[Surgical rescue strategies and techniques for severe intra-abdominal infection].

Severe intra-abdominal infection is complicated with sepsis or septic shock and could also be named as intra-abdominal sepsis. Surgical rescue is an effective intervention for severe intra-abdominal infection, which can be caused by surgery, trauma or acute abdomen. Institutional factors associated with failure of surgical rescue include hospital volume, technology, surgeons and nurses. Patient factors contributing to failure include advanced age, diabetes mellitus and chronic organ dysfunction. The surgical rescue strategy for severe intra-abdominal infection includes damage control surgery and damage control resuscitation. Stepwise escalated procedures based on the severity of the infections should be performed as soon as possible to control the infection source, including removal of catheter in blood vessel, change of intra-abdominal drainage, trochar-assisted percutaneous abscess drainage (TA-PAD), laparotomy and open abdomen therapy. Since most of the pathogenic microorganisms of severe abdominal infections are multi-drug resistant bacteria expressing Klebsiella pneumoniae carbapenemase (KPC), the choice of empirical antibiotics can be guided by rapid identification of the KPC type before the results of antibiotic susceptibility testing are available, namely the antibiotic selection strategy of "enzyme first, then bacteria".

[Surgical management for the perforation of digestive tract with intraabdominal infection].

Perforation of digestive tract with intra-abdominal infection is one of the common causes of emergency surgery. After the resection with intestine, primary anastomosis or stoma remains a subject of debate. With the continuous improvement of surgical technology and the need to improve patients' quality of life, primary anastomosis is supposed to be the most ideal surgery. However, the rate of stoma is still high due to concerns about postoperative anastomotic leakage. This paper summarizes the surgical treatment of intra-abdominal infection caused by gastrointestinal perforation in recent years, and discuss the best operation plan according to the perforation location and etiology. We also discuss a variety of treatment methods for the prevention of anastomotic leakage (perioperative management, gastrointestinal anastomosis, enteric lavage decompression and other techniques) to improve the primary anastomosis, improve the quality of life of patients and reduce the medical burden.

Intracorporeal Anastomosis Versus Extracorporeal Anastomosis in Laparoscopic Right Colectomy: An Observational Cohort Study.

BACKGROUND: Current studies did not draw definitive conclusions on comparison of intracorporeal anastomosis (ICA) with extracorporeal anastomosis (ECA) in laparoscopic right colectomy. Whether the intraperitoneal contamination induced by ICA can result in higher risk of postoperative abdominal infection remains unclear. This study was aimed to compare the short-term outcomes, especially the risk of abdominal infection after ICA versus ECA. METHODS: This was an observational cohort study as a secondary analysis of a randomized controlled trial (RCT)-RELARC trial (NCT02619942). The patients enrolled in the RELARC trial were diagnosed with primary colon adenocarcinoma without distant metastasis and underwent radical laparoscopic right colectomy between Jan 2016 and Dec 2019. In our study the patients who converted to open surgery in RELARC trial were excluded. The short-term outcomes were compared between ICA and ECA. The primary endpoint was abdominal infection. The inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) was used for adjusting the potential confounders. RESULTS: This study enrolled 975 patients with 119 patients undergoing ICA and 856 patients undergoing ECA. The incidence of abdominal infection was higher in ICA group (9.2% versus 1.5%, RR from IPTW = 5.7 (95%CI: 2.6-12.6), P < 0.001) as well as the incidence of wound infection (14.3% vs 3.3%, RR from IPTW = 5.0 (95%CI: 2.9-8.6), P < 0.001). ICA was associated with higher incidence of Clavien-Dindo (CD) grade I and II complications (CD-I: 15.1% versus 6.8%, RR from IPTW = 2.4 (95%CI: 1.5-3.9), P < 0.001; CD-II: 26.9% versus 8.2%, RR from IPTW = 3.6 (95%CI: 2.5-5.1), P < 0.001) but similar incidence of CD-III ~ IV complications compared to ECA (3.4% vs 2.1%, RR from IPTW = 1.2 (95%CI: 0.4-4.0), P = 0.73). In ICA group, choosing another incision rather than lengthening main port site decreased the incidence of wound infection although without statistical significance (17.3% (14/81) versus 7.9% (3/38), crude RR = 2.2 (95%CI: 0.7-7.2), P = 0.17). CONCLUSION: ICA is likely to be associated with higher risk of abdominal infection and CD-I ~ II complications.

Impact of postoperative intra-abdominal infectious complications on survival outcomes in patients with gastric cancer who underwent laparoscopic surgery.

BACKGROUND: Postoperative intra-abdominal infection is known to adversely affect survival outcomes in patients with gastric cancer; however, previous reports have investigated this complication only in open surgery. This adverse effect is expected to be weakened by less invasive surgery, such as a laparoscopic approach, by way of maintaining immune function. METHODS: This study included 1223 patients with gastric cancer who underwent open (n = 439) or laparoscopic (n = 784) curative surgery between 2010 and 2015. For each approach, patients were divided into two groups based on presence or absence of postoperative intra-abdominal infection of Clavien-Dindo grade II or higher (C-group and NC-group, respectively). Survival outcomes were compared in propensity-matched cohorts to evaluate the impact of the complication. RESULTS: The incidences of Clavien-Dindo ≥ grade II postoperative intra-abdominal infectious complications were 9.7% (43/439) in open surgery and 9.8% (70/714) in laparoscopic surgery. After propensity score matching, 86 patients in open surgery and 138 in laparoscopic surgery were extracted for analysis. The 5-year overall survival rate in the open C-group (n = 43) was worse than that in the open NC-group (n = 43) but with no significant difference (70.9% vs. 82.8%, log-rank P = 0.18). The 5-year overall survival rates were equivalent between the laparoscopic C-group (n = 69) and the laparoscopic NC-group (n = 69) (90.5% vs. 90.4%, log-rank P = 0.99). CONCLUSION: In general, postoperative intra-abdominal infection adversely affects survival outcomes; however, its impact may be weakened by less invasive surgery. Further evaluation using larger datasets is necessary before reaching definitive conclusions.

Early supplemental parenteral nutrition is associated with reduced mortality in critically ill surgical patients with high nutritional risk.

BACKGROUND & AIMS: Adequate nutritional provision is important for critically ill patients to improve clinical outcomes. Starting enteral nutrition (EN) as early as possible is recommended and preferred to parenteral nutrition (PN). However, patients who undergo emergency abdominal operations may have alterations in their intra-abdominal environment and gastrointestinal motility leading to limitation in starting an enteral diet. Therefore, our study was designed to evaluate the benefit of early supplemental PN to achieve adequate calorie and protein supply in critically ill patients undergoing surgery who are not eligible for early EN. METHODS: We reviewed the medical records of 317 patients who underwent emergency abdominal surgery for complicated intra-abdominal infection (cIAI) between January 2013 and December 2018. The nutritional data of the patients were collected for 7 days in maximum, starting on the day of intensive care unit (ICU) admission. The patients were divided by low or high malnutrition risk using the modified Nutrition Risk in Critically ill (mNUTRIC) score and body mass index. The low- and high-risk groups were subdivided into the following two categories: those who received PN within 48 h ("early") and those who did not ("usual"). Data regarding the baseline characteristics, initial severity of illness, morbidity, and mortality rates were also obtained. The average calorie and protein supply per day were calculated in these groups. RESULTS: Patients in all groups showed no significant differences in baseline characteristics, initial status, and infectious complications. In terms of outcomes, patients with low malnutrition risk had no significant difference in mortality. However, among patients with high malnutrition risk, the "Early" group had lower rates of 30-day mortality (7.6% vs. 26.7%, p = 0.006) and in-hospital mortality (13.6% vs. 28.9%, p = 0.048) than those of the "Usual" group. Kaplan-Meier survival curves for 30-day mortality in these groups also showed a statistically significant difference (p = 0.001). The caloric adequacy of the "Early" group and the "Usual" group were 0.88 ± 0.34 and 0.6 ± 0.29, respectively. Amounts of protein received were 0.94 ± 0.39 g/kg in the "Early" group and 0.47 ± 0.34 g/kg in the "Usual" group, respectively. There was no significant difference in infectious complications between both groups. CONCLUSIONS: Mortality in patients with high malnutrition risk who received early PN supply within 48 h after emergency surgery for cIAI was lower than those who did not receive PN earlier. PN may be necessary to fulfill the caloric and protein requirements for critically ill patients who cannot achieve their nutritional requirements to the fullest with EN alone.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Endoscopic drainage with local infusion of antibiotics to avoid necrosectomy of infected walled-off necrosis.

BACKGROUND: Current treatment of infected pancreatic necrosis (IPN) follows a step-up approach. Our group designed a step-up protocol that associates endoscopic drainage with local infusion of antibiotics through transmural nasocystic catheter. Aim of our study was to evaluate our step-up protocol for IPN in terms of proportion of patients avoiding necrosectomy. METHODS: Retrospective analysis of patients admitted with acute pancreatitis (AP) between January 2015 and December 2018. The number of patients who responded to each therapeutic step were analysed: step 1, systemic antibiotics; step 2, endoscopic transmural drainage and local infusion of antibiotics; step 3, endoscopic necrosectomy. RESULTS: 1158 patients with AP were included. 110 patients (8.4%) suffered from necrotising pancreatitis; 48 of them had IPN (42.6% of necrotising pancreatitis) and were treated with systemic antibiotics. Nineteen patients (39.6% of IPN) responded and did not required any invasive therapy. Six patients with IPN on systemic antibiotics died within the first 4 weeks of disease before step 2 could be applied. Urgent surgical necrosectomy in the first 4 weeks was performed in three additional patients. Endoscopic drainage and local antibiotic therapy was performed in the remaining 20 patients; 9 (45% of them) did well and 9 patients underwent necrosectomy (18.7% of IPN). Two patients died on drainage. Overall mortality of the total cohort of AP was 2.53% CONCLUSIONS: Addition of local infusion of antibiotics to endoscopic drainage avoids the need of necrosectomy in half of patients with IPN not responding to systemic antibiotics.

[Four-steps surgery for infected pancreatic necrosis based on "Step-up" strategy: a retrospective study].

Objective: To examine the effect of the "four-steps" treatment on infectious pancreatic necrosis(IPN). Methods: The data of 207 patients who were diagnosed with IPN from January 2013 to December 2017 at Department of Pancreaticobiliary Surgery, the First Affiliated Hospital of Harbin Medical University were analyzed retrospectively. Among 207 patients, 132(63.8%) were males and 75(36.2%) were females. The median age was 45 years old (range: 19 to 80 years old). One hundred and fifty-eight patients(76.3%) suffered severe acute pancreatitis and 49 patients(23.7%) suffered moderately severe acute pancreatitis. Percutaneous catheter drainage(PCD) was performed on all the patients(Step 1). Patients received "four-steps" minimally invasive treatment strategy in step-up group(173 patients). The following steps after PCD were mini-incision access pancreatic necrosectomy(MIAPN) (Step 2), sinus tract endoscopic debridement and(or) PCD for residual infections(Step 3) and finally conventional open pancreatic necrosectomy(OPN) (Step 4). Patients(34 cases) received conventional open pancreatic necrosectomy after invalided PCD in OPN group. The perioperative parameters and prognosis were compared between Step-up group and OPN group. Normally distributed quantitative variables were analyzed by t-test, non-normally distributed quantitative variables were analyzed by Wilcoxon chi-square test and categorical variables were analyzed by χ(2) test or Fisher exact test, respectively. Results: The basic characteristics of the two groups of patients were similar, but the referral rate of patients and the rate of preoperative 3 days organ failure in the OPN group were significantly higher than those of step-up group patients(47.1% vs. 28.9%, χ(2)=4.313, P=0.038; 26.5% vs. 9.2%, χ(2)=2.819, P=0.011). The frequency of PCD and the number of PCD tube (root) were less than those in the step-up group(1(1) vs. 2(1), Z=-3.373, P=0.018; 2(1) vs. 3(2), Z=-2.208, P=0.027). Compared with the OPN group, the interval time from onset to surgery and the MIAPN operation time were significantly shorter in the step-up group(29(15) days vs. 36(17)days, Z=-0.567, P=0.008; 58(27)minutes vs. 90(56)minutes, Z=-3.908, P<0.01); postoperative mortality was lower(5.8% vs.17.6%, χ(2)=4.070, P=0.044); the overall incidence of postoperative complications was reduced(23.1% vs. 55.9%, χ(2)=14.960, P<0.01) and the incidence of new-onset organ failure was decreased after operation in the step-up group(37.5% vs.47.4%, χ(2)=7.133, P=0.007). The incidence of local abdominal complications (pancreatic fistula, intra-abdominal hemorrhage, gastrointestinal fistula) showed no significant difference between the two groups (P>0.05). Fewer patients required ICU treatment after operation in the step-up group compared with OPN group(22.0% vs. 44.1%, χ(2)=6.204, P=0.013). Patients in the Step-up group has shorter hospital stay than patients in OPN group (46(13) days vs. 52(13)days, Z=-1.993, P=0.046). Conclusions: The clinical effects of "four-steps" exhibited the superiority of minimally invasive treatment of IPN.And MIAPN is a simple, safe and effective procedure to remove pancreatic necrotic tissue and decrease complications.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations.

BACKGROUND: Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. METHODS: The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. RESULTS: The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. CONCLUSIONS: The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review.

BACKGROUND: Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice. METHODS: From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review. RESULTS: The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period. CONCLUSION: The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.

Burden of Complicated Intra-Abdominal Infections in Children in Nigeria: Recent Experience and Systematic Review.

Background: Intra-abdominal infections encompass a wide range of conditions from uncomplicated appendicitis to fecal peritonitis. Little is known about the burden of complicated intra-abdominal infection (cIAIs) in children in low- and middle-income countries (LMICs). Method: This a report of recent experience and a systematic review of the burden in Nigeria. Results: Of 85 children with cIAIs, the most common primary cause was typhoid intestinal perforation (54; 63.5%) and complicated appendicitis (20; 23.5%). The complication rate after surgery was high, including surgical site infection (SSI) in 49 (57.6%), post-operative intra-abdominal abscess in 14 (16.5%), and complete abdominal wound dehiscence in 13 (15.3%). The rate of re-operation was 19 (22.4%) and 12 (14.1%) patients required re-admission for adhesion intestinal obstruction and unresolved SSI. Eight (9.4%) died from overwhelming infection. Systematic review revealed only a few publications, but these were mostly on specific causes of cIAIs and publications providing comprehensive data are lacking. Conclusion: Investment in research into cIAIs in children in LMICs is needed. Efforts need to be focused on the role of source control in reducing the high complication rate and mortality.

Protocol for a parallel economic evaluation of a trial comparing two surgical strategies in severe complicated intra-abdominal sepsis: the COOL-cost study.

BACKGROUND: The risk of death in severe complicated intra-abdominal sepsis (SCIAS) remains high despite decades of surgical and antimicrobial research. New management strategies are required to improve outcomes. The Closed Or Open after Laparotomy (COOL) trial investigates an open-abdomen (OA) approach with active negative pressure peritoneal therapy. This therapy is hypothesized to better manage peritoneal bacterial contamination, drain inflammatory ascites, and reduce the risk of intra-abdominal hypertension leading to improved survival and decreased complications. The total costs and cost-effectiveness of this therapy (as compared with standard fascial closure) are unknown. METHODS: We propose a parallel cost-utility analysis of this intervention to be conducted alongside the 1-year trial, extrapolating beyond that using decision analysis. Using resource use metrics (e.g., length of stay, re-admissions) from patients at all study sites and microcosting data from patients enrolled in Calgary, Alberta, the mean cost difference between treatment arms will be established from a publicly-funded health care payer perspective. Quality of life will be measured at 6 months and 1 year postoperatively with the Euroqol EQ-5D-5 L and SF-36 surveys. A within-trial analysis will establish cost and utility at 1 year, using a bootstrapping approach to provide confidence intervals around an estimated incremental cost-effectiveness ratio. If neither operative strategy is economically dominant, Markov modeling will be used to extrapolate the cost per quality-adjusted life years gained to 2-, 5-, 10-year, and lifetime horizons. Future costs and benefits will be discounted at 1.5% per annum. A cost-effectiveness acceptability curve will be generated using Monte Carlo simulation. If all trial outcomes are similar, the primary analysis will default to a cost-minimization approach. Subgroup analysis will be carried out for patients with and without septic shock at presentation, and for patients whose initial APACHE II scores are > 20 versus ≤ 20. DISCUSSION: In addition to an estimate of the clinical effectiveness of an OA approach for SCIAS, an understanding of its cost effectiveness will be required prior to its adoption in any resource-constrained environment. We will estimate this key parameter for use by clinicians and policymakers. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03163095, registered May 22, 2017.

The impact of age and comorbidity on the postoperative outcomes after emergency surgical management of complicated intra-abdominal infections.

Age-adjusted Charlson Comorbidity Index (a-CCI) score has been used to weight comorbid conditions in predicting adverse outcomes. A retrospective cohort study on adult patients diagnosed with complicated intra-abdominal infections (cIAI) requiring emergency surgery was conducted in order to elucidate the role of age and comorbidity in this scenario. Two main outcomes were evaluated: 90-day severe postoperative complications (grade ≥ 3 of Dindo-Clavien Classification), and 90-day all-cause mortality. 358 patients were analyzed. a-CCI score for each patient was calculated and then divided in two comorbid categories whether they were ≤ or > to percentile 75 ( = 4): Grade-A (0-4) and Grade-B ( ≥ 5). Univariate and multivariate regression analyses were performed, and the predictive validity of the models was evaluated by the area under the receiver operating characteristics (AUROC) curve. Independent predictors of 90-day severe postoperative complications were Charlson Grade-B (Odds Ratio [OR] = 3.49, 95% confidence interval [95%CI]: 1.86-6.52; p < 0.0001), healthcare-related infections (OR = 7.84, 95%CI: 3.99-15.39; p < 0.0001), diffuse peritonitis (OR = 2.64, 95%CI: 1.45-4.80; p < 0.01), and delay of surgery > 24 hours (OR = 2.28, 95%CI: 1.18-4.68; p < 0.02). The AUROC was 0.815 (95%CI: 0.758-0.872). Independent predictors of 90-day mortality were Charlson Grade-B (OR = 8.30, 95%CI: 3.58-19.21; p < 0.0001), healthcare-related infections (OR = 6.38, 95%CI: 2.72-14.95; p < 0.0001), sepsis status (OR = 3.98, 95%CI: 1.04-15.21; p < 0.04) and diffuse peritonitis (OR = 3.06, 95%CI: 1.29-7.27; p < 0.01). The AUROC for mortality was 0.887 (95%CI: 0.83-0.93). Post-hoc sensitivity analyses confirmed that the degree of comorbidity, estimated by using an age-adjusted score, has a critical impact on the postoperative course following emergency surgery for cIAI. Early assessment and management of patient's comorbidity is mandatory at emergency setting.

One-Step verse Step-Up Laparoscopic-Assisted Necrosectomy for Infected Pancreatic Necrosis.

BACKGROUND: Percutaneous or endoscopic drainage was usually performed as the first step in step-up approach for infected pancreatic necrosis (IPN). However, drainage was unnecessary or unavailable in some patients. OBJECTIVE: To estimate the safety and effect of one-step laparoscopic-assisted necrosectomy in IPN patients. METHODS: A retrospective analysis of IPN patients received surgical therapy in our center between January 2015 and December 2017 was performed. Patients were assigned to either one-step or step-up groups according to the received therapeutic approach. Incidence of complications, death, total number of interventions, and total hospital stay were compared. Logistic regression and nomogram were used to explore the risk factors and probability for patients undergoing interventions ≥3 times. RESULTS: There were 45 and 49 patients included in one-step and step-up groups, respectively. No significant difference between groups in terms of new organ failure (14.29 vs. 14.33%, p = 0.832), death (8.89 vs.8.17%, p = 0.949), and long-term complications (18.37 vs. 15.56%, p = 0.717). However, the number of interventions in one-step group was significantly less than in step-up group with shorter hospital stay. After multivariate analysis, C-reactive protein, interleukin-6, and surgical approach were independent predicators for patients undergoing interventions ≥3. A nomogram was built with area under ROC curve 0.891. CONCLUSION: Compared with step-up approach, one-step surgery was safe and effective in selected IPN patients with less interventions and shorter hospital stay.

Vulvar lymphangiectasia secondary to gastrointestinal tuberculosis infection in a teenager.

We report a rare presentation of vulvar lymphangiectasia that developed secondary to gastrointestinal tuberculosis in a teenager, and its spontaneous resolution after anti-tuberculous treatment was completed.

Enhanced recovery after surgery for emergency colorectal surgery: Are there any differences between intra-abdominal infection and other indications?

AIM OF THE STUDY: Enhanced recovery after surgery (ERAS) has become the standard of care for elective colorectal operations. However, there are few data regarding ERAS in emergency setting. This study aimed to evaluate the results of ERAS protocol for emergency colorectal resection and to compare its difference between patients with intra-abdominal infection (IAI) and those without. PATIENTS AND METHODS: Patients undergoing emergency colectomy and/or proctectomy with ERAS protocol from 2011 to 2017 a university hospital was reviewed. Clinical outcomes and ERAS compliance were analyzed and compared depending on whether there was IAI. RESULTS: This study included 60 patients; 14 (23%) had IAI. Median ERAS compliance was 75% (IQR: 63-83). Rates of overall complication and severe complication were 35% and 15%, respectively. The 60-day mortality was 6.7%. Median length of postoperative stay was 5days (IQR: 4-8). Thirty-three patients (55%) achieved targeted discharge within postoperative day 5. High adherence to ERAS protocol was associated with lower morbidity (P<0.001) and shorter hospitalization (P=0.006). Patients with IAI had less ERAS compliance (50% vs. 78%; P<0.001), higher complication rates (64% vs. 26%; P=0.009), and higher mortality (21% vs. 2%; P=0.036), and longer time to first defecation (4days vs. 3days; P=0.049). Of note, patients with IAI had significant lower compliance with preoperative optimization, scheduled removal of urinary catheter and early mobilization than the other group. CONCLUSIONS: ERAS program is applicable for patients undergoing emergency colorectal surgery. In patients with intra-abdominal sepsis, the ERAS compliance was lower and the complications rate was higher.

The role of the intra-abdominal view in complicated intra-abdominal infections.

Background: The prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality. Methods: The study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission. Results: A total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05-3.73), diffuse peritonitis (OR 2.15, 1.02-4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12-15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11-30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions. Conclusions: The extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems. Trial registration: The study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932).

Current Evaluation of Antibiotic Usage in Complicated Intra-Abdominal Infection after the STOP IT Trial: Did We STOP IT?

BACKGROUND: After publication of the Study to Optimize Peritoneal Infection Therapy (STOP IT) trial, we sought to determine if we were implementing study findings into practice appropriately. We had three objectives: evaluate antibiotic usage; evaluate patient outcomes; and delineate differences in antibiotic usage between general surgeons (GS) and trauma/acute care surgery trained surgeons (TACS). PATIENTS AND METHODS: This was an analysis of patients with complicated intra-abdominal infection admitted via the emergency department from February 2014 through May 2017. Complicated intra-abdominal infection (cIAI) was defined as perforated viscus, complicated appendicitis, or ischemic bowel. Patients were excluded if they had an ICD-9/10 code for diverticular/anorectal disease, did not undergo source control, or if the post-operative antibiotic course was not given or was incomplete because of withdrawal of care, change in code status, or death. Outcomes and antibiotic usage were compared before and after the STOP IT publication date. Short-course antibiotic regimens were defined as four days or less of antibiotics after source control. RESULTS: A total of 133 patients met inclusion criteria, with 47 admitted before STOP IT and 86 admitted after. Demographics and other characteristics were similar between these groups. Total antibiotic days and antibiotic days after source control decreased after STOP IT publication (p = 0.031 and p = 0.047, respectively). There were no differences in hospital length of stay (LOS), intensive care unit (ICU) LOS, surgical site infections, intra-abdominal abscesses, or death between the two groups. Short-course antibiotic compliance increased after publication from 30% to 52% (p = 0.012). Compared with GS, patients managed by TACS had decreased total antibiotic days (p = 0.030) and antibiotic days after source control (p = 0.025). CONCLUSION: We demonstrated decreased antibiotic days and increased use of short-course antibiotic regimens for patients with cIAI after the publication of STOP IT. However, there still appears to be opportunity for improved adherence to short-course regimens, as well as opportunities to educate our colleagues.

Endoscopic Transgastric Versus Surgical Approach for Infected Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis.

Surgical approach (SA) is the standard treatment for infected necrotizing pancreatitis (INP) and endoscopic transgastric approach (ETA) is a promising alternative treatment. This systematic review and meta-analysis aimed to compare the effectiveness and safety of ETA versus SA in INP. Several databases were systematically searched for eligible studies that compared ETA with SA for INP. Predefined criteria were used for study selection. Three reviewers independently assessed the risk of bias. Primary outcomes included clinical resolution rate, short-term mortality, major complications, and hospital stay. Study-specific effect sizes and their 95% confidence interval (CI) were combined to calculate the pooled value using fixed-effects or random-effects model. Six studies were included with 295 patients. Major complication rate [odds ratio (OR), 0.13; 95% CI, 0.06-0.29], new-onset organ failure rate (OR, 0.26; 95% CI, 0.12-0.54), postoperative pancreatic fistula rate (OR, 0.09; 95% CI, 0.03-0.28), and incisional hernia rate (OR, 0.10; 95% CI, 0.01-0.85) were lower in the ETA group. There was a shorter hospital stay (mean difference, -17.72; 95% CI, -21.30 to -14.13) in the ETA group. No differences were found in clinical resolution, short-term mortality, postoperative bleeding, perforation of visceral organ, and endocrine or exocrine insufficiency. Compared with SA, ETA showed comparable effectiveness and safety for the treatment of INP based on current evidence.