Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies.

Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed.

Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment.

The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.

Intra-Abdominal Hypertension and Abdominal Compartment Syndrome after Abdominal Wall Reconstruction: Quaternary Syndromes?

BACKGROUND AND AIMS: Reconstruction with reconstitution of the container function of the abdominal compartment is increasingly being performed in patients with massive ventral hernia previously deemed inoperable. This situation places patients at great risk of severe intra-abdominal hypertension and abdominal compartment syndrome if organ failure ensues. Intra-abdominal hypertension and especially abdominal compartment syndrome may be devastating systemic complications with systematic and progressive organ failure and death. We thus reviewed the pathophysiology and reported clinical experiences with abnormalities of intra-abdominal pressure in the context of abdominal wall reconstruction. MATERIAL AND METHODS: Bibliographic databases (1950-2015), websites, textbooks, and the bibliographies of previously recovered articles for reports or data relating to intra-abdominal pressure, intra-abdominal hypertension, and the abdominal compartment syndrome in relation to ventral, incisional, or abdominal hernia repair or abdominal wall reconstruction. RESULTS: Surgeons should thus consider and carefully measure intra-abdominal pressure and its resultant effects on respiratory parameters and function during abdominal wall reconstruction. The intra-abdominal pressure post-operatively will be a result of the new intra-peritoneal volume and the abdominal wall compliance. Strategies surgeons may utilize to ameliorate intra-abdominal pressure rise after abdominal wall reconstruction including temporizing paralysis of the musculature either temporarily or semi-permanently, pre-operative progressive pneumoperitoneum, permanently removing visceral contents, or surgically releasing the musculature to increase the abdominal container volume. In patients without complicating shock and inflammation, and in whom the abdominal wall anatomy has been so functionally adapted to maximize compliance, intra-abdominal hypertension may be transient and tolerable. CONCLUSIONS: Intra-abdominal hypertension/abdominal compartment syndrome in the specific setting of abdominal wall reconstruction without other complication may be considered as a quaternary situation considering the classification nomenclature of the Abdominal Compartment Society. Greater awareness of intra-abdominal pressure in abdominal wall reconstruction is required and ongoing study of these concerns is required.

Emergency room arteriography: an updated digital technology.

BACKGROUND: Emergency room arteriography (ERA) is a safe, accurate, simple and cost-effective method of defining arterial injuries. Limitations include the difficulty of evaluating limb vasculature distal to the suspected site of injury. Statscan is a novel, low-dose digital X-ray machine that can rapidly obtain a whole body image in a single scan. Our goal was to evaluate the role of Statscan technology in ERA. METHODS: A 24 month retrospective review of all patients who underwent a Statscan assisted ERA at the Groote Schuur Hospital Trauma Unit was completed. Indications for ERA included a hemodynamically stable patient with hard signs of a vascular injury in conjunction with the clinical assessment of a threatened limb. Contraindications encompassed instability, massive bleeding or a rapidly expanding hematoma. RESULTS: Ten patients underwent Statscan assisted ERA of their lower limbs. Eight had cold, pulseless limbs with impaired neurological examinations. Common femoral, superficial femoral and popliteal artery lacerations were displayed. Three patients had no identifiable injury and were observed. Seven patients underwent operative management for threatened limbs. Two had Statscan evidence of arterial emboli distal to the site of injury leading to further exploration and distal embolectomy. CONCLUSIONS: Statscan ERA is safe, rapid, simple and accurate. It has the advantage of providing arteriography distal to the site of injury. This directly altered patient care in 20% of cases, primarily by detecting distal arterial emboli. Thirty percent of patients with normal ERA also avoided an unnecessary operation. This study demonstrates a new role for Statscan technology.

Laparoscopic appendectomy for complicated appendicitis: an evaluation of postoperative factors.

BACKGROUND: The use of laparoscopic appendectomy for complicated appendicitis is controversial. Outcomes were compared between patients who had complicated appendicitis and those who had uncomplicated appendicitis. METHODS: Consecutive patients (n = 304) who underwent laparoscopic appendectomy were studied. Patients undergoing open appendectomies also were compared ad hoc. Analgesia use, length of hospital stay, return to activity, and complication rates for the complicated and uncomplicated appendicitis subgroups were analyzed. RESULTS: Complete data were available for 243 patients (80%). There were no statistical differences in characteristics between the two groups. The operating times, lengths of hospital stay, return to activity times, complication rates, and analgesia requirements, both in the hospital and after discharge, were equivalent. A greater number of complicated cases required open conversion. Considering those with complicated appendicitis, the open group had a significantly longer mean hospital stay and a higher complication rate than those treated with laparoscopic appendectomy. CONCLUSIONS: The minimally invasive laparoscopic technique is safe and efficacious. It should be the initial procedure of choice for most cases of complicated appendicitis.