Vacuum-assisted closure (VAC) for postoperative secondary peritonitis: Effect on bacterial load as well as local and systemic cytokine response (initial results)

[Surgical wound closure in advanced peritonitis]

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.

Effects of negative-pressure therapy with and without ropivacaine instillation in the early evolution of severe peritonitis in pigs

PURPOSE

The abdomen is the second most common source of sepsis and secondary peritonitis, which likely lead to death. In the present study, we hypothesized that instillation of local anesthetics into the peritoneum might mitigate the systemic inflammatory response syndrome (SIRS) in the open abdomen when combined with negative-pressure therapy (NPT) to treat severe peritonitis.

METHODS

We performed a study in 21 pigs applying a model of sepsis based on ischemia/reperfusion and fecal spread into the peritoneum. The pigs were randomized into three groups, and treated for 6 h as follows: Group A: temporary abdominal closure with ABTHERA™ Open Abdomen Negative-Pressure Therapy; Group B: temporary abdominal closure with ABTHERA™ Open Abdomen Negative-Pressure Therapy plus abdominal instillation with physiological saline solution (PSS); and Group C: temporary abdominal closure with ABTHERA™ Open Abdomen Negative-Pressure Therapy plus peritoneal instillation with a solution of ropivacaine in PPS.

RESULTS

A comparison between the three groups revealed no statistically significant difference for any of the parameters registered (p > 0.05), i.e., intra-abdominal pressure, blood pressure, heart rate, O2 saturation, diuresis, body temperature, and blood levels of interleukin 6 (IL-6), tumor necrosis factor alpha (TNFα), and c-reactive protein (CRP). In addition, histological studies of the liver, ileum, kidney and lung showed no difference between groups.

CONCLUSIONS

The use of abdominal instillation (with or without ropivacaine) did not change the effect of 6 h of NPT after sepsis in animals with open abdomen. The absence of adverse effects suggests that longer treatments should be tested.

Cytokine clearance in serum and peritoneal fluid of patients undergoing damage control surgery with abdominal negative pressure therapy for abdominal sepsis

Objectives

Open abdomen technique with negative pressure therapy (NPT) is widely used in patients with severe abdominal sepsis. The aim of this study was to evaluate cytokine clearance in serum and peritoneal fluid during NPT.

Methods

This prospective pilot study included six patients with severe abdominal sepsis requiring discontinuity resection and NPT for 48 h followed by planned reoperation. Cytokines (IL6, IL8, IL10, TNFalpha, and IL1beta) were measured in the serum and peritoneal fluid during index operation, on postoperative days 0, 1, and 2.

Results

Concentrations of cytokines in peritoneal fluid were higher than in serum. IL10 showed a clearance both in serum (to 16.6%, p=0.019) and peritoneal fluid (to 40.9%, p=0.014). IL6 cleared only in serum (to 24.7%, p=0.001) with persistently high levels in peritoneal fluid. IL8 remained high in both serum and peritoneal fluid. TNFalpha and IL1beta were both low in serum with wide range of high peritoneal concentrations. Only TNFalpha in peritoneal fluid showed significant differences between patients with ischemia vs. perforation (p=0.006).

Conclusions

The present pilot study suggests that cytokines display distinct patterns of clearance or persistence in the peritoneal fluid and serum over the first 48 h of treatment in severe abdominal sepsis with NPT.

Surgical Site Infections Complicating the Use of Negative Pressure Wound Therapy in Renal Transplant Recipients

Surgical site infections (SSI) of the abdominal wall in renal transplant recipients can on occasion require management with negative pressure wound therapy (NPWT). This is often successful, with a low risk of further complications. However, we describe three cases in which persistent or recurrent surgical site sepsis occurred, whilst NPWT was being deployed in adults with either wound dehiscence or initial SSI. This type of complication in the setting of NPWT has not been previously described in renal transplant recipients. Our case series demonstrates that in immunosuppressed transplant recipients, there may be ineffective microbial or bacterial bioburden clearance associated with the NPWT, which can lead to further infections. Hence recognition for infections in renal transplant patients undergoing treatment with NPWT is vital; furthermore, aggressive management of sepsis control with early debridement, antimicrobial use, and reassessment of the use of wound dressing is necessary to reduce the morbidity associated with surgical site infections and NPWT.