Re-evaluation of Mannheim prognostic index in perforative peritonitis: prognostic role of advanced age. A prospective cohort study. Int J Surg. 2015;13:54-59. [PMID: 25475872 DOI: 10.1016/j.ijsu.2014.11.035]

Emergency laparotomy for peritonitis in the elderly: A Multicentre observational study of outcomes in Sub-Saharan Africa

Background

Globally, interest in surgical diseases in the elderly was rekindled recently mainly due to a surge in the aging population and their increased susceptibility to infections. In sub-Saharan Africa, infective diseases are major causes of high morbidity and mortality especially in elderly cohorts, hence this study was set to evaluate current status of this scourge in the elderly in our environment.

Aim

To document the aetiologic factors and analyze the impact of selected clinical and perioperative indices on mortality and morbidity rates of peritonitis in the elderly.

Methods

This was a multicenter prospective study involving elderly patients aged 65years and above managed between October 2015 and September 2021 in Southeast Nigeria.

Results

Of the 236 elderly patients examined, approximately two-third (150, 63.6%) were aged 65-74years. The rest were aged ≥ 75years. There were 142(60.2%) males and 94(39.8%) females. Perforated peptic ulcer (89,37.7%) was the most common cause of peritonitis followed by ruptured appendix (59, 25.0%), then typhoid perforation (44,18.6%). However, typhoid perforation was the deadliest with a crude mortality rate of 40.9%. Overall, morbidity and mortality rates were 33.8% and 28.5% respectively. The main independent predictors of mortality were peritonitis arising from typhoid perforation (p = 0.036), late presentation (p = 0.004), district location of hospital (p = 0.011) and intestinal resection (p = 0.003).

Conclusion

Generalized peritonitis is a cause of significant morbidity and mortality in the elderly patients in our environment. Perforated peptic ulcer was the most common cause, but typhoid perforation remains the deadliest. Late presentation, district hospital setting and bowel resection were associated with elevated mortality.

A comparative analytical study on outcome of secondary peritonitis using Mannheim's peritonitis index in geographically diverse Indian patients

Objectives

Secondary peritonitis is caused by infection of the peritoneal cavity due to perforation of the alimentary tract. Mannheim's peritonitis ındex (MPI) is a prognostic scoring system that predicts outcomes in peritonitis. Increasing MPI scores correlate with poor outcomes and mortality. The objective of this study is to evaluate the effectiveness of MPI-based prognosis and its impact on Indian patients with secondary peritonitis.

Material and Methods

For understanding the effectiveness of the MPI scoring system, a cross-sectional data analysis of published studies on secondary peritonitis from 10 geographical locations in India was performed. The 10-site study results were compared with unpublished in-house study data for individual MPI parameters to analyze any variations of MPI score-based predictions across a diverse Indian population. Patients were divided into risk groups on the basis of MPI scores: <21 mild, MPI= 21-29 moderate, MPI> 29 severe risk.

Results

We observed a significant correlation between mortality with age and gender as reported worldwide. Site of perforations were prevalent in the upper alimentary tract with the majority being gastro-duodenal for the Indian population as opposed to distal parts in the western population. Higher lethality in India is often associated with evolution time, organ failure, and sepsis due to delayed presentation and poor management.

Conclusion

MPI scoring is effective in predicting risk across geographically diverse Indian populations. The sensitivity and specificity of MPI scores are more reliable and a score >29 specifically recommends aggressive resuscitation & monitoring of patients, initiation of broad-spectrum antibiotics, and intensive care support to reduce mortality and morbidity.

Epidemiology and Age-Related Mortality in Critically Ill Patients With Intra-Abdominal Infection or Sepsis: An International Cohort Study

BACKGROUND

The objective of this study is to describe the epidemiology and age-related mortality in older critically ill adults with intra-abdominal infections.

METHODS

This is a secondary analysis of a prospective, multinational, observational study (AbSeS, ClinicalTrials.gov #NCT03270345) including patients with intra-abdominal infection from 309 ICUs in 42 countries (January-December, 2016). Mortality was considered as ICU mortality with a minimum of 28 days of observation when patients were discharged earlier. Relationships with mortality were assessed by logistic regression analysis.

RESULTS

The cohort included 2337 patients. Four age groups were defined: middle-aged patients as reference category (40-59 years; n=659 [28.2%]), young-old (60-69 years; n=622 [26.6%]), middle-old (70-79 years; n=667 [28.5%]) and very-old patients (≥80 years; n=389 [16.6%]). Secondary peritonitis was the predominant infection (68.7%) and equally prevalent across age groups. Mortality increased with age: 20.9% in middle-aged patients, 30.5% in young-old, 31.2% in middle-old, and 44.7% in very-old patients (p<0.001). Compared to middle-aged patients, young-old age (OR 1.62, 95% CI 1.21-2.17), middle-old age (OR 1.80, 95% CI 1.35-2.41), and very-old age (OR 3.69, 95% CI 2.66-5.12) were independently associated with mortality. Other independent risk factors for mortality included late-onset hospital-acquired intra-abdominal infection, diffuse peritonitis, sepsis/septic shock, source control failure, liver disease, congestive heart failure, diabetes, and malnutrition.

CONCLUSIONS

For ICU patients with intra-abdominal infections, age above 60 years was associated with mortality while patients above 80 years had the worst prognosis. Comorbidities and overall disease severity further compromised survival. As all these factors are non-modifiable it remains unclear how to improve outcomes.

Pre and postoperative lactate levels and lactate clearance in predicting in-hospital mortality after surgery for gastrointestinal perforation

Background

This study aimed to compare the prognostic significance of pre and postoperative lactate levels and postoperative lactate clearance in the prediction of in-hospital mortality after surgery for gastrointestinal (GI) perforation.

Methods

Among patients who underwent surgery for GI perforation between 2013 and 2017, only patients whose lactate were measured before and after surgery were included and divided into an in-hospital mortality group and a survival group. Data on demographics, comorbidities, pre and postoperative laboratory test results, and operative findings were collected. Risk factors for in-hospital mortality were identified, and receiver-operating characteristic (ROC) curve analysis was performed for pre and postoperative lactate levels and postoperative lactate clearance.

Results

Of 104 included patients, 17 patients (16.3%) died before discharge. The in-hospital mortality group demonstrated higher preoperative lactate (6.3 ± 5.1 vs. 3.5 ± 3.2, P = 0.013), SOFA score (4.5 ± 1.7 vs. 3.4 ± 2.3, P = 0.004), proportions of patients with lymphoma (23.5% vs. 2.3%, P = 0.006), and rates of contaminated ascites (94.1% vs. 68.2%, P = 0.036) and lower preoperative hemoglobin (10.4 ± 1.6 vs. 11.8 ± 2.4, P = 0.018) compare to the survival group. Multivariate analysis revealed that postoperative lactate (HR 1.259, 95% CI 1.084–1.463, P = 0.003) and preoperative hemoglobin (HR 0.707, 95% CI 0.520–0.959, P = 0.026) affected in-hospital mortality. In the ROC curve analysis, the largest area under the curve (AUC) was shown in the postoperative lactate level (AUC = 0.771, 95% CI 0.678–0.848).

Conclusion

Of perioperative lactate levels in patients underwent surgery for GI perforation, postoperative lactate was the strongest predictor for in-hospital mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01479-1.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study

BACKGROUND

Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA).

METHODS

The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality.

RESULTS

182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications.

CONCLUSIONS

Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.

Clinical evaluation of the Mannheim Prognostic Index in post-operative peritonitis: a prospective cohort study

Postoperative peritonitis (PoP), despite their relatively low incidence, are associated with high mortality. Such poor outcomes are also related to the high proportion of aged patients, whose intra-abdominal infections are difficult to manage. The study included 84 consecutive patients with PoP. The aim was the validation of the Mannheim Prognostic Index (MPI) in the context of PoP and the assessment of the prognostic impact of age and other clinical factors in a large series from a tertiary center. PoP had an incidence of 3.9% in all the abdominal surgeries in the study period. Surgical control of POP focus was achieved in 90.5% of cases and a complete abdominal clearance in 58.3%. Complication rate was 75% with a mortality of 26.2%. For MPI score, the ROC curve indicated a cut-off value of 29 with a sensitivity of 72.7% and specificity of 67.7% in predicting death. At univariate analysis, factors significantly related to poorer prognosis included advanced age (p 0.001), site of primary surgery (p 0.05), lack of abdominal clearance (p 0.003), generalized peritonitis (p 0.04) and high MPI score (p < 0.001). Age, MPI score and absence of abdominal clearance resulted in independent prognostic factors at multivariate analysis. MPI showed good efficacy in identifying POP patients at high risk of death. The increased risk of mortality related to advanced age should be considered with MPI score in planning the treatment. An aggressive and early diagnostic-therapeutic approach is required to reduce the MPI score and improve the prognosis.

Personalized medicine with IgGAM compared with standard of care for treatment of peritonitis after infectious source control (the PEPPER trial): study protocol for a randomized controlled trial

Background

Peritonitis is responsible for thousands of deaths annually in Germany alone. Even source control (SC) and antibiotic treatment often fail to prevent severe sepsis or septic shock, and this situation has hardly improved in the past two decades. Most experimental immunomodulatory therapeutics for sepsis have been aimed at blocking or dampening a specific pro-inflammatory immunological mediator. However, the patient collective is large and heterogeneous. There are therefore grounds for investigating the possibility of developing personalized therapies by classifying patients into groups according to biomarkers. This study aims to combine an assessment of the efficacy of treatment with a preparation of human immunoglobulins G, A, and M (IgGAM) with individual status of various biomarkers (immunoglobulin level, procalcitonin, interleukin 6, antigen D-related human leucocyte antigen (HLA-DR), transcription factor NF-κB1, adrenomedullin, and pathogen spectrum).

Methods/design

A total of 200 patients with sepsis or septic shock will receive standard-of-care treatment (SoC). Of these, 133 patients (selected by 1:2 randomization) will in addition receive infusions of IgGAM for 5 days. All patients will be followed for approximately 90 days and assessed by the multiple-organ failure (MOF) score, by the EQ QLQ 5D quality-of-life scale, and by measurement of vital signs, biomarkers (as above), and survival.

Discussion

This study is intended to provide further information on the efficacy and safety of treatment with IgGAM and to offer the possibility of correlating these with the biomarkers to be studied. Specifically, it will test (at a descriptive level) the hypothesis that patients receiving IgGAM who have higher inflammation status (IL-6) and poorer immune status (low HLA-DR, low immunoglobulin levels) have a better outcome than patients who do not receive IgGAM. It is expected to provide information that will help to close the knowledge gap concerning the association between the effect of IgGAM and the presence of various biomarkers, thus possibly opening the way to a personalized medicine.

Trial registration

EudraCT, 2016–001788-34; ClinicalTrials.gov, NCT03334006. Registered on 17 Nov 2017.

Trial sponsor: RWTH Aachen University, represented by the Center for Translational & Clinical Research Aachen (contact Dr. S. Isfort).

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3244-4) contains supplementary material, which is available to authorized users.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

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

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

Risk factors for mortality in postoperative peritonitis in critically ill patients

AIM

To identify the risk factors for mortality in intensive care patients with postoperative peritonitis (POP).

METHODS

This was a retrospective analysis using a prospective database that includes all patients hospitalized in a surgical intensive care unit for POP from September 2006 to August 2011. The data collected included demographics, comorbidities, postoperative severity parameters, bacteriological findings, adequacy of antimicrobial therapy and surgical treatments. Adequate source control was defined based on a midline laparotomy, infection source control and intraoperative peritoneal lavage. The number of reoperations needed was also recorded.

RESULTS

A total of 201 patients were included. The overall mortality rate was 31%. Three independent risk factors for mortality were identified: The Simplified Acute Physiological II Score (OR = 1.03; 95%CI: 1.02-1.05, P < 0.001), postoperative medical complications (OR = 6.02; 95%CI: 1.95-18.55, P < 0.001) and the number of reoperations (OR = 2.45; 95%CI: 1.16-5.17, P = 0.015). Surgery was considered as optimal in 69% of the cases, but without any significant effect on mortality.

CONCLUSION

The results from the large cohort in this study emphasize the role of the initial postoperative severity parameters in the prognosis of POP. No predefined criteria for optimal surgery were significantly associated with increased mortality, although the number of reoperations appeared as an independent risk factor of mortality.