Septic necrosis of the midline wound in postoperative peritonitis. Successful management by debridement, myocutaneous advancement, and primary skin closure

The Role of Dermal Regeneration Template in Anterior Abdominal Wall Defect after Burst Abdomen: A Case Report in Acute Graft Versus Host Disease of the Gastrointestinal Tract in Aplastic Anemia

Acute graft-versus-host disease of the gastrointestinal tract (GI-aGVHD) is a rare condition, often requiring multiple laparotomies, ultimately leading to a burst abdomen. We report the successful use of a dermal regeneration template (DRT), combined with negative pressure wound therapy (NPWT) and skin grafts, to reconstruct the abdominal skin in an 11-year-old boy. The patient was a case of aplastic anemia, who underwent bone marrow transfers, the first of which failed and the second one was successful. He eventually developed gastrointestinal GVHD. Repeated laparotomies were done for recurrent intestinal obstruction. He also underwent resection anastomosis and end ileostomy, after which he developed an anterior abdominal wall defect due to a burst abdomen. After 12 months of management with multiple dressings, NPWT, and DRT, a stable coverage was achieved, without skin retraction. We report our experience in anterior abdominal wall reconstruction in a case of GI-aGVHD using DRT.

Early Definitive Closure of the Open Abdomen: A Quiet Revolution

Contrary to the management strategy recommended only 2-3 years ago, temporarily covering the open abdomen with an absorbable mesh or a plastic sheath without preserving the peritoneal space is no longer considered in the patient's best interest. The use of the vacuum pack, in conjunction with vacuum-assisted wound management and new biological prostheses now offer patients with an open abdomen a better and simpler alternative to the giant "planned ventral hernia". With very few exceptions in the most critically ill patients, the survivors of damage control surgery or infected pancreatic necrosis should not be sent home with a huge defect only to undergo a complex reconstruction a year later. Simpler and better alternatives exist. The new concepts and technologies presented in this review, when widely adopted, will rapidly translate into safer and better management of the patient with an open abdomen.

Results of an aggressive surgical approach in the management of postoperative peritonitis

BACKGROUND

Treatment of postoperative peritonitis (POP) necessitates adequate control of the source of peritoneal contamination. For most patients, a surgical approach to this requires reoperation to restore intestinal continuity. The aim of this study was to audit our results for the surgical treatment of POP.

METHODS

Medical records of patients treated for POP using a standardized surgical protocol in a dedicated intensive care unit at the Saint-Antoine Hospital between 1995 and 2003 were reviewed. The aim of the study was to consider the effectiveness of our surgical protocol in the eradication of all sources of peritoneal contamination in patients presenting with POP.

RESULTS

There were 87 patients (34 women, mean age of 58.4 +/- 14.7) with a mean Acute Physiology and Chronic Health Evaluation II score of 17.2 +/- 4.7 (median 16.5, range 9-28). Eight patients died and there were complications in 60 patients. Nine patients of the 79 survivors either did not require or could not have an operation to restore intestinal continuity. Intestinal continuity was re-established through a parastomal incision for 26 patients, whereas 44 patients required a further laparotomy. Two patients of the latter group died and 11 patients had a complication. It was not possible to restore intestinal continuity at laparotomy for one patient.

CONCLUSION

An aggressive surgical approach, as reported in this series, including stoma formation whenever possible, diversion or intubation, provides effective control of the source of peritoneal contamination. Restoration of intestinal continuity is possible in most patients. The overall mortality rate for this treatment is 11.5%.

A new technique in closure of burst abdomen: TI, TIE and TIES incisions

BACKGROUND

Burst abdomen is a continuing problem for the general surgeon as the incidence of such complication may reach 3% with a mortality rate exceeding 25%.

METHODS

New technique: A lateral incision is done from inside the abdomen along a line between the costal margin above to the iliac crest below in the area between the mid and anterior axillary line. According to the depth of the incision, the incision may either involve the transversus abdominus and internal oblique muscles (TI incision), or include in addition the external oblique muscle (TIE incision), or it may also involve the Scarpa's fascia (TIES incision). Such incisions would give an extra length on each side towards medial advancement. Eight patients, 5 men and 3 women aged 34-67 years, with burst abdomen after major gastrointestinal and hepatobiliary surgery failed to close primarily were managed using this technique. Long-term follow-up patients was done for development of complications. Electromyogram (EMG) for the rectus muscle and sensory loss for the abdominal wall were also tested. The distance between the 2 cut edges of the different release incisions was measured clinically (TIES incisions) or using ultrasound device (TI and TIE incisions). Scarpa's fascia biopsy was taken from 1 patient of the TIE group for histopathological study 6 years after surgery.

RESULTS

One patient died on the third postoperative day (mortality 12.5%), and 2 patients developed sub-incisional abscesses (25%). No single case of re-burst occurred. Long-term follow-up showed no single case of incisional hernia in the site of the midline surgical incision, but incisional hernia did occur in all the sites of TIES incisions. Incisional hernia did not occur in the TI incision and, more strangely, neither did it occur in any of the TIE incisions. Follow-up of the incisions width showed a significant increase in width of the TIES with time while there was no significant increase in that of the TI or TIE. There was a sensory loss at and below the level of umbilicus in the TIES group. EMG showed evidence of motor affection to the rectus muscle at and below the level of the umbilicus in all groups. Scarpa's fascia biopsy was taken to try to find an explanation for the absence of incisional hernia in TIE incisions and was found to be 3 times as thick and the type I collagen was replaced by collagen type III.

CONCLUSION

The new method described is simple, straightforward and tension free, with a comparable mortality and morbidity. The Scarpa's fascia adaptation and its ability to change have enormous applications in general and reconstructive surgery, but further evaluation of such phenomenon is needed.

Management of postoperative peritonitis after anterior resection: experience from a referral intensive care unit

PURPOSE

Anastomotic leakage is the main cause of death after anterior resection. If it causes a single abscess, it may be successfully cured by percutaneous drainage, but in case of extensive peritoneal infection (multiple abscesses and generalized peritonitis), it is associated with a 40 to 60 percent mortality. This study aimed at evaluating aggressive, one-stage surgical management in such cases.

METHODS

All patients referred to our surgical intensive care unit during the past ten years with generalized, multilocular, intra-abdominal sepsis after anterior resection were reviewed. There were 32 patients, with a mean age of 65 years, among which 15 (47 percent) were referred from other institutions. The mean Acute Physiology and Chronic Health Evaluation II score on admission was 18. All patients underwent a laparotomy with complete peritoneal exploration, intraoperative lavage, fecal diversion, capillary drainage of the pelvis excluding the rectal stump or the leaking anastomosis from the peritoneal cavity, and primary closure of the abdomen. A Hartmann's operation was done in 22 cases, and conservation of the anastomosis with proximal colostomy was done in 10 cases. The choice was based on the size of the leak, the viability of the colon, and the site of the anastomosis.

RESULTS

Four patients died (12 percent), and five patients (16 percent) had recurrent sepsis. When the anastomosis had been conserved, restoration of continuity was achieved in all cases. After Hartmann's operation 8 patients of 19 survivors kept a permanent stoma; 7 had undergone a low anterior resection.

CONCLUSIONS

Extensive intra-abdominal infection after anterior resection may be efficiently controlled by a surgical approach combining peritoneal debridement, fecal diversion, and capillary drainage of the pelvis. Intestinal continuity may be restored after diversion stoma or Hartmann's procedure after high anterior resection. This is not the case after a Hartmann's operation after a low colorectal anastomosis, and this procedure should be avoided whenever possible.

Postoperative peritonitis originating from the duodenum: operative management by intubation and continuous intraluminal irrigation

BACKGROUND

The mortality rate associated with postoperative peritonitis remains high, especially when the source of infection cannot be eradicated. Such is the case with peritonitis arising from the duodenum, as primary closure is futile and intubation alone may be followed by local complications.

METHODS

Forty-nine consecutive patients with postoperative peritonitis originating from a duodenal leak and a mean Acute Physiology And Chronic Health Evaluation II score of 17.7 were treated according to the following procedure: a three-channelled spiral drain was inserted through the leak and extraluminal drains were placed near the duodenal defect. Intraluminal irrigation was undertaken immediately through the infusion channel of the spiral drain.

RESULTS

Eleven patients died and 26 suffered complications. The mean duration of intubation was 21 days.

CONCLUSION

Intubation with intraluminal irrigation has proved effective in a homogeneous group of patients with peritonitis due to duodenal leakage.

Management of secondary peritonitis

OBJECTIVE

The authors review current definition, classification, scoring, microbiology, inflammatory response, and goals of management of secondary peritonitis.

SUMMARY BACKGROUND DATA

Despite improved diagnostic modalities, potent antibiotics, modern intensive care, and aggressive surgical treatment, up to one third of patients still die of severe secondary peritonitis. Against the background of current understanding of the local and systemic inflammatory response associated with peritonitis, there is growing controversy concerning the optimal antibiotic and operative therapy, intensified by lack of properly conducted randomized studies. In this overview the authors attempt to outline controversies, suggest a practical clinical approach, and highlight issues necessitating further research.

METHODS

The authors review the literature and report their experience.

RESULTS

The emerging concepts concerning antibiotic treatment suggest that less-in terms of the number of drugs and the duration of treatment-is better. The classical single operation for peritonitis, which obliterates the source of infection and purges the peritoneal cavity, may be inadequate for severe forms of peritonitis; for the latter, more aggressive surgical techniques are necessary to decompress increased intra-abdominal pressure and prevent or treat persistent and recurrent infection. The widespread acceptance of the more aggressive and demanding surgical methods has been hampered by the lack of randomized trials and reportedly high associated morbidity rates.

CONCLUSIONS

Sepsis represents the host's systemic inflammatory response to bacterial peritonitis. To improve results, both the initiator and the biologic consequences of the peritoneal infective-inflammatory process should be addressed. The initiator may be better controlled in severe forms of peritonitis by aggressive surgical methods, whereas the search for methods to abort its systemic consequences is continuing.

Reconstructive abdominal operations after laparostomy and multiple repeat laparotomies for severe intra-abdominal infection

Between 1980 and 1993, 18 patients underwent formal laparotomy after laparostomy and healing of the peritoneal cavity by granulation. The majority (12 patients) were men and the median age was 47 (range 22-67) years. Intraabdominal infection following surgery for Crohn's disease (four patients) and necrotizing pancreatitis (six) was the most common primary condition requiring laparostomy. A total of 23 reconstructive operations were carried out on the 18 patients a median of 6 (range 1-18) months after laparostomy. The indication for surgery was for closure and/or resection of an enteric fistula in 13 patients. The site of the fistula included three gastric, two duodenal, 11 small bowel and seven colonic. A further four patients required operation for closure or refashioning of a stoma. Five patients subsequently required a second laparotomy: two for elective restoration of bowel continuity, two for recurrent fistula and one for an acute abdomen. After reconstructive surgery following laparostomy 16 patients were discharged home alive and well, one requiring home parenteral nutrition for short bowel syndrome. In contrast, the two oldest patients in the series died from multiple organ failure immediately after initial reconstructive surgery. Both had pre-existing medical problems and in neither was there evidence of further intra-abdominal infection after reconstruction.

Gastrointestinal fistulas associated with large abdominal wall defects: experience with 43 patients

Experience with 43 patients with gastrointestinal fistulas associated with a large abdominal wall defect is presented. The overall mortality rate was 60 per cent; 37 per cent in patients who underwent the primary procedure in the home unit and 74 per cent in those from elsewhere. An average of five operations per patient was performed. The abdominal wall defect developed spontaneously as a consequence of postoperative peritonitis in 24 patients (mortality rate, 71 per cent) and was created intentionally as a part of the 'open management' in 19 cases (mortality rate, 47 per cent). Errors in management were identified in 63 per cent of the patients and this adversely influenced the outcome. Patients with this condition should be referred early to tertiary care facilities where diversion of the intestinal leak away from the defect, prompt control of the associated intra-abdominal infection and adequate handling of the defect itself can be performed.

High-output external fistulae of the small bowel: management with continuous enteral nutrition

Three hundred and thirty-five patients with high-output enterocutaneous fistulae arising from the small intestine are reported. Median fistula output was 1350 ml/24 h. Eighty-two per cent of patients were referred from other institutions. The fistula opening was associated with evisceration in 165 cases (49 per cent). One or more severity factors were present in 75.5 per cent of the patients. Patients were divided into three groups according to their initial therapy: 21 patients (6 per cent) referred in a moribund state were not operated on (non-intervention); 80 patients (24 per cent) were operated on as an emergency, and the fistula was either exteriorized or defunctioned; 234 patients (70 per cent) were initially managed conservatively. Appropriate local care and nutrition were provided in all cases. Enteral nutrition was the exclusive nutritional support in 285 patients (85 per cent). In 92 cases with proximal fistulae, methods limiting the fistula output or allowing reinfusion of chyme were required. The overall mortality rate was 34 per cent: 100 per cent in the non-intervention group, 55 per cent after emergency surgery, and 19 per cent after conservative treatment. In the latter group, spontaneous closure was obtained in 88 patients (38 per cent). Overall mortality rate was reduced to 19 per cent in patients treated since 1980. Enteral nutrition with appropriate local care may be used in the majority of high-output enterocutaneous fistulae, with an acceptable rate of spontaneous closure. Conservative management is the treatment of choice in the initial period. Emergency surgery should be restricted to the treatment of haemorrhage or intra-abdominal abscesses associated with uncontrolled systemic sepsis.