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Chammas M, Abdul Jawad K, Saberi RA, Gilna G, Urrechaga EM, Cioci A, Rattan R, Pust GD, Namias N, Yeh DD. Role of Empiric Antifungal Therapy in Patients with Perforated Peptic Ulcers. Surg Infect (Larchmt) 2022; 23:174-177. [PMID: 35021885 DOI: 10.1089/sur.2021.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: It is unclear if the addition of antifungal therapy for perforated peptic ulcers (PPU) leads to improved outcomes. We hypothesized that empiric antifungal therapy is associated with better clinical outcomes in critically ill patients with PPU. Patients and Methods: The 2001-2012 Medical Information Mart for Intensive Care (MIMIC-III) database was searched for patients with PPU and the included subjects were divided into two groups depending on receipt of antifungal therapy. Propensity score matching by surgical intervention, mechanical ventilation (MV), and vasopressor administration was then performed and clinically important outcomes were compared. Multiple logistic regression was performed to calculate the odds of a composite end point (defined as "alive, hospital-free, and infection-free at 30 days"). Results: A total of 89 patients with PPU were included, of whom 52 (58%) received empiric antifungal therapy. Propensity score matching resulted in 37 pairs. On logistic regression controlling for surgery, vasopressors, and MV, receipt of antifungal therapy was not associated with higher odds (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.5-4.7; p = 0.4798) of the composite end point. Conclusions: In critically ill patients with perforated peptic ulcer, receipt of antifungal therapy, regardless of surgical intervention, was not associated with improved clinical outcomes. Selection bias is possible and therefore randomized controlled trials are required to confirm/refute causality.
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Affiliation(s)
- Majid Chammas
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Khaled Abdul Jawad
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Rebecca A Saberi
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gareth Gilna
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Eva M Urrechaga
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Alessia Cioci
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gerd Daniel Pust
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Daniel Dante Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
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Primary closure versus Graham patch omentopexy in perforated peptic ulcer: A systematic review and meta-analysis. Surgeon 2021; 20:e61-e67. [PMID: 34090810 DOI: 10.1016/j.surge.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/28/2021] [Accepted: 04/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND There are different methods to repair a perforated peptic ulcer, the two most frequently used are the Graham patch omentopexy and the primary closure. Currently there is no high-level evidence to provide guidance of the optimal method of repair. The aim of this study is to compare the outcomes of the two methods so as to provide improved guidance for surgeons undertaking this repair. METHODS A systematic review and meta-analysis was conducted including any study that compared Graham patch omentopexy with primary closure in adults. Embase, Medline, Cochrane and Google's search engine were searched. The primary outcome was breakdown of the repair resulting in bile leak and the secondary outcomes were mortality, operation time, wound infection and time to start oral intake. The meta-analysis was conducted using Review Manager Software version 5:4. Outcome data were reported as odd ratios and weighted mean differences with their 95% confidence intervals. RESULTS Of the 229 studies identified, 6 were suitable for analysis, 4 were retrospective, one was a prospective cohort study and one was a randomized controlled trial. Meta-analysis showed no difference in occurrence of bile leak or mortality between primary closure and Graham patch omentopexy (OR 0.64; 95% (0.26-1.54) & 0.66; 95% (0.25-1.76) respectively). There was no difference in the rates of wound infection OR 0.65; 95% (0.4-1.05). The duration of the operation was shorter in the primary closure group by 5.6 min; 95% (-21 + 10.4). CONCLUSION There was no difference in the clinical outcomes between the two modes of repair.
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Barmparas G, Alhaj Saleh A, Huang R, Eaton BC, Bruns BR, Raines A, Bryant C, Crane CE, Scherer EP, Schroeppel TJ, Moskowitz E, Regner JL, Frazee R, Campion EM, Bartley M, Mortus JR, Ward J, Margulies DR, Dissanaike S. Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer. Trauma Surg Acute Care Open 2021; 6:e000662. [PMID: 34079912 PMCID: PMC8137227 DOI: 10.1136/tsaco-2020-000662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/24/2021] [Accepted: 04/24/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI). Methods This was a secondary analysis of a multicenter, case–control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts. Results A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53). Conclusion For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary. Study type Original article, case series. Level of evidence III.
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Adel Alhaj Saleh
- Department of Surgery, Texas Tech University Health Sciences Center School of Medicine-Lubbock Campus, Lubbock, Texas, USA
| | - Raymond Huang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Barbara C Eaton
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Brandon R Bruns
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Alexander Raines
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Cressilee Bryant
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Christopher E Crane
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Elizabeth P Scherer
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Thomas J Schroeppel
- Department of Surgery, University of Colorado, Colorado Springs, Colorado, USA
| | - Eliza Moskowitz
- Department of Surgery, University of Colorado, Colorado Springs, Colorado, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott and White Health, Temple, Texas, USA
| | - Richard Frazee
- Department of Surgery, Baylor Scott and White Health, Temple, Texas, USA
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Matthew Bartley
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Jared R Mortus
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremy Ward
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center School of Medicine-Lubbock Campus, Lubbock, Texas, USA
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Zhang CX, Rasane RR, Zhang Q, Fonseca RA, Aldana JA, Rincon JE, Sorini MJ, Bochicchio KM, Leonard JM, Ilahi ON, Bochicchio GV. Temporary Abdominal Closure Is Associated with Increased Risk for Fungal Intra-Abdominal Infections in Trauma Patients. Surg Infect (Larchmt) 2020; 21:745-751. [PMID: 32186973 DOI: 10.1089/sur.2019.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Fungal infections are associated with increased morbidity and death. Few studies have examined risk factors associated with post-operative fungal intra-abdominal infections (FIAIs) in trauma patients after exploratory laparotomy. In this study, we evaluated potential risk factors for acquiring post-operative FIAIs and their impact on clinical outcomes. Methods: This was a retrospective analysis of trauma patients admitted from 2005 to 2018 who underwent exploratory laparotomy and subsequently had development of intra-abdominal infection (IAI). Demographics, comorbidities, culture data, antimicrobial usage, Injury Severity Scores (ISS), and clinical outcomes were abstracted. All post-operative IAIs were evaluated and stratified as either bacterial, fungal, combined, and with or without colonization. All groups were compared. Risk factors for the development of post-operative IAI and clinical outcomes were analyzed by Student t test and chi-square test. Multi-variable logistic regression was used to determine independent predictors of post-operative FIAIs. Results: There were 1675 patients identified as having undergone exploratory laparotomy in the setting of traumatic injury, 161 of whom were suspected of having IAI. A total of 105 (6.2%) patients had a diagnosis of IAI. Of these patients, 40 (38%) received a diagnosis of FIAI. The most common fungal pathogens were unspeciated yeast (48.3%), followed by Candida albicans (42.7%), C. glabrata (4.5%), C. dubliniensis (2.25%), and C. tropicalis (2.25%). There were no significant differences in demographics, comorbidities, and percentage of gastric perforations between FIAI and bacterial IAI (BIAI) groups. Patients with FIAIs, however, had a 75% temporary abdominal closure (TAC) rate compared with 51% in BIAIs (p = 0.01). The FIAI group had higher ISS (27 vs. 22, p = 0.03), longer hospital days (34 vs. 25, p = 0.02), and longer intensive care unit (ICU) days (17 vs. 9, p = 0.006) when compared with BIAI. The FIAI group also had a five-fold greater mortality rate. Logistic regression identified TAC as an independent risk factor for the development of post-operative FIAIs (odds ratio [OR] 6.16, confidence interval [CI] 1.14-28.0, p = 0.02). Conclusions: An FIAI after exploratory laparotomy was associated with greater morbidity and death. A TAC was associated independently with increased risk of FIAI after exploratory laparotomy in the setting of traumatic injury. Clinicians should suspect fungal infections in trauma patients in whom post-operative IAI develops after undergoing exploratory laparotomy using TAC techniques.
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Affiliation(s)
- Christina X Zhang
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rohit R Rasane
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Qiao Zhang
- Institute for Informatics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ricardo A Fonseca
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jose A Aldana
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Javier E Rincon
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Maya J Sorini
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kelly M Bochicchio
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jennifer M Leonard
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Obeid N Ilahi
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Grant V Bochicchio
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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5
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Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I, Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 2020; 15:3. [PMID: 31921329 PMCID: PMC6947898 DOI: 10.1186/s13017-019-0283-9] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. Methods The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. Conclusions The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Dieter G. Weber
- Royal Perth Hospital, Perth, Australia & The University of Western Australia, Crawley, Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Fabio C. Campanile
- Division of Surgery, ASL VT - Ospedale “Andosilla”, Civita Castellana, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Michael D. Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO USA
| | - Andrew Peitzman
- University of Pittsburgh, School of Medicine, UPMC – Presbyterian, Pittsburgh, PA USA
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Marco Ceresoli
- Department of General and Emergency Surgery, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ronald V. Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | - Michael Sugrue
- Letterkenny University Hospital, Donegal Clinical Research Academy Centre for Personalized Medicine, Donegal, Ireland
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
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6
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Kwan JR, Lim M, Ng F, Shelat V. Fungal Isolates in Peritoneal Fluid Culture Do Not Impact Peri-Operative Outcomes of Peptic Ulcer Perforation. Surg Infect (Larchmt) 2019; 20:619-624. [PMID: 31099700 DOI: 10.1089/sur.2019.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Fungal isolates from peritoneal fluid sampling in patients with perforated peptic ulcer (PPU) is not uncommon and its management unclear. This study aims to evaluate whether the presence of fungus in peritoneal fluid cultures is a predictor of morbidity and mortality after laparotomy for PPU. Method: This is a single-center retrospective study including adult patients with perforated gastric and duodenal ulcers over a 10-year period (January 2004 to January 2014). Evaluation of predictors contributing to fungal growth was conducted using multiple logistic regression analysis. Operative factors and 30-day mortality and morbidity outcomes were compared against fungal growth using a multivariable generalized linear mixed model analysis. Results: The median age was 58 (interquartile range [IQR] 44-70) years with 110 (20.3%) females. In addition to hypertension and hyperlipidemia, diabetes mellitus (13.5%), ischemic heart disease (2.6%), and heart failure (2.4%) were common. Fungus was cultured from peritoneal fluid in 209 (38.6%) patients. Median American Society of Anesthesiology (ASA) score was 2 (IQR 2-3) and median Mannheim peritonitis index (MPI) score was 15 (IQR 10-20). Free air was detected in 323 (59.6%) patients and 52 (9.6%) patients had gastrectomy. Median length of stay was 7 (IQR 6-11) days. All-cause complications were seen in 53 (9.8%) patients, of whom 37 patients (6.8%) developed intra-abdominal collection, 20 patients (3.7%) had anastomotic leakage, and 12 patients (2.2%) required repeat operation. Thirty-day mortality was seen in 47 (8.7%) patients. Multivariable analysis showed age (median age, 64; IQR 53-74) as a predictor of fungal growth (p < 0.001) but fungal growth not a predictor of adverse peri-operative outcomes. Conclusion: Fungal isolates in peritoneal fluid cultures are more likely to occur in older patients who have PPU. Presence of fungal isolates does not impact peri-operative outcomes.
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Affiliation(s)
- Jia Rui Kwan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Melvin Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Felicia Ng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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7
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Huston JM, Kreiner L, Ho VP, Sanders JM, Duane TM. Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions. Surg Infect (Larchmt) 2019; 20:593-600. [PMID: 31188069 DOI: 10.1089/sur.2019.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Peptic ulcer disease (PUD) affects four million people worldwide. Perforated peptic ulcer (PPU) occurs in less than 15% of cases but is associated with significant morbidity and mortality rates. Administration of antibiotics is standard treatment for gastrointestinal perforations, including PPU. Although fungal growth is common in peritoneal fluid cultures from patients with PPU, current data suggest empiric anti-fungal therapy fails to improve outcomes. To examine the role of anti-fungal agents in the treatment of PPU, the Surgical Infection Society hosted an Update Symposium at its 37th Annual Meeting. Here, we provide a synopsis of the symposium's findings and a brief review of prospective and retrospective reports on the subject. Methods: A search of Pubmed/MEDLINE, EMBASE, and the Cochrane Library was performed between January 1, 2000, and November 1, 2018, comparing outcomes of PPU following empiric anti-fungal treatment versus no anti-fungal therapy. We used the search terms "perforated peptic ulcer," "gastroduodenal ulcer," "anti-fungal," and "perforated" or "perforation." Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.
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Affiliation(s)
- Jared M Huston
- Departments of Surgery and Science Education, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Laura Kreiner
- Department of Surgery, Case Western Reserve University School of Medicine, The MetroHealth System, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, Case Western Reserve University School of Medicine, The MetroHealth System, Cleveland, Ohio
| | - James M Sanders
- Department of Pharmacy, John Peter Smith Health Network, Fort Worth, Texas
| | - Therese M Duane
- Department of Surgery, John Peter Smith Health Network, Fort Worth, Texas
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8
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Horn CB, Coleoglou Centeno AA, Rasane RK, Aldana JA, Fiore NB, Zhang Q, Torres M, Mazuski JE, Ilahi ON, Punch LJ, Bochicchio GV. Pre-Operative Anti-Fungal Therapy Does Not Improve Outcomes in Perforated Peptic Ulcers. Surg Infect (Larchmt) 2018; 19:587-592. [PMID: 30036134 DOI: 10.1089/sur.2018.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND With the advent of anti-Helicobacter pylori therapy, hospital admissions for peptic ulcer disease (PUD) have declined significantly since the 1990s. Despite this, operative treatment of PUD still is common. Although previous papers suggest that Candida in peritoneal fluid cultures may be associated with worse outcomes in patients with perforated peptic ulcers (PPUs), post-operative anti-fungal therapy has not been effective. We hypothesized that pre-operative anti-fungal drugs improve outcomes in patients with PPUs undergoing operative management. PATIENTS AND METHODS A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with PPUs. Demographics and clinical outcomes were abstracted. Pre-operative anti-fungal use, intra-operative peritoneal fluid cultures, and infectious outcomes were abstracted manually. We compared outcomes and the presence of fungal infections in patients receiving peri-operative anti-fungal drugs in the entire cohort and in patients with intra-operative peritoneal fluid cultures. Frequencies were compared by the Fisher exact or χ2 test as appropriate. The Student's t-test was used for continuous variables. RESULTS There were 107 patients with PPUs who received operative management; 27 (25.2%) received pre-operative anti-fungal therapy; 33 (30.8%) received peritoneal fluid culture, and 17 cultures (51.5%) were positive for fungus. The presence of fungus in the cultures did not affect the outcomes. There were no differences in length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, 30-day re-admission rates, or rates of intra-abdominal abscess formation or fungemia in patients who received pre-operative anti-fungal drugs regardless of the presence of fungi in the peritoneal fluid. CONCLUSION Candida has been recovered in 29%-57% of peritoneal fluid cultures in patients with PPUs. However, no studies have evaluated pre-operative anti-fungal therapy in PPUs. Our data suggest that pre-operative anti-fungal drugs are unnecessary in patients undergoing operative management for PPU.
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Affiliation(s)
- Christopher B Horn
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | | | - Rohit K Rasane
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Jose A Aldana
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Nicholas B Fiore
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Qiao Zhang
- 2 Institute for Informatics, Washington University in St Louis , St. Louis, Missouri
| | - Marlon Torres
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - John E Mazuski
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Obeid N Ilahi
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Laurie J Punch
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
| | - Grant V Bochicchio
- 1 Department of Surgery, Washington University in St Louis , St. Louis, Missouri
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9
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Pramod J, Vijayakumar C, Srinivasan K, Maroju NK, Raj Kumar N, Balasubramaniyan G. Clinical Significance of Candida in an Intraoperative Peritoneal Specimen with Perforation Peritonitis: An Institutional Perspective. Cureus 2018; 10:e2275. [PMID: 29736359 PMCID: PMC5935435 DOI: 10.7759/cureus.2275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction Fungal infection of the peritoneum has become more common in recent years, the most common cause of which is Candida. Candida peritonitis is considered as a severe disease and is regarded as an independent risk factor for mortality in postoperative peritonitis. This study was planned to find out the clinical significance of Candida isolation on the outcome of the patients with peritonitis in terms of morbidity and mortality. Methods This prospective study included consecutive patients admitted and operated for secondary peritonitis over a two-year period in a tertiary care hospital in South India. The time delay was assessed from the onset of symptoms to surgery. The intraoperative peritoneal fluid aspirate was analyzed for culture sensitivity (fungal and bacterial). Patients were followed until their discharge from the hospital or death. This study analyzed the clinico-microbiological profile in patients with perforation peritonitis with special reference to Candida isolation. The analysis also looked the results of antifungal therapy (fluconazole) in patients positive for Candida isolation. Results The study included 407 consecutive patients with hollow viscus perforation diagnosed intraoperatively. Fungal organisms were identified in 153 patients (37.6%). Old age (> 50 years), high lag period (≥ 48 hours), peritoneal contamination, length of hospital stay, the presence of co-morbidities, shock at presentation, and postoperative complications were found to be significantly associated with fungal infection (p < 0.05). The study noted a significant decrease in the perioperative complications in patients who were started on antifungal treatment early (within 72 hours after surgery). There were significant reductions in the length of hospital stay, intensive care unit (ICU) stay, ventilator support, and inotropic support in the postoperative period. However, we did not find any difference in mortality due to early treatment with fluconazole. Conclusion Candida peritonitis was associated with an increase in the mortality and morbidity, especially when associated with diabetes mellitus and fungemia. Early antifungal therapy (within 72 hours after surgery) reduced the morbidity due to Candida peritonitis but did not affect the mortality.
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Affiliation(s)
- Jagannath Pramod
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Chellappa Vijayakumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Krishnamachari Srinivasan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nanda Kishore Maroju
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nagarajan Raj Kumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Gopal Balasubramaniyan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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10
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Current insight into pathophysiology of gastroduodenal ulcers: Why do only some ulcers perforate? J Trauma Acute Care Surg 2018; 80:1045-8. [PMID: 26998777 DOI: 10.1097/ta.0000000000001035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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11
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Invasive Candida Infection after Upper Gastrointestinal Tract Surgery for Gastric Cancer. Int J Surg Oncol 2017; 2017:6058567. [PMID: 29234525 PMCID: PMC5695031 DOI: 10.1155/2017/6058567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 09/03/2017] [Accepted: 10/10/2017] [Indexed: 11/17/2022] Open
Abstract
Upper gastrointestinal tract (GIT) surgical procedures are more likely to cause nosocomial Candida peritonitis than lower GIT procedures and they thus constitute an independent risk factor for mortality. Because of the severity of postsurgical fungal infections complications, intensivists and surgeons need to be extremely aware of their clinical importance in critically ill postsurgical intensive care unit (ICU) patients. We analyzed the clinical and microbiological data of 149 oncologic patients who were hospitalized in the ICU at Soroka Medical Center between January 2010 and January 2015 after undergoing upper GIT surgery for gastric cancer. Invasive fungal infections related to secondary peritonitis following oncologic upper GIT surgery had a higher mortality rate than patients with nonfungal postoperative infectious complications. The presence of gastroesophageal junction leakage and advanced age were found to be independent risk factors for invasive fungal infection after oncologic upper GIT surgery.
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12
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Abstract
Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Ewen M Harrison
- MRC Centre for Inflammation Research, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Morten H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Michael Ohene-Yeboah
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jon Arne Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Li WS, Lee CH, Liu JW. Antifungal therapy did not improve outcomes including 30-day all-cause mortality in patients suffering community-acquired perforated peptic ulcer-associated peritonitis with Candida species isolated from their peritoneal fluid. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 50:370-376. [PMID: 26321461 DOI: 10.1016/j.jmii.2015.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 06/07/2015] [Accepted: 07/06/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Although patients suffering community-acquired perforated peptic ulcer (PPU)-associated peritonitis with Candida species isolated from their peritoneal fluid have higher chances of mortality and experiencing a complicated postoperative clinical course, universal antifungal therapy for these patients remains controversial. METHODS This is a retrospective analysis of the impacts of antifungal therapy on outcomes of patients suffering community-acquired PPU-associated peritonitis with Candida species isolated from their ascites at a medical center in Taiwan. All included patients received source control and antibiotic treatment, with or without additional postoperative antifungal therapy with fluconazole or an echinocandin for at least 3 days. RESULTS Among the 133 included patients, 76 did not receive (Group 1) and 57 did receive (Group 2) antifungal therapy. Sixteen (12%) of the overall included patients died within 30 days. Shock [odds ratio (OR), 5.6; 95% confidence interval (CI), 1.9-16.5; p = 0.002] and higher Acute Physiology and Chronic Health Evaluation II score (>20; OR, 9.5; 95% CI, 1.1-80.7; p = 0.04) were independently associated with 30-day mortality. Among the 80 matched patients from Groups 1 and 2 (1:1 matched) with the closest propensity score, no significant difference was found in 30-day all-cause mortality, time to mortality, the need for reoperation/abscess formation/anastomotic leakage, prolonged intensive care unit stay, and prolonged mechanical ventilator dependence between patients with and without antifungal therapy. CONCLUSION Our study provides solid evidence supporting the notions that antifungal therapies do not benefit patients suffering PPU peritonitis with Candida species isolated from their ascites in general, and antifungal therapy could be reserved for patients who are critically ill and/or severely immunocompromised.
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Affiliation(s)
- Wei-Sin Li
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan; School of Medicine, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jien-Wei Liu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan; School of Medicine, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Montravers P, Dupont H, Leone M, Constantin JM, Mertes PM, Laterre PF, Misset B, Bru JP, Gauzit R, Sotto A, Brigand C, Hamy A, Tuech JJ. Guidelines for management of intra-abdominal infections. Anaesth Crit Care Pain Med 2015; 34:117-30. [PMID: 25922057 DOI: 10.1016/j.accpm.2015.03.005] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Intra-abdominal infections are one of the most common gastrointestinal emergencies and a leading cause of septic shock. A consensus conference on the management of community-acquired peritonitis was published in 2000. A new consensus as well as new guidelines for less common situations such as peritonitis in paediatrics and healthcare-associated infections had become necessary. The objectives of these Clinical Practice Guidelines (CPGs) were therefore to define the medical and surgical management of community-acquired intra-abdominal infections, define the specificities of intra-abdominal infections in children and describe the management of healthcare-associated infections. The literature review was divided into six main themes: diagnostic approach, infection source control, microbiological data, paediatric specificities, medical treatment of peritonitis, and management of complications. The GRADE(®) methodology was applied to determine the level of evidence and the strength of recommendations. After summarising the work of the experts and application of the GRADE(®) method, 62 recommendations were formally defined by the organisation committee. Recommendations were then submitted to and amended by a review committee. After 2 rounds of Delphi scoring and various amendments, a strong agreement was obtained for 44 (100%) recommendations. The CPGs for peritonitis are therefore based on a consensus between the various disciplines involved in the management of these patients concerning a number of themes such as: diagnostic strategy and the place of imaging; time to management; the place of microbiological specimens; targets of empirical anti-infective therapy; duration of anti-infective therapy. The CPGs also specified the value and the place of certain practices such as: the place of laparoscopy; the indications for image-guided percutaneous drainage; indications for the treatment of enterococci and fungi. The CPGs also confirmed the futility of certain practices such as: the use of diagnostic biomarkers; systematic relaparotomies; prolonged anti-infective therapy, especially in children.
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Affiliation(s)
- Philippe Montravers
- Département d'anesthésie-réanimation, CHU Bichat-Claude-Bernard, AP-HP, université Paris VII Sorbonne Cité, 46, rue Henri-Huchard, 75018 Paris, France.
| | - Hervé Dupont
- Pôle anesthésie-réanimation, CHU d'Amiens, 80054 Amiens, France
| | - Marc Leone
- Département d'anesthésie-réanimation, CHU Nord, 13915 Marseille, France
| | | | - Paul-Michel Mertes
- Service d'anesthésie-réanimation, CHU de Strasbourg, Nouvel Hopital Civil, BP 426, 67091 Strasbourg, France
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Dupont H, Guilbart M, Ntouba A, Perquin M, Petiot S, Regimbeau JM, Chouaki T, Mahjoub Y, Zogheib E. Can yeast isolation be predicted in complicated secondary non-postoperative intra-abdominal infections? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:60. [PMID: 25849844 PMCID: PMC4350296 DOI: 10.1186/s13054-015-0790-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/05/2015] [Indexed: 01/05/2023]
Abstract
Introduction The aim of this study was to create a predictive score for yeast isolation in patients with complicated non-postoperative intra-abdominal infections (CNPIAI) and to evaluate the impact of yeast isolation on outcome. Methods All patients with a CNPIAI undergoing emergency surgery over a three-year period were included in the retrospective cohort (RC, n = 290). Patients with a yeast-positive peritoneal fluid culture (YP) were compared with patients with a yeast-negative culture (YN). Multivariate logistic regression was used to identify factors independently associated with yeast isolation and a predictive score was built. The score’s performance was then established in the prospective cohort (PC, n = 152) over an 18-month period. Outcome of the whole cohort was evaluated and independent risks factors of mortality searched. Results In the RC, 39 patients (13.4%) were YP. Four factors were independently associated with the YP group: length of stay before surgery ≥48 h (odds ratio (OR) (95% confidence interval (CI)) = 3.1 (1.4 to 6.9), P = 0.004, 1 point), per-operative cardiovascular failure (2.4 (1.1 to 5.8), P = 0.04, 1 point), generalized peritonitis (6.8 (2.7 to 16.7), P <0.001, 2 points) and upper gastrointestinal tract perforation (2.5 (1.2 to 5.6), P = 0.02, 1 point). In the PC, the area under the curve (95%CI) of the predictive score’s receiver operating characteristic curve was 0.79 (0.72 to 0.86). For predicting an intra-abdominal candidiasis (IAC), a score ≥3 had a sensitivity of 0.60, a specificity of 0.84, a positive predictive value of 0.49 and a negative predictive value of 0.89. Furthermore, yeast isolation was associated with worse outcome and independently associated with mortality in the whole cohort (OR = 2.15; 95%CI (1.03 to 4.46), P = 0.04). Conclusions The new predictive score can be used to rule out intra-abdominal candidiasis and thus avoid the initiation of antifungal treatment. It is suited to less severe infections than previously published scores. IAC is associated independently with an increased mortality in this population.
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16
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Søreide K, Thorsen K, Søreide JA. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg 2013; 101:e51-64. [PMID: 24338777 DOI: 10.1002/bjs.9368] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed. METHODS PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred. RESULTS Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence. CONCLUSION Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.
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Affiliation(s)
- K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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17
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Badiee P. Evaluation of human body fluids for the diagnosis of fungal infections. BIOMED RESEARCH INTERNATIONAL 2013; 2013:698325. [PMID: 23984401 PMCID: PMC3747334 DOI: 10.1155/2013/698325] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 07/09/2013] [Accepted: 07/18/2013] [Indexed: 01/01/2023]
Abstract
Invasive fungal infections are a major cause of morbidity and mortality in immunocompromised patients. Because the etiologic agents of these infections are abundant in nature, their isolation from biopsy material or sterile body fluids is needed to document infection. This review evaluates and discusses different human body fluids used to diagnose fungal infections.
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Affiliation(s)
- Parisa Badiee
- Alborzi Clinical Microbiology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Zand Avenue, Shiraz 7193711351, Iran.
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Casali JJ, Franzon O, Kruel NF, Neves BD. Análise epidemiológica e emprego do teste rápido da urease em pacientes com úlcera péptica perfurada. Rev Col Bras Cir 2012. [DOI: 10.1590/s0100-69912012000200003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Analisar o perfil epidemiológico de pacientes com úlcera péptica gastroduodenal perfurada e verificar se a presença do H. pylori nas secreções peritoneais e intraluminais desses pacientes pode ser avaliada pelo teste rápido da urease. MÉTODOS: Realizou-se estudo prospectivo, transversal, descritivo, com dados de pacientes atendidos em um hospital de abrangência regional, em portadores de úlcera péptica perfurada. Coletou-se, no transoperatório, amostras de líquido peritoneal (na proximidade da perfuração) e da secreção intraluminal, sendo encaminhadas para cultura e teste rápido de urease. RESULTADOS: Quatorze pacientes foram analisados. A média etária foi 41,06 anos, todos homens, brancos (71,4%), tabagistas (57,2%), IMC < 30 (85,7%), com história prévia de dispepsia (78,6%). Sorologia para H. pylori foi positiva em 84,6% dos casos. O teste rápido da urease foi positivo em 78,6% das amostras do tubo digestivo e em 42,8% das amostras da cavidade peritoneal; 41,6% foram positivos em ambos os locais, 50% somente na cavidade digestiva e 8,4% exclusivamente na cavidade peritoneal. Dos 11 pacientes com sorologia positiva para H. pylori 100% apresentaram positividade em pelo menos um dos sítios pesquisados. CONCLUSÃO: Verificou-se que a incidência foi menor que a esperada. Há associação significativa entre a infecção pelo H. pylori e a ocorrência de perfuração. A presença deste patógeno pode ser avaliada tanto pela sorologia quanto pela realização do teste rápido da urease do fluido coletado na cavidade peritoneal e na luz gástrica/duodenal.
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Abstract
The rate of elective surgery for peptic ulcer disease has been declining steadily over the past 3 decades. During this same period, the rate of emergency ulcer surgery rose by 44%. This means that the gastrointestinal surgeon is likely to be called on to manage the emergent complications of peptic ulcer disease without substantial experience in elective peptic ulcer disease surgery. The goal of this review is to familiarize surgeons with our evolving understanding of the pathogenesis, epidemiology, presentation, and management of peptic ulcer disease in the emergency setting, with a focus on peptic ulcer disease-associated bleeding and perforation.
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Affiliation(s)
- Constance W Lee
- Department of Surgery, University of Florida College of Medicine, 1600 Southwest Archer Road, PO Box 100109, Gainesville, FL 32610-0109, USA
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20
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Carneiro HA, Mavrakis A, Mylonakis E. Candida Peritonitis: An Update on the Latest Research and Treatments. World J Surg 2011; 35:2650-9. [DOI: 10.1007/s00268-011-1305-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
Fungal peritonitis, which was once a rare entity, is becoming increasingly common due to various immunocompromised conditions. Candida species are considered the common cause of fungal peritonitis in most cases. However, at present, other yeasts and filamentous fungi are replacing the dominance of Candida albicans as well as other Candida species. Trichosporon species are widely distributed in nature and are normal flora in the gastrointestinal tract of humans. Ever since the report of disseminated trichosporonosis in 1970, several cases of infections by various Trichosporon species in different clinical patients have been published. Here, we present a patient with Trichosporon peritonitis after duodenal perforation. To the best of our knowledge, this is the first case report of its kind from India.
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Affiliation(s)
- Usha Kalawat
- Department of Microbiology, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, Andhra Pradesh, India.
| | - Krishna K. Sharma
- Department of Microbiology, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, Andhra Pradesh, India
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Abstract
A recent hypothesis postulates that sepsis moves through different phases, with periods of enhanced inflammation alternating with periods of immune suppression. In this study we determined the levels of inflammation present during early and late septic deaths to examine whether death was due to hyperinflammation or immunosuppression. The murine model of sepsis induced by cecal ligation and puncture (CLP) was used. Complete blood counts, plasma interleukin-6 (IL-6) levels, and body weights were determined. Mice that died within the first 4 days had increased plasma levels of IL-6, indicating that there was activation of the immune system. Cecal resection on day 4 after CLP resulted in decreased abscess size, lower circulating neutrophil counts, decreased anemia, and improved survival compared to the results for mice that received only antibiotic and fluid therapy. All of the mice that died in the chronic phase of infection (after day 4) had positive peritoneal cultures containing significantly more bacteria than the cultures for surviving mice. After day 4, none of the surviving mice exhibited increases in the plasma levels of IL-6. Dying mice exhibited mixed IL-6 responses; for 41% of the mice there was never an increase in the IL-6 levels in the chronic phase, while for other mice the levels of IL-6 transiently increased prior to death. Peritoneal macrophages were obtained in the late phase of sepsis from moribund and healthy mice and were stimulated ex vivo. The cells from the moribund mice produced significantly less IL-6 than the cells obtained from healthy mice produced. These results indicate that in mice that die in the early phase there is uniformly increased inflammation. However, during the chronic phase of sepsis, some mice die with evidence of immunosuppression (increased bacterial growth and low IL-6 levels), while other mice die with immunostimulation (high IL-6 levels and bacterial growth). Determining the inflammatory status of individual patients may help guide appropriate, targeted therapy.
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Affiliation(s)
- Hongyan Xiao
- Department of Pathology, University of Michigan, 2210 Medical Science I Building, 1301 Catherine Road, Ann Arbor, MI 48109-0602, USA
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Gupta S, Kaushik R. Peritonitis - the Eastern experience. World J Emerg Surg 2006; 1:13. [PMID: 16759427 PMCID: PMC1475566 DOI: 10.1186/1749-7922-1-13] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Accepted: 04/26/2006] [Indexed: 02/07/2023] Open
Abstract
Peritonitis is a common emergency encountered by surgeons the world over. This paper aims to provide an overview of the spectrum of peritonitis seen in the East. Studies dealing with the overall spectrum of secondary peritonitis in various countries of this region were identified using Pubmed and Google. These were analyzed for the site and cause of perforation and the mortality. It was observed that perforation of duodenal ulcers was the most the commonly encountered perforations. These are followed by small bowel and appendicular perforations. Colonic perforations were uncommon. The overall mortality ranges between 6–27%.
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Affiliation(s)
- Sanjay Gupta
- Department of Surgery Government Medical College and Hospital Chandigarh, India
| | - Robin Kaushik
- Department of Surgery Government Medical College and Hospital Chandigarh, India
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Kujath P, Bouchard R, Nolde J, Scheele J. Therapie der intraabdominellen Pilzinfektionen. Therapy of intraabdominal fungal infections. Mycoses 2005; 48 Suppl 1:61-5. [PMID: 15826290 DOI: 10.1111/j.1439-0507.2005.01115.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Candida albicans is the fourth most germ that can be identified on surgical intensive care unit (SICU). During the course of severe peritonitis recognition of Candida is crucial for physicians but interpretation of Candida-positive microbiologic samples is difficult. The indication for antimycotic therapy requires differentiation between harmless contamination or severe invasive mycosis associated with high mortality. Therefore, we propose a four-stage classification. Stage I is the initial contamination of the abdominal cavity by Candida spp. Stage IIa is characterized by persistence of fungi in patients without risk factors, IIb with risk factors respectively. Stage III means histological evidence of Candida invasion into the peritoneal layer. Stage IV is a generalized infection with fungemia/fungal sepsis. We recommend antimycotic therapy in stage IIb or higher.
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Affiliation(s)
- P Kujath
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, D-23538 Lübeck, Germany.
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