1.08-1.64, respectively). EGDT has no significant effect on mortality (90 days, 60 days, 28 days, and mortality by the time of hospital discharge). EGDT has no significant effect in reducing the length of hospital stay, the necessity of respiratory and renal function support, and the duration of respiratory and cardiocirculatory support.

CONCLUSIONS

EGDT seems to increase the resource demand in terms of ICU admissions and cardiocirculatory support necessity without reducing mortality, renal and respiratory organ support necessity, respiratory and cardiocirculatory support duration, and length of hospital stay.

LEVEL OF EVIDENCE

Systematic review, level I.

Acute calculous cholecystitis: Review of current best practices

Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.

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

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

Non-Occlusive Mesenteric Ischemia (NOMI) in Parkinson's disease: case report

Non-occlusive mesenteric ischemia (NOMI) is a severe pathological condition characterized by signs and symptoms of bowel obstruction, intestinal necrosis resulting from acute and/or chronic inadequate blood perfusion, in the absence of an organic vascular obstruction detectable by imaging techniques. A 64 years old man case with a history of Parkinson's disease in high-functioning levodopa treatment is presented. Clinical and radiological signs of intestinal obstruction were observed. He underwent surgical operation with total colectomy and terminal ileostomy for generalized secondary peritonitis due to perforation of sigmoid colon. Ischemic pancolitis was first suspected. In third post-operative day a contrastenhanced CT scan was performed in the evidence of fever and sub-occlusive symptoms. It was found absence of reliable evidence of vascular changes; superior mesenteric artery and vein patency is maintained A NOMI was then diagnosed. NOMI represents about 0.04% of mesenteric artery diseases. It is correlated with a poor prognosis with a mortality estimated of 70-90%. Parkinson's disease, considering neurodegenerative alterations that characterize it, can be considered as a predisposing factor. The combined treatment with high doses of levodopa and vasodilators, such as PGE (Prostaglandin E), can contribute to an improvement in prognosis.

Complication of endoscopic tattooing: a case report of covered perforation

AIM

Laparoscopy is considered a good approach in treatment of colorectal neoplastic diseases; the endoscopic tattooing is then recommended (Evidence Level III and grade of recommendation A) to mark a lesion or a polypectomy site for intraoperative identification. We describe the case of perforation after tattoing treated conservatively.

CASE REPORT

63 years old woman, underwent colonoscopy for lipoma tattooing with India ink SPOT® solution kit and saline test. Immediately after the procedure the patient has been referred the appearance of colic epi-mesogastric pain and fever; Computed Tomography (CT) without MDC identified an irregular thickening of transverse colon with some microbubbles compatible with focal peritonitis. Initial paralytic ileus was present too. The blood count and metabolic panel examinations reveal a neutrophil leucocytosis (WBC: 11.000/mmc, 80% neutrophils).

RESULTS

On the base of WSES sepsis severity score and recent literature patient was treated conservatively with total parenteral nutrition, and intravenous antibiotic therapy. After the resolution of fever and reactivation of peristalsis. The discharge occurred after six days with no early complications.

CONCLUSION

India ink tattooing with SPOT® solution kit and saline test represent the first choice. It is a feasible technique although perforation is a possible complication. It may need an immediately surgical operation but in most cases a conservative management is a good and safe tool even if surgery may be attempted too.

Large retroperitoneal abscess extended to the inferior right limb secondary to a perforated ileal Crohn's disease: the importance of the multidisciplinary approach

The typical complications of Crohn's disease concerns small and large bowel. The full thickness inflammation of the intestinal wall develops in strictures, fistulas and abdominal abscesses. Nowadays the most accepted therapeutic for intra-abdominal abscess option is antibiotic therapy and, in case of need, percutaneous drainage of the abscess. If the abscess passes through the pelvic foramen the abscess can involve the inferior limbs. We report a case a perforation of terminal ileum in Crohn's disease complicated by a large abscess of the right iliac fossa reaching the spaces between the anterior lateral muscles of the right thigh as far as the anterior lateral pre-tibial region. We discuss the diagnostic and therapeutic options in a multidisciplinary context.