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Fernandez CA. Damage Control Surgery and Transfer in Emergency General Surgery. Surg Clin North Am 2023; 103:1269-1281. [PMID: 37838467 DOI: 10.1016/j.suc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.
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Affiliation(s)
- Carlos A Fernandez
- Department of Surgery, Creighton University Medical Center, 7710 Mercy Road, Suite 2000, Omaha, NE 68124, USA.
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2
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Lebedev NV, Klimov AE, Shadrina VS, Belyakov AP. [Surgical wound closure in advanced peritonitis]. Khirurgiia (Mosk) 2023:66-71. [PMID: 37379407 DOI: 10.17116/hirurgia202307166] [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: 06/30/2023]
Abstract
To date, mortality in widespread peritonitis is still high (15-20%) and increased up to 70-80% in case of septic shock. Surgeons actively discuss wound closure technique in these patients considering intraoperative findings and severity of illness. The authors present scientific data and opinions of national and foreign surgeons regarding the methods of laparotomy closure. There are still no generally accepted criteria for choosing the method of laparotomy closure in secondary widespread peritonitis. Indications and clinical efficacy of each procedure require additional research.
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Affiliation(s)
- N V Lebedev
- Peoples' Friendship University of Russia, Moscow, Russia
| | - A E Klimov
- Peoples' Friendship University of Russia, Moscow, Russia
| | - V S Shadrina
- Peoples' Friendship University of Russia, Moscow, Russia
| | - A P Belyakov
- Peoples' Friendship University of Russia, Moscow, Russia
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3
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Špička P, Chudáček J, Řezáč T, Vomáčková K, Ambrož R, Molnár J, Klos D, Vrba R. Prognostic significance of comorbidities in patients with diffuse peritonitis. Eur Surg 2022. [DOI: 10.1007/s10353-022-00780-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Summary
Background
Diffuse peritonitis is a severe disease with high mortality and morbidity rates. Therapy is fundamentally surgical. It is important to identify patients with a significantly worse prognosis and patients who may benefit from more aggressive surgical and postsurgical care such as NPWT (Narrow Pressure Wound Therapy) prior to surgery. We tried to identify a determining factor for higher morbidity and mortality rates resulting in a worse prognosis among initial data and patient comorbidities in order to focus therapy towards more aggressive surgical management.
Methods
In a group of 274 patients with diffuse peritonitis, we evaluated the type of peritonitis according to effusion, origin, surgery type, and the age, gender, and present comorbidities of the patients, and compared it with the overall mortality, morbidity rate, and duration of hospitalization.
Results
Patients without comorbidities had a significantly lower burden in both morbidity and mortality. We recorded the highest difference in mortality in patients with two or more comorbidities, with pulmonary and cardiovascular diseases, with malignancy and hypertension. Morbidity was found to be significantly exacerbated by the presence of two or more severe diseases, cardiovascular disease, malignancy, and hypertension.
Conclusion
We identified age, effusion type, and the presence of comorbidities as key factors for the prognosis of our patients—the morbidity and mortality rates were substantially increased in patients with two or more comorbidities, as well as by the presence of cardiovascular disease, malignancy, and hypertension. A more aggressive approach should be considered to improve the prognosis in these patients.
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4
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Iranya RN, Mbiine R, Semulimi AW, Nasige J, Makumbi T, Galukande M. Comparison of the PIPAS severity score tool and the QSOFA criteria for predicting in-hospital mortality of peritonitis in a tertiary hospital in Uganda: a prospective cohort study. BMC Surg 2022; 22:291. [PMID: 35902850 PMCID: PMC9331107 DOI: 10.1186/s12893-022-01743-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 07/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The majority of the prognostic scoring tools for peritonitis are impractical in low resource settings because they are complex while others are quite costly. The quick Sepsis-related Organ Failure Assessment (qSOFA) score and the Physiologic Indicators for Prognosis in Abdominal Sepsis (PIPAS) severity score are two strictly bedside prognostic tools but their predictive ability for mortality of peritonitis is yet to be compared. We compared the predictive ability of the qSOFA criteria and the PIPAS severity score for in-hospital mortality of peritonitis. METHOD This was a prospective cohort study on consecutive peritonitis cases managed surgically in a tertiary hospital in Uganda between October 2020 to June 2021. PIPAS severity score and qSOFA score were assessed preoperatively for each case and all cases were then followed up intra- and postoperatively until discharge from the hospital, or up to 30 days if the in-hospital stay was prolonged; the outcome of interest was in-hospital mortality. We used Receiver Operating Characteristic curve analysis to assess and compare the predictive abilities of these two tools for peritonitis in-hospital mortality. All tests were 2 sided (p < 0.05) with 95% confidence intervals. RESULTS We evaluated 136 peritonitis cases. Their mean age was 34.4 years (standard deviation = 14.5). The male to female ratio was 3:1. The overall in-hospital mortality rate for peritonitis was 12.5%. The PIPAS severity score had a significantly better discriminative ability (AUC = 0.893, 95% CI 0.801-0.986) than the qSOFA score (AUC = 0.770, 95% CI 0.620-0.920) for peritonitis mortality (p = 0.0443). The best PIPAS severity cut-off score (a score of > = 2) had sensitivity and specificity of 76.5%, and 93.3% respectively, while the corresponding values for the qSOFA criteria (score > = 2), were 58.8% and 98.3% respectively. CONCLUSIONS The in-hospital mortality in this cohort of peritonitis cases was high. The PIPAS severity score tool has a superior predictive ability and higher sensitivity for peritonitis in-hospital mortality than the qSOFA score tool although the latter tool is more specific. We recommend the use of the PIPAS severity score as the initial prognostic tool for peritonitis cases in the emergency department.
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Affiliation(s)
| | - Ronald Mbiine
- Department of Surgery, School of Medicine, Makerere University, Kampala, Uganda
| | - Andrew Weil Semulimi
- Department of Physiology, School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | - Joan Nasige
- Department of Surgery, School of Medicine, Makerere University, Kampala, Uganda
| | - Timothy Makumbi
- Department of Surgery, School of Medicine, Makerere University, Kampala, Uganda
| | - Moses Galukande
- Department of Surgery, School of Medicine, Makerere University, Kampala, Uganda
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5
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Rajabaleyan P, Michelsen J, Tange Holst U, Möller S, Toft P, Luxhøi J, Buyukuslu M, Bohm AM, Borly L, Sandblom G, Kobborg M, Aagaard Poulsen K, Schou Løve U, Ovesen S, Grant Sølling C, Mørch Søndergaard B, Lund Lomholt M, Ritz Møller D, Qvist N, Bremholm Ellebæk M. Vacuum-assisted closure versus on-demand relaparotomy in patients with secondary peritonitis-the VACOR trial: protocol for a randomised controlled trial. World J Emerg Surg 2022; 17:25. [PMID: 35619144 PMCID: PMC9137120 DOI: 10.1186/s13017-022-00427-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Secondary peritonitis is a severe condition with a 20–32% reported mortality. The accepted treatment modalities are vacuum-assisted closure (VAC) or primary closure with relaparotomy on-demand (ROD). However, no randomised controlled trial has been completed to compare the two methods potential benefits and disadvantages. Methods This study will be a randomised controlled multicentre trial, including patients aged 18 years or older with purulent or faecal peritonitis confined to at least two of the four abdominal quadrants originating from the small intestine, colon, or rectum. Randomisation will be web-based to either primary closure with ROD or VAC in blocks of 2, 4, and 6. The primary endpoint is peritonitis-related complications within 30 or 90 days and one year after index operation. Secondary outcomes are comprehensive complication index (CCI) and mortality after 30 or 90 days and one year; quality of life assessment by (SF-36) after three and 12 months, the development of incisional hernia after 12 months assessed by clinical examination and CT-scanning and healthcare resource utilisation. With an estimated superiority of 15% in the primary outcome for VAC, 340 patients must be included. Hospitals in Denmark and Europe will be invited to participate. Discussion There is no robust evidence for choosing either open abdomen with VAC treatment or primary closure with relaparotomy on-demand in patients with secondary peritonitis. The present study has the potential to answer this important clinical question. Trial Registration The study protocol has been registered at clinicaltrials.gov (NCT03932461). Protocol version 1.0, 9 January 2022. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00427-x.
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Affiliation(s)
- Pooya Rajabaleyan
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark. .,University of Southern Denmark, Odense, Denmark.
| | - Jens Michelsen
- Research Unit for Anaesthesiology, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Uffe Tange Holst
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Palle Toft
- Research Unit for Anaesthesiology, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Jan Luxhøi
- Surgical Department, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Musa Buyukuslu
- Surgical Department, Hospital of Southwest Jutland, Esbjerg, Denmark
| | | | - Lars Borly
- Surgical Department, Holbæk Hospital, Holbæk, Denmark
| | | | | | - Kristian Aagaard Poulsen
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | | | - Sophie Ovesen
- Surgical Department, Viborg Hospital, Viborg, Denmark
| | | | | | | | | | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
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6
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Špička P, Chudáček J, Řezáč T, Starý L, Horáček R, Klos D. Prognostic Significance of Simple Scoring Systems in the Prediction of Diffuse Peritonitis Morbidity and Mortality. Life (Basel) 2022; 12:life12040487. [PMID: 35454980 PMCID: PMC9028034 DOI: 10.3390/life12040487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/11/2022] [Accepted: 03/26/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction: Diffuse peritonitis is a serious disease. It is often addressed within urgent management of an unstable patient in shock. The therapy consists of treatment of the source of peritonitis, decontamination of the abdominal cavity, stabilization of the patient and comprehensive resuscitation care in an intensive care unit. A number of scoring systems to determine patient prognosis are available, but most of them require complex input data, making their practical application a substantial problem. Objective: Our aim was to assess simple scoring systems within a cohort, evaluate the level of mortality, morbidity, and duration of hospital stay, followed by a comparison of the acquired data with the literature and determination of an easily implementable scoring system for use in clinical practice. Material and Methods: We evaluated a group of patients with diffuse peritonitis who underwent surgery in the 2015–2019 period. Medical history, surgical findings, and paraclinical examinations were used as the input for four scoring systems commonly used in practice—MPI, qSOFA, ECOG, and ASA. We compared the results between the systems and with the literature. Results: Our cohort included 274 patients diagnosed with diffuse peritonitis. Mortality was 22.6%, morbidity 73.4%, with a 25.2 day average duration of hospital stay. Mortality and morbidity increased with rising MPI and qSOFA, well-established scoring systems, but also with rising ASA and ECOG, similarly to MPI and qSOFA. Conclusions: The utilized scoring systems correlated well with the severity of the condition and with predicted mortality and morbidity as reported in the literature. Simple scoring systems primarily used in other indications (i.e., ASA and ECOG) have a similar predictive value in our cohort as commonly used systems (MPI, qSOFA). We recommend them in routine clinical practice due to their simplicity.
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Affiliation(s)
- Petr Špička
- First Department of Surgery, University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (T.Ř.); (L.S.); (D.K.)
- Correspondence: (P.Š.); (J.C.)
| | - Josef Chudáček
- First Department of Surgery, University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (T.Ř.); (L.S.); (D.K.)
- Correspondence: (P.Š.); (J.C.)
| | - Tomáš Řezáč
- First Department of Surgery, University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (T.Ř.); (L.S.); (D.K.)
| | - Lubomír Starý
- First Department of Surgery, University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (T.Ř.); (L.S.); (D.K.)
| | - Rostislav Horáček
- Department of Anesthesiology, Resuscitation and Intensive Care, University Hospital Olomouc, 779 00 Olomouc, Czech Republic;
| | - Dušan Klos
- First Department of Surgery, University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (T.Ř.); (L.S.); (D.K.)
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7
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Lebedev NV, Popov VS, Klimov AE, Svanadze GT. [Eritonitis outcome prediction]. Khirurgiia (Mosk) 2021:92-98. [PMID: 34941215 DOI: 10.17116/hirurgia202112192] [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: 11/17/2022]
Abstract
The review is devoted to the most common general clinical and specific grading systems for peritonitis outcome prediction. Particular attention is paid to methodological approaches, prediction reliability, simplicity of use in clinical practice and their importance in decision-making. It is shown that none of the modern grading systems is universal and absolutely reliable. Combining several systems is quite difficult and will take additional time that is impossible for intraoperative environment. Despite various systems for peritonitis outcome prediction, none of them can completely satisfy surgeons, primarily in choice of surgical access, intervention type and option for its completion.
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Affiliation(s)
- N V Lebedev
- Peoples' Friendship University of Russia, Moscow, Russia
| | - V S Popov
- Peoples' Friendship University of Russia, Moscow, Russia
| | - A E Klimov
- Peoples' Friendship University of Russia, Moscow, Russia
| | - G T Svanadze
- Peoples' Friendship University of Russia, Moscow, Russia
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8
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Tartaglia D, Marin JN, Nicoli AM, De Palma A, Picchi M, Musetti S, Cremonini C, Salvadori S, Coccolini F, Chiarugi M. Predictive factors of mortality in open abdomen for abdominal sepsis: a retrospective cohort study on 113 patients. Updates Surg 2021; 73:1975-1982. [PMID: 33683639 PMCID: PMC8500907 DOI: 10.1007/s13304-021-01012-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/22/2021] [Indexed: 11/26/2022]
Abstract
Over the past few years, the open abdomen (OA) as a part of Damage Control Surgery (DCS) has been introduced as a surgical strategy with the intent to reduce the mortality of patients with severe abdominal sepsis. Aims of our study were to analyze the OA effects on patients with abdominal sepsis and identify predictive factors of mortality. Patients admitted to our institution with abdominal sepsis requiring OA from 2010 to 2019 were retrospectively analyzed. Primary outcomes were mortality, morbidity and definitive fascial closure (DFC). Comparison between groups was made via univariate and multivariate analyses. On 1474 patients operated for abdominal sepsis, 113 (7.6%) underwent OA. Male gender accounted for 52.2% of cases. Mean age was 68.1 ± 14.3 years. ASA score was > 2 in 87.9%. Mean BMI, APACHE II score and Mannheim Peritonitis Index were 26.4 ± 4.9, 15.3 ± 6.3, and 22.6 ± 7.3, respectively. A negative pressure wound system technique was used in 47% of the cases. Overall, mortality was 43.4%, morbidity 76.6%, and DFC rate was 97.8%. Entero-atmospheric fistula rate was 2.2%. At multivariate analysis, APACHE II score (OR 1.18; 95% CI 1.05-1.32; p = 0.005), Frailty Clinical Scale (OR 4.66; 95% CI 3.19-6.12; p < 0.0001) and ASA grade IV (OR 7.86; 95% CI 2.18-28.27; p = 0.002) were significantly associated with mortality. OA seems to be a safe and reliable treatment for critically ill patients with severe abdominal sepsis. Nonetheless, in these patients, co-morbidity and organ failure remain the major obstacles to a better prognosis.
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Affiliation(s)
- Dario Tartaglia
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy.
| | - Jacopo Nicolò Marin
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Alice Maria Nicoli
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Andrea De Palma
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Martina Picchi
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Serena Musetti
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Camilla Cremonini
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Stefano Salvadori
- Consiglio Nazionale delle Ricerche Area della Ricerca di Pisa, Pisa, Toscana, Italy
| | - Federico Coccolini
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Massimo Chiarugi
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
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9
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Lebedev NV, Agrba SB, Popov VS, Klimov AE, Svanadze GT. New System For Predicting The Outcome Of Secondary Peritonitis. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Despite improvements in the methods of diagnostics, surgical interventions and intensive care, the problem of treating patients with diffuse peritonitis remains relevant. Diffuse peritonitis is a major contributor to mortality in all urgent care settings and the second leading cause of sepsis in critically ill patients. At the same time, even in developed countries, the number of patients with peritonitis does not tend to decrease, and mortality rates remain high, reaching 90-93% with the development of abdominal sepsis and toxic shock syndrome. One of the ways to reduce mortality in peritonitis is the use of objective systems for prognosis of the peritonitis outcome, allowing to compare the results of patient treatment and to choose the optimal treatment tactics for each particular patient. The objective — To develop a new system for predicting the outcome of secondary peritonitis (survival or death) focused on the criteria of abdominal sepsis and multiple organ dysfunction syndrome (associated or not associated with peritonitis), and to analyze its accuracy versus the most common comparable systems. Material and Methods — Our study was based on analyzing the treatment outcomes in 352 patients with secondary diffuse peritonitis. On admission, sepsis was diagnosed in 15 (4.3%), and toxic shock in 4 (1.1%) patients. The main causes of death were purulent intoxication and/or sepsis (51 cases or 87.9%), cancer intoxication (4 cases or 6.9%), and acute cardiac failure (3 cases or 5.2%). We analyzed the effectiveness of several systems of predicting the peritonitis outcomes: the Mannheim’s Peritoneal Index (MPI), World Society for Emergency Surgery Sepsis Severity Score (WSES SSS), Acute Physiology and Chronic Health Evaluation II (APACHE II) system, general Sequential Organ Failure Assessment Score (gSOFA), as well as the Peritonitis Prognosis System (PPS) developed by the authors. The probability of the effect of 40 clinical and laboratory parameters on the outcome of patients with secondary peritonitis was analyzed via using parametric and nonparametric methods of statistical analysis (Fisher’s test, Mann-Whitney U test, Chi-squared test with Yates’s continuity correction). The criteria were selected that had a predictive power for the lethal outcome (p <0.05), and they were included in the PPS system. To compare the predictive value of the PPS, ROC analysis was conducted with construction of receiver operating characteristic curves for each analyzed system of predicting the peritonitis outcome. The STATISTICA 8 software was used for performing the statistical analysis. Results — The following criteria were of greatest importance in predicting the lethal outcome: a patient’s age, a presence of a malignant neoplasm, a nature of the exudate, the development of sepsis (toxic shock), as well as multiple organ dysfunction not associated with the developed peritonitis. PPS exhibited the greatest accuracy in terms of predicting mortality in patients with secondary diffuse peritonitis (AUC=0.942) versus minimal in APACHE II (AUC=0.840). Conclusion — APACHE II, MPI, WSES SSS and PPS can be considered reliable in terms of mortality prognosis in peritonitis patients. PPS has the greatest accuracy of predicting the mortality in patients with secondary diffuse peritonitis (94%).
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Affiliation(s)
| | - Sariya B. Agrba
- Burdenko National Medical Research Center for Neurosurgery, Moscow, Russia
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10
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Outcome in patients with open abdomen treatment for peritonitis: a multidomain approach outperforms single domain predictions. J Clin Monit Comput 2021; 36:1109-1119. [PMID: 34247307 PMCID: PMC9294021 DOI: 10.1007/s10877-021-00743-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/07/2021] [Indexed: 11/12/2022]
Abstract
Numerous patient-related clinical parameters and treatment-specific variables have been identified as causing or contributing to the severity of peritonitis. We postulated that a combination of clinical and surgical markers and scoring systems would outperform each of these predictors in isolation. To investigate this hypothesis, we developed a multivariable model to examine whether survival outcome can reliably be predicted in peritonitis patients treated with open abdomen. This single-center retrospective analysis used univariable and multivariable logistic regression modeling in combination with repeated random sub-sampling validation to examine the predictive capabilities of domain-specific predictors (i.e., demography, physiology, surgery). We analyzed data of 1,351 consecutive adult patients (55.7% male) who underwent open abdominal surgery in the study period (January 1998 to December 2018). Core variables included demographics, clinical scores, surgical indices and indicators of organ dysfunction, peritonitis index, incision type, fascia closure, wound healing, and fascial dehiscence. Postoperative complications were also added when available. A multidomain peritonitis prediction model (MPPM) was constructed to bridge the mortality predictions from individual domains (demographic, physiological and surgical). The MPPM is based on data of n = 597 patients, features high predictive capabilities (area under the receiver operating curve: 0.87 (0.85 to 0.90, 95% CI)) and is well calibrated. The surgical predictor “skin closure” was found to be the most important predictor of survival in our cohort, closely followed by the two physiological predictors SAPS-II and MPI. Marginal effects plots highlight the effect of individual outcomes on the prediction of survival outcome in patients undergoing staged laparotomies for treatment of peritonitis. Although most single indices exhibited moderate performance, we observed that the predictive performance was markedly increased when an integrative prediction model was applied. Our proposed MPPM integrative prediction model may outperform the predictive power of current models.
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11
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Lebedev NV, Popov VS, Klimov AE, Svanadze GT. [Comparative assessment of prognostic systems for secondary peritonitis outcome]. Khirurgiia (Mosk) 2021:27-31. [PMID: 33570351 DOI: 10.17116/hirurgia202102127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To compare the most common prognostic systems in patients with peritonitis. MATERIAL AND METHODS The study included 352 patients with secondary peritonitis. At admission, sepsis was diagnosed in 15 (4.3%) patients, septic shock - in 4 (1.1%) cases. Mortality was associated with the following main causes: purulent intoxication and/or sepsis - 51 cases (87.9%), cancer-induced intoxication - 4 (6.9%) cases, acute cardiovascular failure - 3 cases (5.2%). We analyzed the efficacy of Manheim Peritoneal Index (MPI), WSES prognostic score, APACHE-II scale, gSOFA score and Peritonitis Prediction System (PPS) developed by the authors. RESULTS Age of a patient, malignant tumor, exudate nature, sepsis (septic shock) and organ failure not associated with peritonitis are the most important criteria in predicting fatal outcome. ROC analysis was used to assess prognostic value of various prediction systems. Standard error was less than 0.05 for all scales. Therefore, all prediction systems can be considered accurate for prediction of mortality in patients with peritonitis. CONCLUSION PPS (AUC 0.942) has the greatest accuracy in predicting fatal outcome in patients with advanced secondary peritonitis, APACHE II (AUC 0.840) - minimum accuracy. MPI had predictive accuracy > 90% too.
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Affiliation(s)
- N V Lebedev
- Peoples' Friendship University of Russia, Moscow, Russia
| | - V S Popov
- Peoples' Friendship University of Russia, Moscow, Russia
| | - A E Klimov
- Peoples' Friendship University of Russia, Moscow, Russia
| | - G T Svanadze
- Peoples' Friendship University of Russia, Moscow, Russia
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Räty P, Mentula P, Lampela H, Nykänen T, Helanterä I, Haapio M, Lehtimäki T, Skrifvars MB, Vaara ST, Leppäniemi A, Sallinen V. INtravenous Contrast computed tomography versus native computed tomography in patients with acute Abdomen and impaired Renal functiOn (INCARO): a multicentre, open-label, randomised controlled trial - study protocol. BMJ Open 2020; 10:e037928. [PMID: 33028554 PMCID: PMC7539602 DOI: 10.1136/bmjopen-2020-037928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION CT is the primary imaging option for acute abdominal pain in adults. Intravenous (IV) contrast media use improves CT quality but may cause post-contrast acute kidney injury (PC-AKI). Retrospective studies show no association between reduced baseline renal function and IV contrast CT, but, to our knowledge, no data from randomised controlled trials exist. METHODS AND ANALYSIS The INCARO (INtravenous Contrast computed tomography versus native computed tomography in patients with acute Abdomen and impaired Renal functiOn) trial is a multicentre, open-label, parallel group, superiority, individually randomised controlled trial comparing IV contrast-enhanced CT to native CT in patients requiring emergency abdominal or body CT with impaired renal function defined as an estimated glomerular filtration rate (eGFR) of 15 to 45 mL/min/1.73 m2. The primary outcome is a composite of all-cause mortality or renal replacement therapy (RRT) within 90 days from CT. Secondary outcomes are AKI measured by KDIGO (The Kidney Disease: Improving Global Outcomes) criteria within 72 hours from CT, organ dysfunction defined by mSOFA (modified Sequential Organ Failure Assessment) criteria after 48 hours from CT, alive and hospital-free days within 90 days after CT, and time from imaging to definitive treatment. All-cause mortality, need for RRT and renal transplant in long-term follow-up are also measured. The calculated sample size is 994 patients. Patient recruitment is estimated to take 3 years. ETHICS AND DISSEMINATION The Ethics Committee of Helsinki University Hospital approved the study. The findings will be disseminated in peer-reviewed academic journals. TRIAL REGISTRATION NUMBER NCT04196244.
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Affiliation(s)
- Panu Räty
- Department of Abdominal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Panu Mentula
- Department of Abdominal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Lampela
- Department of Abdominal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Taina Nykänen
- Department of Surgery, Hyvinkää Hospital, Hyvinkää, Finland
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Haapio
- Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Lehtimäki
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Suvi T Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ari Leppäniemi
- Department of Abdominal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Abdominal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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13
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Tolonen M, Kuuliala K, Kuuliala A, Leppäniemi A, Kylänpää ML, Sallinen V, Puolakkainen P, Mentula P. The Association Between Intra-abdominal View and Systemic Cytokine Response in Complicated Intra-abdominal Infections. J Surg Res 2019; 244:436-443. [PMID: 31326710 DOI: 10.1016/j.jss.2019.06.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/03/2019] [Accepted: 06/20/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND There is a wide variety of disease severity in patients with complicated intraabdominal infection (cIAI). The prognostic role of intraabdominal view (IAV) was recently studied, and an IAV score was introduced. The aim of this study was to analyze the associations between the preoperative levels of eight relevant circulating cytokines and IAV components, the IAV score, as well as outcome. MATERIALS AND METHODS This was a single-center prospective study. The study cohort consisted of operatively managed adult patients with a cIAI. Preoperative plasma levels of eight cytokines were determined. The operating surgeon filled a form describing IAV. Outcomes analyzed were 30-day mortality and the development of organ dysfunctions requiring intensive care unit admission. RESULTS A total of 131 patients with cIAI were analyzed, 30-day mortality was 9.9% (n = 13), and 28 (21.4%) patients had postoperative organ dysfunctions. All components of IAV, the IAV score, and outcomes were associated with various cytokine levels. Interleukin-8 was the most competent marker associating with all the variables assessed in this study: diffuse peritonitis (P < 0.001), substantial diffuse redness (P = 0.012), substantial diffuse fibrin (P = 0.003), fecal or bile as exudate (P = 0.001), nonappendiceal source of infection (P < 0.001), IAV Score groups (P < 0.001), organ dysfunctions (P < 0.001), and 30-day mortality (P = 0.035). CONCLUSIONS Various cytokines associate with the IAV and outcome. IL-8 showed the best overall performance. The results emphasize the role of the surgeons' perception of the IAV. IAV provides an approximation of the magnitude of the systemic inflammatory response.
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Affiliation(s)
- Matti Tolonen
- Department of Abdominal Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Krista Kuuliala
- Bacteriology and Immunology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Kuuliala
- Bacteriology and Immunology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ari Leppäniemi
- Department of Abdominal Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marja-Leena Kylänpää
- Department of Abdominal Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Abdominal Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Department of Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pauli Puolakkainen
- Department of Abdominal Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Department of Abdominal Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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14
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Tolonen M, Sallinen V, Leppäniemi A, Bäcklund M, Mentula P. The role of the intra-abdominal view in complicated intra-abdominal infections. World J Emerg Surg 2019; 14:15. [PMID: 30976292 PMCID: PMC6441193 DOI: 10.1186/s13017-019-0232-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/05/2019] [Indexed: 12/29/2022] Open
Abstract
Background The prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality. Methods The study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission. Results A total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05–3.73), diffuse peritonitis (OR 2.15, 1.02–4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12–15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11–30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions. Conclusions The extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems. Trial registration The study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932). Electronic supplementary material The online version of this article (10.1186/s13017-019-0232-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matti Tolonen
- 1Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Ville Sallinen
- 1Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland.,2Abdominal Center, Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ari Leppäniemi
- 1Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Minna Bäcklund
- 3Department of Anesthesiology, Intensive Care and Pain Medicine, Division of Intensive Care Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- 1Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland
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15
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Tolonen M, Coccolini F, Ansaloni L, Sartelli M, Roberts DJ, McKee JL, Leppaniemi A, Doig CJ, Catena F, Fabian T, Jenne CN, Chiara O, Kubes P, Kluger Y, Fraga GP, Pereira BM, Diaz JJ, Sugrue M, Moore EE, Ren J, Ball CG, Coimbra R, Dixon E, Biffl W, MacLean A, McBeth PB, Posadas-Calleja JG, Di Saverio S, Xiao J, Kirkpatrick AW. Getting the invite list right: a discussion of sepsis severity scoring systems in severe complicated intra-abdominal sepsis and randomized trial inclusion criteria. World J Emerg Surg 2018; 13:17. [PMID: 29636790 PMCID: PMC5889572 DOI: 10.1186/s13017-018-0177-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/13/2018] [Indexed: 12/24/2022] Open
Abstract
Background Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database. Methods All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality. Results Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality). Conclusions No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission. Trial registration https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.
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Affiliation(s)
- Matti Tolonen
- 1Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Federico Coccolini
- 2Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Bufalini Hospital of Cesena, Cesna, Italy
| | | | - Derek J Roberts
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada
| | - Jessica L McKee
- 6Regional Trauma Services, Foothills Medical Centre, Calgary, Canada
| | - Ari Leppaniemi
- 1Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Christopher J Doig
- 7Departments of Critical Care Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Fausto Catena
- 8Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Timothy Fabian
- 9University of Tennessee Health Sciences Center, Memphis, TN USA
| | - Craig N Jenne
- 10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
| | - Osvaldo Chiara
- General Surgery and Trauma Team Niguarda Hospital Milano, Milan, Italy
| | - Paul Kubes
- 12Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada.,13Departments of Physiology and Pharmacology Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Gustavo P Fraga
- 15Division of Trauma Surgery, University of Campinas, Campinas, SP Brazil
| | - Bruno M Pereira
- 16Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Jose J Diaz
- 17Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School on Medicine, Baltimore, MD USA
| | - Michael Sugrue
- 18Letterkenny University Hospital, Donegal Clinical Research Academy, Donegal, Ireland
| | - Ernest E Moore
- 19Trauma and Critical Care Research, University of Colorado, Denver, CO USA
| | - Jianan Ren
- 20Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chad G Ball
- 21Acute Care, and Hepatobiliary Surgery, and Regional Trauma Services, University of Calgary, Calgary, Alberta Canada
| | - Raul Coimbra
- 22Riverside University Health System Medical Center, Moreno Valley, USA.,23Loma Linda University School of Medicine, Loma Linda, CA USA
| | - Elijah Dixon
- 24Surgery, Oncology, and Community Health Sciences, City Wide Section of General Surgery, University of Calgary, Calgary, Alberta Canada
| | - Walter Biffl
- 25Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, California USA
| | - Anthony MacLean
- 26Division of General Surgery Foothills Medical Centre, Department of Surgery, University of Calgary, Calgary, Canada
| | - Paul B McBeth
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada.,10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada.,27The Trauma Program, University of Calgary, Calgary, Alberta Canada
| | | | - Salomone Di Saverio
- 28Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Jimmy Xiao
- 6Regional Trauma Services, Foothills Medical Centre, Calgary, Canada
| | - Andrew W Kirkpatrick
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada.,10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada.,27The Trauma Program, University of Calgary, Calgary, Alberta Canada.,29EG23 Foothills Medical Centre, Calgary, Alberta T2N 2T9 Canada
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16
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Open abdomen with vacuum-assisted wound closure and mesh-mediated fascial traction in patients with complicated diffuse secondary peritonitis: A single-center 8-year experience. J Trauma Acute Care Surg 2017; 82:1100-1105. [PMID: 28338592 DOI: 10.1097/ta.0000000000001452] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Open abdomen (OA) treatment in patients with peritonitis is increasing worldwide. Various temporary abdominal closure devices are being used. This study included patients with complicated diffuse secondary peritonitis, OA, and vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). The aim of this study was to describe mortality and major morbidity in terms of delayed primary fascial closure and enteroatmospheric fistula rates. METHODS This was a single-academic-center retrospective study of consecutive patients with diffuse peritonitis, OA, and VAWCM between years 2008 and 2016. Descriptive and univariate analyses were performed. RESULTS Forty-one patients were identified and analyzed. Median age was 59 years, preoperative septic shock was diagnosed in 54% (n = 22), and 59% (n = 24) had a postoperative peritonitis. Mortality was 29% (n = 12), and 76% (n = 31) of patients were admitted in the intensive care unit. The median duration of OA was 7 days with a median of two dressing changes. Delayed primary fascial closure rate among survivors was 92% (n = 33), and enteroatmospheric fistulas developed in 7% (n = 3). In a subgroup analysis, patients with OA in the primary laparotomy for peritonitis (n = 27) were compared with patients with OA in the subsequent laparotomies (n = 14). There were no significant differences between groups. CONCLUSIONS The VAWCM technique in patients with complicated secondary diffuse peritonitis and OA yields excellent results in terms of delayed primary fascial closure rate and a low number of enteroatmospheric fistulas. It seems to be safe to close the abdomen at the index laparotomy, if possible, even if there is a risk of a need of OA later. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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17
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Guercio G, Augello G, Licari L, Dafnomili A, Raspanti C, Bagarella N, Falco N, Rotolo G, Fontana T, Porello C, Gulotta G. Acute appendicitis: should the laparoscopic approach be proposed as the gold standard? Six-year experience in an Emergency Surgery Unit. G Chir 2017; 37:174-179. [PMID: 27938536 DOI: 10.11138/gchir/2016.37.4.174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute appendicitis is common in an Emergency Surgery Unit. Although the laparoscopic approach is a method accepted for its treatment, no strong data are available for determining how many procedures must an experienced surgeon carry out for obtaining all the advantages of this technique and if this approach can become the gold standard in the activity of a general emergency unit with senior surgeons variously skilled on the basic laparoscopy. 142 patients that underwent appendectomy (90 laparoscopic, 52 conventional) for acute appendicitis were enrolled in this institutional retrospective cohort study. The surgeons were classified with a descriptor-based grading and divided in two groups regarding the skill. The only relevant result of our study was the significant reduction of conversion rate in case of laparoscopic approach. No strong differences were found concerning the duration of the procedure and the hospital stay between the two groups. The rate of complications were very low in both groups. In conclusion, the experienced surgeons can easily perform a laparoscopic approach independently from the specific skill in this approach.
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