Emergency spontaneous gastric perforations: ulcus versus cancer

Excisional biopsy of perforated gastric ulcer: mandatory or potentially harmful?

PURPOSE

This study aimed to evaluate the morbidity associated with excisional biopsy in patients with spontaneous gastric perforation.

METHODS

A retrospective, single-center, observational study was performed. All consecutive patients with spontaneous gastric perforation who underwent surgical therapy were included. Outcomes were assessed concerning the performance of excisional biopsy.

RESULTS

A total of 135 adult patients were enrolled. Of these, 110 (81.5%) patients underwent excisional biopsy, while 17 (12.6%) did not. The remaining eight (5.9%) patients who underwent gastric resection were excluded from the analysis. Patients undergoing excisional biopsy developed significantly higher rates of postoperative complications (p = 0.007) and experienced more severe complications according to the Clavien-Dindo classification, particularly type III and above (p = 0.017). However, no significant differences were observed regarding in-hospital mortality, reoperation, suture dehiscence, or length of hospital stay.

CONCLUSION

Excisional biopsy for gastric perforation has been shown to be associated with increased morbidity. Surgical closure followed by early endoscopic biopsy may be a superior approach for gastric perforation management to rule out malignancy.

Gastric perforation biopsy: is it obsolete?

PURPOSE

The aim of the study was to test the established hypothesis that biopsies of spontaneous gastric perforations should be taken to rule out cancer.

METHODS

A prospective observational study was performed. Consecutive patients with spontaneous gastric perforation were included. Biopsies of the edges of the perforation were submitted for histological evaluation. The epithelial type as well as the nature of the pathology were evaluated.

RESULTS

Sixty-eight patients were included. Eight (12%) biopsies revealed duodenal origin. Sixty (88%) biopsies revealed gastric mucosa of which 33 (48%) could be specifically typed. All biopsies revealed benign ulceration. No malignancies were detected in these biopsies or on subsequent gastroscopic follow up.

CONCLUSION

This study suggests that routine intraoperative biopsy of gastric perforation may be questioned. Biopsy is probably better performed endoscopically after recovery.

Gastric, Duodenal, and Small Bowel Emergencies

Gastric and small bowel emergencies are often seen in the emergency department and require rapid assessment and intervention as patients can deteriorate quickly. Some of the more frequently seen gastric emergencies include gastric volvulus and peptic ulcer disease, which can present with ischemia, strangulation, perforation, or severe bleeding. Swift diagnosis is crucial to ensuring the proper management whether that is endoscopic or with surgical exploration. Perforated peptic ulcers that are not contained will require surgical intervention, whereas bleeding ulcers can often be controlled with endoscopic interventions.

Outcomes of omental patch repair in large or giant perforated peptic ulcer are comparable to gastrectomy

PURPOSE

Perforated peptic ulcer (PPU) complicates 2 to 10% of patients with peptic ulcer disease and has mortality risk of up to 20%. Omental patch repair is the mainstay of surgical management and gastric resectional procedures are advocated for a large/giant ulcer or suspected malignancy. Emergency gastrectomy is associated with increased morbidity and mortality. The aim of this study is to compare the outcomes of omental patch repair with gastrectomy in patients with large PPU (≥ 20 mm).

METHODS

A retrospective review of all PPU patients who underwent surgery from January 2008 to December 2014 was done. Patients with PPU < 20 mm were excluded. Patient demographics and perioperative data were recorded. Length of hospital stay, post-operative complications, need for intensive care unit admission and all-cause mortality are reported.

RESULTS

110 patients with a median age of 69.1 (range 28-90) years had PPU ≥ 20 mm. 42 (38.2%) patients presented within 24 h from the onset of abdominal pain. The median American Society of Anaesthesiology score was 3 (range 1-4). 52 patients had omental patch repair and 58 patients had gastrectomy. The overall incidence of intra-abdominal collection, post-operative leakage, re-operation and all-cause mortality was 16.4%, 11.8%, 6.4% and 19.1%, respectively. No difference in post-operative outcomes between the two groups was detected: intra-abdominal collection (p = 0.793), post-operative leakage (p = 0.813), re-operation (p = 0.809) and all-cause mortality (p = 0.736).

CONCLUSION

Omental patch repair confers similar perioperative outcomes as compared to gastrectomy in patients with large PPU.

Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review

A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.

Omental patch versus gastric resection for perforated gastric ulcer: Systematic review and meta-analysis for an unresolved debate

BACKGROUND

Perforated gastric ulcers are surgical emergencies with paucity of data on the preferred treatment modality of resection versus omental patch. We aim to compare outcomes with ulcer repair and gastric resection surgeries in perforated gastric ulcers after systematic review of literature.

METHODS

A systematic literature search was performed for publications in PubMed Medline, Embase, and Cochrane Central Register of Controlled Trials. We included all studies which compared ulcer repair vesus gastric resection surgeries for perforated gastric ulcers. We excluded studies which did not separate outcomes gastric and duodenal ulcer perforations.

RESULTS

The search included nine single-institution retrospective reviews comparing ulcer repair (449 patients) versus gastric resection surgeries (212 patients). Meta-analysis was restricted to perforated gastric ulcers and excluded perforated duodenal ulcers. The majority of these studies did not control for baseline characteristics, and surgical strategies were often chosen in a non-randomized manner. All of the studies included were at high risk of bias. The overall odds ratio of mortality in ulcer repair surgery compared to gastric resection surgery was 1.79, with 95% CI 0.72 to 4.43 and p-value 0.209.

CONCLUSION

In this meta-analysis, there was no difference in mortality between the two surgical groups. The overall equivalence of clinical outcomes suggests that gastric resection is a potentially viable alternative to ulcer repair surgery and should not be considered a secondary strategy. We would recommend a multicenter randomized control trial to evaluate the surgical approach that yields superior outcomes.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Outcomes of laparoscopic primary gastrectomy with curative intent for gastric perforation: experience from a single surgeon

BACKGROUND

Gastric cancer perforation is rare and difficult to distinguish from gastric ulcer perforation before surgery. Peritonitis caused by gastric perforation requires emergency surgery. The optimal surgical strategy for gastric perforation has not been established.

MATERIAL AND METHODS

Data from 43 patients who underwent primary gastrectomy with curative intent for gastric perforation between June 2010 and November 2019 were reviewed. Patients were classified into gastric ulcer and gastric cancer groups. Early surgical outcomes and overall survival were assessed.

RESULTS

There were no significant differences in clinical characteristics between the two groups except regarding preoperative shock. Laparoscopic gastrectomy was performed in 35 of 43 patients. There were no conversions to open surgery. The surgical findings demonstrated that the gastric cancer group had larger mass lesions with significantly larger perforations than did the gastric ulcer group. There were no significant differences in early surgical outcomes. Severe postoperative complications occurred in nine patients, five of whom died within one month of surgery. The majority of patients (90%) had stage III or IV gastric cancer. The 5-year survival rate was 19.5%.

CONCLUSION

We found no definitive differences in clinical characteristics distinguishing gastric cancer from ulcers. Considering our surgical outcomes, laparoscopic primary gastrectomy performed by an expert is a useful technique for emergency gastric perforation. However, unless an expert is available, caution should be used when selecting laparoscopic primary gastrectomy with curative intent as a surgical method.

Perforated and bleeding peptic ulcer: WSES guidelines

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.

Perforated Gastric Cancer: A Systematic Review

Background: Although gastric carcinoma is the fifth most commonly diagnosed cancer, optimal treatment of perforated cancer remains debated. Materials and Methods: The study was conducted according to the guidelines from the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. An electronic systematic search was conducted using MEDLINE databases (PubMed, EMBASE, and Web of Science) by matching the terms "perforated gastric cancer," "gastric cancer perforated," "perforation AND gastric cancer," and "perforated gastric tumor." Results: Fifteen studies published between 1995 and 2018 and including 964 patients matched the inclusion criteria for this systematic review. There were 4 publications from Japan, 3 from Turkey, and 1 from China, Germany, Hong Kong, Italy, Nepal, Serbia, South Korea, and Taiwan, respectively. The sample size of the individual studies ranged from 8 to 514 patients. Perforated gastric carcinoma was rare and more prevalent in elderly males, preoperative diagnosis was uncommon, and the distal stomach was most frequently involved. Mortality was 11.4% and 1.9%, respectively, in one-stage versus two-stage gastrectomy (P = .010). Curative treatment by omental patch repair and staged gastrectomy yielded acceptable 5-year survival rates. There were no significant differences in the recurrence rate and pattern between perforated and nonperforated gastric cancer if a curative operation was performed. Use of laparoscopy was mentioned only in one study. Conclusions: Future studies should evaluate the role of laparoscopic surgery and clarify the indications for hyperthermic intraperitoneal chemotherapy and extensive peritoneal lavage protocols to decrease gastric cancer cell shed in the surgical field and increase long-term survival.

Surgical outcome evaluation of perforated gastric cancer: from the aspects of both acute care surgery and surgical oncology

BACKGROUND

Perforated gastric cancer (PGC) is a rare condition of gastric cancer (GC). In this study, we sought to assess the outcome of PGC from the aspects of both acute care surgery and surgical oncology at a single institute, Chang Gung Memorial Hospital (CGMH).

METHODS

From 1997 to 2013, 6864 patients were diagnosed with GC and 2738 were diagnosed with gastroduodenal perforation at CGMH. In total, 29 patients with PGC were identified. Immediate surgical and long-term oncologic outcomes were evaluated after an appropriate matching process was performed.

RESULTS

The immediate surgical outcome of PGC, i.e., the hospital mortality rate within 30 d after surgery, did not significantly differ from that of non-cancer related gastroduodenal perforation. The long-term oncologic outcome, with matching by age, gender, year of surgery and AJCC 7th stage grouping, also did not significantly differ from that of GC without perforation.

CONCLUSIONS

Aggressive surgical treatment, including an initial emergency procedure for containing peritonitis and radical surgery for GC, may benefit PGC patients in terms of both the immediate and oncologic outcomes.

Gastric cancer with lesion extending to spleen and perforation into free peritoneum

Perforated gastric carcinoma is a rare condition that is hard to diagnose preoperatively. It is associated with advanced cancer stages and has a high mortality, particularly in cases presenting preoperative shock. Few studies have investigated the presentation and adequate management of these carcinomas. In addition, there are no reports in the literature on perforations extending to the spleen, as described in this case, making the management of these lesions challenging. Our article reports a case of gastric tumor perforation extending to the spleen, which presented as a perforated acute abdomen. The patient was treated with total gastrectomy and D2 lymph node resection with splenectomy and progressed well with current survival of one year at disease stage IV.

Surgical Scales: Primary Closure versus Gastric Resection for Perforated Gastric Ulcer - A Surgical Debate

Perforated gastric ulcer is one of the most life-threatening complications of peptic ulcer disease with high morbidity and mortality rates. The surgical strategy for gastric perforation in contrast with duodenal perforations often requires consilium and intraoperative debates. The subject of the debate is a 59-year-old male patient who presented with perforated giant gastric ulcer complicated by generalized peritonitis and severe sepsis. The debate is based on a systematized table dividing all factors into three groups and putting them on surgical scales. Pathology-related factors influencing the decision-making are size and site of perforation, local tissue inflammation, signs of malignancy, simultaneous complications of peptic ulcer, peritonitis, and sepsis. Besides these factors, patient- and healthcare-related factors should also be considered.

Spontaneous perforation of primary gastric B-cell lymphoma of MALT: a case report and literature review

Primary gastric lymphoma is a rare malignant tumor that can sometimes present as spontaneous perforation. We present below a case of spontaneous primary gastric lymphoma perforation that was managed in our institution followed by a brief review of the literature and discussion.

Perforation of gastric cancer - What should the surgeon do?

Perforation represents a rare and severe complication of gastric cancer (GC) with a large hospital mortality (8-82%). The aim of this study is to evaluate the clinical-pathological features in patients with perforated gastric cancer (PGC) and to advise the surgical treatment options. A total of 11 patients with PGC were retrospectively reviewed among 376 consecutive cases of GC operated. The clinical-pathological features including tumor stage, survival, and the type of treatment were observed. The perforation was more frequent in stage III (8 patients) and in stage IV (3 patients), but none of the cases in stage I and II GC were observed. All the patients had serosal invasion and lymph node metastasis. Limited lymphadenectomy (D0, D1) was performed in 5 patients, and extended lymphadenectomy (D2, D3) in 3 patients. Emergency gastrectomy was performed in 8 (72.8%) patients, subtotal gastrectomy in 5 (45.5%), and total gastrectomy in 3 (27.2%) cases. Three (27.2%) patients were treated by simple closure with omental patch. The overall 30-day mortality rate was 46%. The survival rate was higher among the patients who underwent curative resection (75.77±68.88 days) than in those who underwent simple closure with omental patch (18.00±24.43 days). The difference between the treatments in these groups was significant (p < 0.05). PGC required surgical emergency. Curative resection improved long-term survival in the patients with potentially curable gastric malignancy. Unsuccessful outcomes after PGC could be attributed to the poor condition of the patients and the advanced disease stage.

Perforated peptic ulcer

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.

Technique to manage persistent leak from a prepyloric ulcer where a distal gastrectomy is not appropriate

Perforated peptic ulcer disease remains a relatively frequent emergency surgery presentation. Persistent leak is the most common indication for return to theatre. We present a technique to manage patients in whom a more substantial resection is not possible. A 45-year-old woman underwent initial laparoscopic primary closure of a non-malignant perforated gastric ulcer. This subsequently leaked on return to the UK and had a further graham patch formed via a laparotomy. Unfortunately, the patch repair leaked and at reoperation a wedge excision or distal gastrectomy was not possible given the friability of the tissues and instability of the patient, a transgastric drain and perigastric drain were therefore placed. This created a controlled fistula, which was managed eventually as an outpatient. Transgastric drains in the context of the persistent perforated gastric ulcer leak are a safe way to manage the unstable patient with poor tissues where more substantial surgeries such as a distal gastrectomy are not possible.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer

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.

The management of perforated gastric ulcers

INTRODUCTION

Perforated gastric ulcers are potentially complicated surgical emergencies and appropriate early management is essential in order to avoid subsequent problems including unnecessary gastrectomy. The aim of this study was to examine the management and outcome of patients with gastric ulcer perforation undergoing emergency laparotomy for peritonitis.

METHODS

Patients undergoing laparotomy at the Royal Infirmary of Edinburgh for perforated gastric ulcers were identified from the prospectively maintained Lothian Surgical Audit (LSA) database over the five-year period 2007-2011. Additional data were obtained by review of electronic records and review of case notes.

RESULTS

Forty-four patients (25 male, 19 female) were identified. Procedures performed were: 41 omental patch repairs (91%), 2 simple closures (4.5%) and 2 distal gastrectomies (4.5%; both for large perforations). Four perforated gastric tumours were identified (8.8%), 2 of which were suspected intra-operatively and confirmed histologically, 1 had unexpected positive histology and 1 had negative intra-operative histology, but follow-up endoscopy confirmed the presence of carcinoma (1 positive biopsy in 21 follow-up endoscopies); all 4 were managed without initial resection. Median length of stay was 10 days (range 4-68). Overall 7 patients died in hospital (15.9%) and there were 21 morbidities (54.5%). Registrars performed the majority of the procedures (16 alone, 21 supervised) with no significant difference in post-operative morbidity (P = 0.098) or mortality (P = 0.855), compared to consultants.

CONCLUSION

Almost all perforated gastric ulcers can be effectively managed by laparotomy and omental patch repair. Initial biopsy and follow-up endoscopy with repeat biopsy is essential to avoid missing an underlying malignancy.

Emergency presentation of the gastric cancer; prognosis and implications for service planning

Aims

To compare emergency and elective presentation of gastric cancer by mode of clinical presentation, initial stage, intervention and prognosis.

Methods

Data were collected prospectively for all cases of gastric cancer presenting to a tertiary referral centre between 2003 and 2010. This was stratified by emergency and elective presentation and was analysed for mode of presentation, initial stage and outcome. Statistical analysis was performed using unpaired t-test and Chi² test.

Results

A total of 291 patients presented: Forty-two (14.43%) were emergencies and 249 (85.57%) elective presentations. Analysis of the emergency cohort showed 25 patients presented with obstruction (59.52%), 15 presented with haematemesis (35.71%) and 2 with perforation (4.76%).

Eighteen of the emergency patients (45%) presented with stage 4 disease compared to 60 (25.42%) in the elective group (p < 0.005). Fourteen of the emergency patients were treated with curative intent (33.3%) compared with 130 (55.56%) in the elective group (p < 0.01). Over 6 years only 2 patients needed operation within 24 hours of presentation.

Overall survival at one year for emergency patients was 48.3% compared to 63.4% in elective patients (p < 0.05). There were no survivors from the emergency group after 3 years but 32.46% of the elective patients survived (p < 0.02). Elective presentation with disease stage 1A-3B had a two year survival rate of 54.95% compared to only 20% in the emergency group (p < 0.05). Of patients who underwent operative intervention 67.44% of patients who presented electively survived to 2 years. This compared to just 25% presenting as emergencies (p < 0.001).

Conclusions

Emergency presentation of gastric cancer is rare; is associated with higher stage of disease at presentation and lower rates of operability. The necessity to perform emergency operation within 24 hours is exceedingly rare. Emergency presentation is a marker of poor long term outcome for equivalent cancer stage in non-advanced (stages 1A-3B) disease.

Surgical management of gastric perforation in the setting of gastric cancer

BACKGROUND

Gastric perforation is a rare presentation of gastric cancer and is thought to be a predictor of advanced disease and, thus, poor prognosis. Guidelines do not exist for the optimal management strategy. We aimed to identify, review, and summarize the literature pertaining to perforation in the setting of gastric cancer.

METHODS

A qualitative, systematic review of the literature was performed from January 1, 1985, to January 1, 2010. Searches of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were performed using search terms related to gastric cancer surgery. Abstracts were examined by two independent reviewers and a standardized data collection tool was used to extract relevant data points. Summary tables were created.

RESULTS

Nine articles were included. Perforation was reported to occur in fewer than 5% of gastric cancer patients. Preoperative diagnosis of a gastric cancer was rated and occurred in 14-57% of patients in the papers reviewed. Mortality rates for emergency gastrectomy ranged from 0 to 50% and for simple closure procedures the rates ranged from 8 to 100%. Patients able to receive an R0 gastrectomy demonstrated better long-term survival (median 75 months, 50% 5-year) compared with patients who had simple closure procedures.

CONCLUSIONS

Gastric cancer patients presenting with a gastric perforation demonstrate improved overall survival with an R0 resection; however, implementation of this management technique is complicated by infrequent preoperative gastric cancer diagnosis, and inability to perform an oncologic resection due to patient instability and intra-abdominal contamination.

Emergency surgery for perforated gastric malignancy: An institution's experience and review of the literature

OBJECTIVES

The aim was to evaluate the outcome of patients who underwent surgery for perforated gastric malignancies.

METHODS

A review of all patients who underwent surgery for perforated gastric malignancy was performed.

RESULTS

Twelve patients (nine gastric adenocarcinoma and three B-cell lymphoma) formed the study group. Ten (83.3%) had subtotal gastrectomy performed, while two (16.7%) underwent total gastrectomy. All eight patients with adenocarcinoma who survived the initial operation fared poorly. The two patients with lymphoma who survived the surgery underwent subsequent chemotherapy has no disease recurrence currently.

CONCLUSION

Surgery in perforated gastric malignancy is fraught with numerous challenges.

A focus on intra-abdominal infections

Complicated intra-abdominal infections are an important cause of morbidity and are frequently associated with poor prognosis, particularly in higher risk patients.

Well defined evidence-based recommendations for intra-abdominal infections treatment are partially lacking because of the limited number of randomized-controlled trials.

Factors consistently associated with poor outcomes in patients with intra-abdominal infections include increased illness severity, failed source control, inadequate empiric antimicrobial therapy and healthcare-acquired infection.

Early prognostic evaluation of complicated intra-abdominal infections is important to select high-risk patients for more aggressive therapeutic procedures.

The cornerstones in the management of complicated intra-abdominal infections are both source control and antibiotic therapy.

The timing and the adequacy of source control are the most important issues in the management of intra-abdominal infections, because inadequate and late control of septic source may have a negative effect on the outcomes.

Recent advances in interventional and more aggressive techniques could significantly decrease the morbidity and mortality of physiologically severe complicated intra-abdominal infections, even if these are still being debated and are yet not validated by limited prospective trials.

Empiric antimicrobial therapy is nevertheless important in the overall management of intra-abdominal infections. Inappropriate antibiotic therapy may result in poor patient outcomes and in the appearance of bacterial resistance.

Antimicrobial management is generally standardised and many regimens, either with monotherapy or combination therapy, have proven their efficacy. Routine coverage especially against Enterococci and candida spp is not always recommended, but can be useful in particular clinical conditions. A de escalation approach may be recommended in patients with specific risk factors for multidrug resistant infections such as immunodeficiency and prolonged antibacterial exposure.

Therapy should focus on the obtainment of adequate source control and adequate use of antimicrobial therapy dictated by individual patient risk factors. Other critical issues remain debated and more controversies are still open mainly because of the limited number of randomized controlled trials.