Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality, a Cohort of 191 Patients.

BACKGROUND: Postoperative peritonitis (POP) following gastrointestinal surgery is associated with significant morbidity and mortality, with no clear management option proposed. The aim of this study was to report our surgical management of POP and identify pre- and perioperative risk factors for morbidity and mortality. METHODS: All patients with POP undergoing relaparotomy in our department between January 2004 and December 2013 were included. Pre- and perioperative data were analyzed to identify predictors of morbidity and mortality. RESULTS: A total of 191 patients required relaparotomy for POP, of which 16.8% required >1 reinterventions. The commonest cause of POP was anastomotic leakage (66.5%) followed by perforation (20.9%). POP was mostly treated by anastomotic takedown (51.8%), suture with derivative stoma (11.5%), enteral resection and stoma (12%), drainage of the leak (8.9%), stoma on perforation (8.4%), duodenal intubation (7.3%) or intubation of the leak (3.1%). The overall mortality rate was 14%, of which 40% died within the first 48 h. Major complications (Dindo-Clavien > 2) were seen in 47% of the cohort. Stoma formation occurred in 81.6% of patients following relaparotomy. Independent risk factors for mortality were: ASA > 2 (OR = 2.75, 95% CI = 1.07-7.62, p = 0.037), multiorgan failure (MOF) (OR = 5.22, 95% CI = 2.11-13.5, p = 0.0037), perioperative transfusion (OR = 2.7, 95% CI = 1.05-7.47, p = 0.04) and upper GI origin (OR = 3.55, 95% CI = 1.32-9.56, p = 0.013). Independent risk factors for morbidity were: MOF (OR = 2.74, 95% CI = 1.26-6.19, p = 0.013), upper GI origin (OR = 3.74, 95% CI = 1.59-9.44, p = 0.0034) and delayed extubation (OR = 0.27, 95% CI = 0.14-0.55, p = 0.0027). CONCLUSION: Mortality following POP remains a significant issue; however, it is decreasing due to effective and aggressive surgical intervention. Predictors of poor outcomes will help tailor management options.

Evaluation of the effect of a laparoscopic robotized needle holder on ergonomics and skills.

BACKGROUND: Laparoscopy generates technical and ergonomics difficulties due to limited degrees of freedom (DOF) of forceps. To reduce this limitation, a new 5-mm robotized needle holder with two intracorporeal DOF, Jaimy(®), has been developed. The aim of this study was to evaluate its effects on ergonomics and skills. METHODS: Fourteen surgeons including eight senior and six residents were crossover randomized and stratified based on experience. Three suturing tasks were performed with both Jaimy(®) and a classic needle holder (NH): task 1: Peg-Board; task 2: hexagonal suture; task 3: frontal suture. Postural ergonomics of the dominant arm were evaluated with an ergonomics score (RULA score) thanks to motion capture, and muscular ergonomics with electromyography of six muscular groups (flexor and extensor carpis, biceps, triceps, deltoid, trapeze). Performance outcomes are a quantitative and qualitative score, and skills outcomes are the measurement of the number of movements and the path length travelled by the instrument. RESULTS: The RULA score showed a statistically improved posture with Jaimy(®) (p < 0.001). The cumulative muscular workload (CMW) of four muscles was not different. However, the CMW was in favor of the NH for the flexor carpi ulnaris (p < 0.001) and the triceps (p = 0.027). The number of movements was not different (p = 0.39) although the path length was shorter with Jaimy(®) (p = 0.012). The score for task 1 was in favor of the NH (p = 0.006) with a higher quantity score. Task 2 score was not different (p = 0.086): The quality part of the score was in favor of Jaimy(®) (p = 0.009) and the quantity part was higher with the NH (p = 0.04). The score for task 3 was higher with Jaimy(®) (p = 0.001). CONCLUSION: This study suggests that the use of a robotized needle holder improves both posture and the quality of laparoscopic sutures.