Non-traumatic ruptured splenic abscess presenting with pneumoperitoneum in an immunocompetent patient: a diagnostic dilemma.

Splenic abscess is a rare life-threatening clinical entity. There are only a handful of reported cases of spontaneous splenic abscess rupture with pneumoperitoneum. Rupture of splenic abscess associated with gas-producing pathogens may lead to pneumoperitoneum. We hereby report the case of a ruptured splenic abscess with pneumoperitoneum in a young immunocompetent woman masquerading as hollow viscus perforation peritonitis. Ruptured splenic abscess should be kept in mind for treating surgeons as a differential diagnosis of pneumoperitoneum or peritonitis, particularly for immunocompromised patients.

[Non-perforation tensionpneumoperitoneum resulting from primary non-aerobic bacterial peritonitisin a previously healthy middle-aged man: A case report].

Background: Tension pneumoperitoneumis a rare surgical emergency in which free intra-peritoneal gas accumulates under pressure. The known sources of free gas are perforated hollow viscera. We believe this is the first published case of atension non-perforation pneumoperitoneum secondary to anaerobic gas production. This occurred in a background of primary non-aerobic bacterial peritonitis, which developed in an immunocompetent adult male. Case presentation: A previously healthy 45-year-old Bulgarian male presented with a 3-week history of abdominal pain. He displayed signs of shock, peritonitis, and abdominal compartment syndrome. A plain abdominal X-ray showed thepathognomonic "saddlebag sign" with the liver displaced downwards and medially. An emergency laparotomy released pressurized gas, accompanied by 3100 mL of foamy pus. A sudden haemodynamic deterioration occurred soon after decompression. The sources of infection and tension pneumoperitoneum were not found. The peritoneal exudate sample did not recover aerobes. A laparostomy was created and three planned re-laparotomies were performed. During the second re-operation we placed an intraperitoneal silo and the abdomen was closed with skin sutures. Definitive fascial closure was achieved through separation of the two rectus muscles from their posterior sheaths. The patient was discharged in good healthon the 25th postoperative day. Conclusion: Our case provides evidence supporting the theory that anaerobic infection may underlie the etiology of tension pmeumoperitoneum. Prior to decompressive laparotomy the patient should receive an intravenous volume bolus to compensate for possible hypotension. If laparostomy leads to lateralization of the rectus muscles with a gap of 6 cm or less, the posterior part of the components separation technique is effective in achieving fascial closure. We present an original classification of tension pneumoperitoneum defining it as primary or secondary.

[Possibilities of surgical treatment for advanced multiresistant pulmonary tuberculosis].

The results of surgical treatment of 37 patients, suffering relatively advanced pulmonary tuberculosis (PT), were analyzed. Chemoresistant PT was revealed in 35 (94.6%) observed patients, and multiresistant one--in 30 (81.1%). Preoperative preparation during 2-3 mo was conducted in two main directions: administration of a line II antibacterial preparations and a pneumoperitoneum (PP) establishment. A main operative procedure was resection. Intrapleural thoracoplasty in our own modification have constituted a seconf direction of treatment, it consisted obligatory of the 5 ribs resection. Initially a rib V was partially resected 8-10 cm in length, and a rib I was excised completely. Complications were absent. The patients were discharged from the hospital in 2-3 mo postoperatively. PP in 34 (91.9%) patients was completed in a same terms. In a remote postoperative period (1-4 yrs) a tuberculosis reactivation was absent. All operated patients were bacilli free.

Severe pneumoperitoneum caused by infected pelvic hematoma: report of a case and review of the literature.

BACKGROUND: Pneumoperitoneum usually is caused by hollow viscus perforation with associated peritonitis. Severe pneumoperitoneum secondary to infection of a hematoma with gas-forming organisms is exceedingly rare. METHODS: Case report and literature review. RESULTS: A 43-year-old man with a history of abdominoperineal resection for rectal cancer developed abdominal distention, fever, and elevated white blood cell count after lysis of adhesions with bowel resection for recurrent small bowel obstruction. Abdominal radiography and a computed tomography scan demonstrated a large amount of free air in the peritoneal cavity. Contrary to expectations, reexploration revealed no signs of viscus perforation or anastomotic leak, but instead a large pelvic hematoma with an odor was identified and evacuated. Cultures from the hematoma yielded anaerobic gram-negative bacilli (not Bacteroides fragilis). The patient recovered uneventfully. CONCLUSION: Infected hematoma should be recognized as a cause of pneumoperitoneum after surgery. Awareness of this rare condition may prevent unnecessary surgical explorations in doubtful situations.

Analysis of the bactericidal effect of ozone pneumoperitoneum.

PURPOSE: To assess the bactericidal action of ozone pneumoperitonium, and to compare the results with CO2. METHODS: It was used 36 Wistar rats. The animals, under anesthesia, were inoculated with 2ml of E. coli ATCC at a concentration of 10(10)UFC, and 1ml of BaSO4, into the peritoneal cavity. They were divided into three groups: Group 1, CO2 pneumoperitoneum was performed for 15 minutes; Group 2, ozone pneumoperitoneum was performed for 5 minutes at a concentration of 42microg/ml, and Group 3, ozone pneumoperitoneum was performed for 5 minutes at a concentration of 62microg/ml. Six animals from each group were sacrificed after the experiment, and the remaining 6 observed for 24 hours. Material was collected from the cavity of all animals for microbiological study. RESULTS: Ozone presented a greater bactericidal effect than CO2 in those animals sacrificed immediately after pneumoperitoneum. In the animals studied 24 hours after pneumoperitoneum evidenced no difference in bactericidal effect between the two gases. Moreover, no difference in mortality was observed. CONCLUSION: Ozone has a more potent bactericidal effect than carbon dioxide gas, although this did not influence survival of the animals.

Analysis of the bactericidal effect of ozone pneumoperitoneum / Análise do efeito bactericida do pneumoperitônio de ozônio

PURPOSE: To assess the bactericidal action of ozone pneumoperitonium, and to compare the results with CO2. METHODS: It was used 36 Wistar rats. The animals, under anesthesia, were inoculated with 2ml of E. coli ATCC at a concentration of 10(10)UFC, and 1ml of BaSO4, into the peritoneal cavity. They were divided into three groups: Group 1, CO2 pneumoperitoneum was performed for 15 minutes; Group 2, ozone pneumoperitoneum was performed for 5 minutes at a concentration of 42µg/ml, and Group 3, ozone pneumoperitoneum was performed for 5 minutes at a concentration of 62µg/ml. Six animals from each group were sacrificed after the experiment, and the remaining 6 observed for 24 hours. Material was collected from the cavity of all animals for microbiological study. RESULTS: Ozone presented a greater bactericidal effect than CO2 in those animals sacrificed immediately after pneumoperitoneum. In the animals studied 24 hours after pneumoperitoneum evidenced no difference in bactericidal effect between the two gases. Moreover, no difference in mortality was observed. CONCLUSION: Ozone has a more potent bactericidal effect than carbon dioxide gas, although this did not influence survival of the animals.

OBJETIVO: Avaliar a ação bactericida do pneumoperitônio de ozônio comparando-o à ação do CO2. MÉTODOS: Foram utilizados 36 ratos Wistar. Após anestesia e inoculação de 2ml de E. coli ATCC na concentração de 10(10) UFC e 1ml de BaSO4 na cavidade peritoneal, os animais foram divididos em três grupos: Grupo 1, realização de pneumoperitônio de CO2 por 15 minutos; Grupo 2, realização de pneumoperitônio de ozônio durante 5 minutos na concentração de 42µg/ml, e Grupo 3, realização de pneumoperitônio de ozônio durante 5 minutos na concentração de 62µg/ml. Seis animais de cada grupo foram sacrificados após experimento e os outros seis foram observados por 24 horas. Em todos os animais colheu-se material da cavidade para estudo microbiológico. RESULTADOS: O ozônio teve maior efeito bactericida em comparação ao CO2 nos animais sacrificados logo após pneumoperitônio. Nos animais estudados após 24 horas não houve diferença do efeito bactericida entre os gases. Também não se observou alteração da mortalidade. CONCLUSÃO: O ozônio tem efeito bactericida mais potente que o gás carbônico, embora não tenha influenciado a sobrevida dos animais.

Computed tomography features of spontaneously perforated pyometra: a case report.

Spontaneous perforation of pyometra is an extremely rare emergent gynecologic disease. We report a 73-year-old woman with a spontaneously perforated pyometra presenting with acute abdomen in the emergency department. A dedicated computed tomography examination of the abdominal and pelvic regions revealed the diagnosis. The patient recovered well after surgical intervention and antibiotic treatment.

Respuesta peritoneal inmediata a la contaminación durante la cirugía laparoscópica en un modelo experimental en el ratón / Immediate peritoneal response to contamination during laparoscopic surgery in an experimental rat model

Introducción. En diversos estudios se ha demostrado que la cirugía laparoscópica (CL) minimiza el traumatismo quirúrgico y preserva la repuesta inmunológica. Otra ventaja es la observación de una menor incidencia de complicaciones infecciosas. Sin embargo, en diferentes estudios in vitro se ha demostrado que la atmósfera con CO2 afecta a la fisiología del macrófago, lo que incidiría en la respuesta a la contaminación peritoneal. Sin embargo, éste es un aspecto controvertido ante la evidencia experimental de una respuesta mejor conservada a la contaminación peritoneal. Este estudio se planteó para investigar la repuesta inmediata del peritoneo a la contaminación en una atmósfera con CO2. Material y método. Se distribuyeron 192 ratones CD-1 en 3 grupos: grupo I, LP, n = 64 (laparotomía); grupo II, LC-CO2, n = 64 (laparoscopia-CO2), y grupo III, LC-T, n = 64, (laparoscopia-tracción). Los ratones fueron aleatorizados para recibir 1 ml de una suspensión de Escherichia coli (1 x 104 UFC/ml) (contaminación [C]) o suero salino (sin contaminación [SC]). Se obtuvo fluido peritoneal a las 1,5, 3, 6 y 12 h tras la cirugía. Se determinaron MCP-1, IL-6 y PGE-2. Resultados. Los valores MCP-1 fueron significativamente superiores y de forma más precoz en el grupo II (LC-CO2-SC) que en el grupo I (LP-SC) (p < 0,007). De manera simultánea, el incremento en el grupo tracción (LC-T-SC, grupo III) fue significativamente mayor (p < 0,002) que tras la laparotomía, sin diferencias respecto al grupo II (LC-C02-SC). Cuando se añadió la contaminación hubo un incremento significativo en los 3 grupos (p < 0,5). Las modificaciones de MCP-1 en el grupo LP-C fueron estadísticamente superiores y aparecieron de forma más tardía que en los grupos con tracción LC-T-C (p < 0,002) y LC-CO2-C (p < 0,02). Interlieucine (IL)-6: los 3 modelos presentaron un incremento significativo, que fue más tardío en el grupo LP-SC. Simultáneamente, el incremento de IL-6 fue más precoz y significativamente superior en el grupo LC-T-SC que en el grupo LP (p < 0,003), sin diferencias entre LC-CO2-SC y LC-T-SC. Se observó una diferencia significativa entre los grupos contaminados y no contaminados en el modelo LC-CO2. El modelo de tracción (grupo LC-T-C) presentó un incremento superior respecto a los grupos LP-C y LC-CO2-C (p < 0,001). Prostaglandine E2 (PGE-2): en los 3 modelos sin contaminación se observó un incremento significativo. Sin embargo, no se encontraron diferencias cuando se añadió la contaminación. Conclusión. El neumoperitoneo con CO2 induce una respuesta peritoneal cualitativamente diferente de la cirugía abierta y modifica la respuesta a la contaminación, con una menor elevación de MCP-1 e IL-6 (AU)

Introduction. Several studies have shown that laparoscopic surgery (LS) minimizes surgical trauma and preserves immune response. Another advantage is the lower incidence of infectious complications. However, several in vitro studies have shown that an atmosphere with CO2 affects macrophage physiology, which would affect the response to peritoneal contamination. This observation is controversial, given the experimental evidence of a better conserved response to peritoneal contamination. The aim of the present study was to investigate the immediate response of the peritoneum to contamination in an atmosphere with CO2. Material and method. A total of 192 CD-1 rats were distributed into three groups: group I, LP, n=64, (laparotomy); group II, LC-CO2, n=64, (laparoscopy-C02), group III, LC-T, n= 64, (laparoscopy-traction). The rats were randomized to receive 1 ml of a suspension of Escherichia coli (1x104 CFU/ml) (contamination [C]) or saline serum (no contamination [NC]). Peritoneal fluid was obtained at 1.5, 3, 6, and 12 h after surgery. Monocyte chemotactic protein-1 (MCP-1), interleukin (IL)-6 and prostaglandin•E2 (PGE2) were determined. Results. MCP-1 levels were significantly higher and increased earlier in group II (LC-C02-NC) than in group I (LP-NC) (p<.007). Simultaneously, the increase in the traction group was significantly higher (p<.002) than after laparotomy, without differences with respect to group II (LC-C02-NC). When contamination was added, there was a significant increase in the three groups (p<.5). The modifications in MCP-1 in the LP-C group were statistically significantly greater and appeared earlier than those in the traction groups, LC-T-C (p<.002) and LC-C02-C (p<.02). Interleukin 6: the three models showed a significant increase, which appeared later in the LP-NC group. Simultaneously, the increase in IL-6 appeared earlier and was significantly greater in the LC-T-NC group than in the LP group (p<.003), with no differences between the LC-C02-NC and LC-T-NC groups. There was a significant difference between contaminated and uncontaminated groups in the LC-CO2 model. The traction model (LC-T-C group) showed a greater increase than the LP-C and LC-C02-C groups (p<.001). PGE2: a significant increase was observed in the three models without contamination. However, when contamination was added, no differences were observed. Conclusion. Pneumoperitoneum with CO2 provokes a peritoneal response that is qualitatively different from open surgery and modifies the response to contamination with a greater increase in MCP-1 and IL-6 (AU)

Effects of pneumoperitoneum on hemodynamic and systemic immunologic responses to peritonitis in pigs.

BACKGROUND: Experimental evidence supporting the safety of laparoscopic intervention during sepsis is limited. The purpose of this study was to evaluate the effects of pneumoperitoneum on immunologic and hemodynamic responses to peritoneal sepsis. MATERIALS AND METHODS: A porcine model of peritonitis was created using an intraperitoneal autologous fecal inoculum. Pigs were then subjected to one of four procedures 24 h postinoculation (n = 6 per group): laparotomy, CO(2) laparoscopy, helium laparoscopy, and anesthesia only (1.5% isoflurane in 100% O(2), mechanical ventilation). Venous blood samples were obtained prior to inoculation, and at 24 (prior to procedure), 30, 48, 72, and 96 h postinoculation to determine white blood count (WBC) with differential, C-reactive protein (CRP), tumor necrosis factor, and bacteremia. Heart rate, end-tidal CO(2) (ETCO(2)), mean arterial blood pressure (MAP), and arterial blood gas variables were also measured at baseline and every 30 min throughout the procedure. RESULTS: Postoperative blood cultures confirmed systemic bacteremia in all groups at all time periods postinoculation. Following inoculation, WBC, band cell count, and CRP remained elevated above baseline in all groups throughout the study (P < 0.01). However, no significant differences in these parameters were observed among groups. In the CO(2) laparoscopy group, MAP, ETCO(2), and arterial pCO(2) were increased above baseline, while pH was decreased throughout the procedure (P < 0.01). CONCLUSIONS: In this animal model of peritonitis, CO(2) pneumoperitoneum induced hypercapnia, acidemia, and systemic hypertension intraoperatively, without a discernable effect on systemic immune function.

Effect of carbon dioxide pneumoperitoneum on bacteraemia and endotoxaemia in an animal model of peritonitis.

Laparoscopy is increasingly used in conditions complicated by peritonitis. A theoretical concern is that carbon dioxide pneumoperitoneum may increase bacteraemia. This study examines the effect of carbon dioxide pneumoperitoneum on bacteraemia, endotoxaemia and physiological correlates of sepsis in an animal model of peritonitis. New Zealand white rabbits were assigned to three groups of six animals. Group 1 received an intraperitoneal inoculation of 10(9) colony-forming units of Escherichia coli followed by a 10-cm midline laparotomy. Group 2 received an identical bacterial inoculum followed by a 12-mmHg carbon dioxide pneumoperitoneum for 1 h. Group 3 received no bacteria but had a 12-mmHg carbon dioxide pneumoperitoneum for 1 h. Groups 1 and 2 had significantly higher levels of bacteraemia (P < 0.01) and endotoxaemia (P < 0.01) accompanied by significantly lower mean arterial pressures (P < 0.05) and higher heart rates (P < 0.05) compared with group 3. After 6 h groups 1 and 2 were significantly hypocarbic (P < 0.01), leucopenic (P < 0.01) and thrombocytopenic (P < 0.01). There was no difference between group 1 and group 2. A carbon dioxide pneumoperitoneum of 12 mmHg does not increase bacteraemia or endotoxaemia, nor does it adversely affect physiological or laboratory correlates of sepsis compared with laparotomy in this animal model of peritonitis.

[Effects of intraperitoneal insufflation on hematogenous seeding of abdominal infections. Preliminary results of an experimental study in rats]. / Effets de l'insufflation intra-péritonéale sur la dissémination hématogène des infections abdominales. Résultats préliminaires d'une étude expérimentale chez le rat.

Most laparoscopic procedures require the creation of a pneumoperitoneum. In order to evaluate the potential hazards of bacteriemia related to insufflation, we conducted a study in the rat. Two groups of 20 Wistar rats were used for this study. Peritonitis was induced by opening the terminal ileum. Twenty-four hours later, 20 rats were insufflated at a mean pressure of 6 mm Hg (Group I). After one hour of insufflation, an hemoculture was performed via direct intracardiac puncture and in the other group of 20 non-insufflated rats (Group NI). Five of the 18 hemoculture were positive in the Gr. I (27.7%) and 6 out of 20 in the Gr. NI (30%) (chi 2 = 0.238 p = 0.62 non significant difference). These results suggest that insufflation does not facilitate hematogenous dissemination of bacteria from intraperitoneal sepsis in this animal model.

[Pneumoperitoneum: infrequent complication of lithiasic pyonephrosis]. / Neumoperitoneo: complicación infrecuente de la pionefrosis litiásica.

A case of lithiasic pyonephrosis evolving with intrapyelic gas formation, with positive urinary culture for Escherichia coli, is presented. Original clinical presentation was a picture of acute peritonitis with pneumoperitoneum. Clinical and radiological findings were indicative of exploratory laparotomy. The picture was resolved surgically, the procedure adopted being nephrectomy with retroperitoneal space drainage and empirically chosen antibiotics. The paper establishes the uncommon nature of this complication, and includes a literature review.

Pneumoperitoneum without clinical peritonitis due to bilateral pyosalpinx.

A case of pneumoperitoneum without clinical peritonitis due to bilateral pyosalpinx is presented. This clinical condition has in the literature been called "spontaneous or idiopathic pneumoperitoneum", and conservative treatment in such cases has been advocated. As shown in our case severe intraperitoneal pathology may exist, and we therefore advocate early explorative laparotomy in all patients with pneumoperitoneum without peritonitis.