Contemporary utility of diagnostic peritoneal aspiration in trauma.

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) has supplanted diagnostic peritoneal lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic peritoneal aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield. METHODS: All trauma patients presenting to our Level I center who underwent DPA were included (May 2015 to May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the criterion standard of hemoperitoneum at exploratory laparotomy or computed tomography scan. RESULTS: In total, 41 patients underwent DPA, typically after blunt trauma (n = 37, 90%). Patients were almost exclusively hypotensive (n = 20, 49%) or in arrest (n = 18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n = 32, 78%); or had a positive FAST and known cirrhosis (n = 4, 10%). In two (5%) patients, one obese, the catheter failed to access the peritoneal cavity. Diagnostic peritoneal aspiration sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred. CONCLUSION: Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. Diagnostic peritoneal aspiration is most conclusive when positive, without false positives in this study. Diagnostic peritoneal aspiration was most used among blunt hypotensive or postarrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision making branch point. LEVEL OF EVIDENCE: Diagnostic, level III.

The impact of peritoneal lavage cytology in biliary tract cancer (KHBO1701): Kansai Hepato-Biliary Oncology Group.

BACKGROUND: Only few studies in literature have analyzed the clinical effects of peritoneal lavage status in biliary tract cancers. AIM: We aimed to assess the effect of cytology-positive peritoneal lavage on survival for patients with biliary tract cancer who underwent curative resection. METHODS: The KHBO1701 study was a multi-institutional retrospective study that assessed the clinical effects of peritoneal lavage cytology in biliary tract cancers. Using clinicopathological data from 11 Japanese institutions, we compared long-term outcomes between patients with cytology-positive and cytology-negative peritoneal lavage. RESULTS: Of 169 patients who underwent curative resection, 164 were cytology-negative, and five were cytology-positive. The incidence of portal invasion and preoperative carbohydrate antigen 19-9 levels were higher in the cytology-positive group than in the cytology-negative group. The incidence of peritoneal metastatic recurrence was also higher, and overall survival tended to be worse in the cytology-positive group. In contrast, recurrence-free survival was similar between the cytology-negative and cytology-positive groups. CONCLUSIONS: The positive status of peritoneal lavage cytology could moderately affect the survival of patients with biliary tract cancers. Given that surgical resection is the only curative treatment option, it may be acceptable to resect biliary tract cancers without other non-curative factors, regardless of peritoneal lavage cytology status.

Staging Laparoscopy is Underutilized in the Management of Gastric Adenocarcinoma.

BACKGROUND: Staging laparoscopy (SL) with peritoneal lavage is usually performed on a separate day from the planned resection and is recommended in patients with gastric adenocarcinoma as it can identify radiographically occult metastases and malignant cytology, thus altering prognosis and treatment. SL can be done on the same day as planned resection (SLSR) or with delayed resection (SLDR). The purpose of this study was to determine utilization of SL and factors associated with SLSR and SLDR, among patients diagnosed with gastric adenocarcinoma. METHODS: SEER-Medicare linked data were used to identify patients diagnosed with gastric adenocarcinoma from 2004 through 2013. SL were defined as a laparoscopy that occurred up to 3 months postdiagnosis. Multivariate logistic regression was used to identify factors associated with the utilization of SLSR and SLDR. RESULTS: Of the 5610 patients with gastric adenocarcinoma who underwent a surgical procedure, 733 (13%) had a SL. Utilization of SL increased annually from 6.4% to 22.2% (p < 0.01). Receipt of SL was associated with patient demographics, tumor location, and treatment at a National Cancer Institute (NCI) Designated Cancer Center (CC). Of the 733 patients who underwent SL, 475 (65%) received further surgical procedures; 367 (77%) underwent SLSR, while 108 patients (23%) underwent SLDR. Compared with SLSR, SLDR was more common among patients who were younger, treated at an NCI-Designated CC and had proximal tumors. CONCLUSIONS: SL for optimal preoperative staging remains underutilized in the management of gastric adenocarcinoma. Expanded use of laparoscopy as a distinct procedure could minimize unnecessary interventions.

Prognostic importance of peritoneal washing cytology in patients with otherwise resectable pancreatic ductal adenocarcinoma who underwent pancreatectomy: A nationwide, cancer registry-based study from the Japan Pancreas Society.

BACKGROUND: The importance of peritoneal washing cytology status both as a sign of irresectability and as a prognostic factor for pancreatic ductal adenocarcinoma remains controversial. The purpose of this nationwide, cancer registry-based study was to clarify the clinical implications of operative resection in patients who had positive cytology status. METHODS: Clinical data from 1,970 patients who underwent tumor resection were collected from the Pancreatic Cancer Registry in Japan. Clinicopathologic factors and overall survival curves were analyzed, and multivariate Cox proportional hazard models were evaluated. RESULTS: Among the 1,970 patients analyzed, positive cytology status was found in 106 patients and negative cytology status was found in 1,864 patients. The positive cytology status group had a greater frequency of pancreatic body and tail cancer and greater preoperative serum carbohydrate antigen 19-9 levels than the negative cytology status group (P < .001 each). The ratio of peritoneal recurrence tended to be greater in the positive cytology status group (14% vs 43%; P < .001). Overall median survival times were less in the positive cytology status group (17.5 months vs 29.4 months; P < .001). The 5-year survival rates were 13.7% and 31.1% in the positive cytology status and negative cytology status groups, respectively. Multivariate analysis of positive cytology status patients revealed that adjuvant chemotherapy was an independent prognostic factor. CONCLUSION: Positive cytology status was an adverse prognostic factor in patients who underwent resection for pancreatic ductal adenocarcinoma but did not preclude attempted curative resection. Curative resection followed by adjuvant chemotherapy may contribute to long-term prognosis in patients with positive cytology status.

Incidence and prognostic significance of positive peritoneal lavage in colorectal cancer.

PURPOSE: The significance of peritoneal lavage cytology as a prognostic marker has been examined in various types of cancer. However, the meaning of positive peritoneal lavage cytology in colorectal cancer is still controversial. The aim of this review is to evaluate the prognostic significance of positive peritoneal lavage cytology in colorectal cancer. METHODS: An English literature search was performed on all studies published between 1998 and 2014 that compared the detection of peritoneal free cancer cells with survival or recurrence. RESULTS: Eighteen articles met the inclusion criteria. All studies employed one (or more) of the three techniques used to detect free cancer cells in the peritoneal cavity: (1) conventional cytology, (2) immunocytochemistry or (3) polymerase chain reaction. The incidence of positive peritoneal lavage cytology ranged from 2.2 to 47.2% across the studies. The factors correlated with positive peritoneal lavage cytology were tumor penetration and metastases (lymph node, liver and peritoneum). In nine studies, positive lavage findings were associated with a worse survival, and it was associated with increased recurrence in 13 studies. CONCLUSION: Positive peritoneal lavage cytology seems to be an indicator of a poor prognosis in colorectal cancer patients. Further studies are needed to clarify the prognostic impact of peritoneal lavage cytology, by comparing the different methods used for the collection of the peritoneal lavage.

Laparoscopic peritoneal lavage for Hinchey III diverticulitis: is it as effective as it is applicable?

BACKGROUND: Over the past few years, the laparoscopic peritoneal lavage has emerged as a therapeutic alternative to standard resection procedures. However, its effectiveness and applicability remain debatable. OBJECTIVE: The aim of this study was to assess laparoscopic lavage in controlling abdominal sepsis secondary to purulent peritonitis. DESIGN: This study was conducted as a retrospective analysis of prospectively collected data. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Patients requiring emergency surgery for perforated diverticulitis and generalized peritonitis between June 2006 and June 2013 were identified from a prospective database. Laparoscopic assessment was considered in all of the hemodynamically stable patients, and laparoscopic lavage was performed according to intraoperative strict criteria. MAIN OUTCOME MEASURES: Primary outcomes were the effectiveness and applicability of laparoscopic lavage. Secondarily, feasibility, morbidity, and mortality were also assessed. RESULTS: Seventy-five patients required emergency surgery for generalized peritonitis secondary to perforated diverticulitis. Forty-six patients who underwent laparoscopy presented a purulent generalized (Hinchey III) peritonitis and were examined under the intention-to-treat basis to perform a laparoscopic lavage. Thirty-two patients (70.0%; 95% CI 56.2-82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3-90.1) had free air on a CT scan. The conversion rate was 4% (95% CI 0-10). The feasibility of the method was 96.0% (95% CI 90.4-100), and its applicability was 59.0% (95% CI 44.8-73.2). Median operative time was 89 minutes (range, 40-200 minutes). Postoperative morbidity was 24.0% (95% CI 11.7-36.3), and the mortality rate was 0%. We registered 5 failures, and all of them underwent reoperation. The effectiveness of the procedure was 85% (95% CI 76-93). LIMITATIONS: This was a single-institution retrospective study. CONCLUSIONS: The effectiveness of laparoscopic lavage seems to be high. Although its applicability is lower, it could be applied in more than half of patients requiring emergency surgery. This alternative strategy should be considered when laparoscopic assessment reveals Hinchey III diverticulitis.

Evaluating for acute mesenteric ischemia in critically ill patients: diagnostic peritoneal lavage is associated with reduced operative intervention and mortality.

BACKGROUND: The diagnosis of acute mesenteric ischemia among intensive care unit (ICU) patients continues to be difficult and carries high mortality, and yet, it is essential that it be made expeditiously such that lifesaving operative intervention can be offered. A recent study suggested that computed tomography (CT) scan delays operative intervention. Thus, we hypothesized that diagnostic peritoneal lavage (DPL), a rapidly performed bedside procedure of established high sensitivity, is associated with reduced operative intervention, time to operative intervention, and mortality. METHODS: We performed a single-institution, retrospective study of 120 patients admitted to an ICU at the University of Pittsburgh Medical Center's Presbyterian Hospital between January 1, 2002, and December 31, 2010, who were diagnosed with acute mesenteric ischemia. We defined a DPL of greater than 500 cells per cubic millimeter as diagnostic of intra-abdominal pathology. CT scan results were categorized as (1) diagnostic of mesenteric ischemia, (2) abnormal, or (3) normal. We performed multivariate logistic regression, adjusting for difference in case mix, to determine whether DPL is associated with the outcomes of mortality and operative intervention. RESULTS: The cohort was severely ill, with a mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 21.7 (range, 0-48), and 51 patients (42.5%) died. The distribution of preoperative evaluation is as follows: CT, 67; DPL, 11; both modalities, 18; and no preoperative evaluation, 24. Those undergoing DPL were more severely ill, as evidenced by significantly higher APACHE II scores. By comparison with CT, DPL was associated with a reduced risk for operation intervention (adjusted odds ratio, 0.04; 95% confidence interval, 0.01-0.32; p = 0.002) and mortality (adjusted odds ratio, 0.09; 95% confidence interval, 0.01-0.62; p = 0.02). CONCLUSION: DPL is associated with reduced operative intervention yet improved survival, when compared with patients evaluated with either CT or no diagnostic modality. These data support that, for critically ill ICU patients suspected of harboring intra-abdominal pathology such as acute mesenteric ischemia, DPL should be a mainstay in the preoperative diagnostic evaluation. Further investigation is needed, however, to better define the proper place and timing of DPL in evaluating the acute abdomen. LEVEL OF EVIDENCE: Diagnostic study, level III; therapeutic/care management study, level IV.

Comparison of diagnostic peritoneal lavage and focused assessment by sonography in trauma as an adjunct to primary survey in torso trauma: a prospective randomized clinical trial.

BACKGROUND: Lately, Focused Assessment with Sonography in Trauma (FAST) is preferred over diagnostic peritoneal lavage (DPL) as adjunct to primary survey. However, this is not evidence-based as there has been no randomized trial. METHODS: In this study, 200 consecutive torso trauma patients meeting inclusion criteria were randomized to undergo either DPL or FAST. The results were then compared with either contrast enhanced computerized tomography (CECT) (in patients managed non-operatively) or laparotomy findings (in patients undergoing operative treatment). Outcome parameters were: result of the test, therapeutic usefulness, role in diagnosing bowel injury and time taken to perform the procedure. RESULTS: Two hundred patients with a mean age of 28.3 years were studied, 98 in FAST and 102 in DPL group. 104 sustained blunt trauma and 76 sustained penetrating trauma due to stabbing. In addition, 38 (38.7%) were FAST positive and 48 (47%) were DPL positive (p=0.237, not significant). As a guide to therapeutically beneficial laparotomy, negative DPL was better than negative FAST. For non-operative decisions, positive FAST was significantly better than positive DPL. DPL was significantly better than FAST in detecting as well as not missing the bowel injuries. DPL took significantly more time than FAST to perform. CONCLUSION: This study shows that DPL is better than FAST.

Usefulness of early-phase peritoneal lavage for treating severe acute pancreatitis.

OBJECTIVE: To improve the prognosis of severe acute pancreatitis, preventing infectious complications, particularly infected pancreatic necrosis, is important. The present study evaluated the efficacy of peritoneal lavage for improving the prognosis of patients with severe acute pancreatitis. PATIENTS: We retrospectively reviewed the cases of 23 consecutive patients with severe acute pancreatitis who were treated with peritoneal lavage. RESULTS: Peritoneal lavage was started within 72 hours after the initial onset of symptoms in 20 patients (87%). The duration of peritoneal lavage, which was significantly correlated with the number of prognostic factors according to the revised Japanese criteria, Ranson score and serum C-reactive protein level at the start of peritoneal lavage, was a median of seven (3-22) days. There were no adverse events associated with the peritoneal lavage. Eight patients (35%) concurrently underwent continuous regional arterial infusion. Five days after starting peritoneal lavage, the patients' clinical conditions significantly improved. Overall, the survival rate was 96%. One patient (4%) died due to rupture of a pseudoaneurysm of the splenic artery. Complications occurred in seven patients (30%). Infectious complications were observed in three patients (13%) (one patient developed infected pancreatic necrosis and bacteremia, and two patients developed bacteremia). Pseudocysts and pancreatic fistulas developed in five and one patient, respectively. The incidence of complications was lower in the patients receiving peritoneal lavage within 72 hours from the initial onset of symptoms than in the remaining patients (20% vs. 100%; p=0.005). CONCLUSION: We speculate that peritoneal lavage reduces the mortality and incidence of complications in patients with severe acute pancreatitis.

Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis.

BACKGROUND: Transluminal retroperitoneal endoscopic necrosectomy (TREN) is an attractive NOTES technique alternative to surgery for treatment of walled-off pancreatic necrosis (WOPN). The main limitations to this technique are the need for repeated sessions, prolonged external irrigation, and EUS availability. In our study, we introduced new modifications, including the use of hydrogen peroxide, and abandoning the use of EUS and external irrigation. METHODS: This is a retrospective study of outcome of consecutive patients who underwent TREN for WOPN between April 2011 and August 2012. The technique included (1) non-EUS-guided transluminal drainage, and (2) direct endoscopic debridement using hydrogen peroxide and different accessories. No external irrigation was used. RESULTS: Ten patients were included. Initial clinical and technical success was achieved in all patients. Complete radiological success and long-term clinical efficacy was achieved in nine patients (1 patient had an inaccessible left paracolic gutter collection and died 62 days after endotherapy). Mean number of sessions was 1.4 (range 1-2). Complications included bleeding, which was self-limited in three patients and endoscopically controlled in one. All patients avoided surgery, and no recurrence was reported during median follow-up of 289 (range 133-429) days. CONCLUSIONS: TREN is a safe and effective treatment for WOPN and could be performed safely without EUS guidance in selected cases. Hydrogen peroxide played a major role in reduction of number of sessions and timing. External irrigation of WOPN is not necessary, if adequate debridement could be achieved.

Diagnostic peritoneal lavage in hemodynamically stable patients with lower chest or anterior abdominal stab wounds.

BACKGROUND: Managing hemodynamically stable patients with thoracoabdominal stab wounds is still under dispute. This study aimed at discussing cut-off points of red blood cell (RBC) count in diagnostic peritoneal lavage (DPL) effluent in these patients. METHODS: Three hundred and eighty-eight patients with thoracoabdominal stab wounds and hemodynamically stable status were enrolled. In cases without a clear indication of laparotomy, the peritoneal cavity was washed out with 1000 ml of normal saline and the effluent fluid was analyzed for RBC count. RBC counts of >100,000/mm3 in abdominal wounds and of >10,000/mm3 in lower chest wounds were considered as indications for exploratory laparotomy (conventional approach). New cut-off points for RBC count were calculated in backward analysis. RESULTS: Sensitivity and specificity of the conventional approach were 90% and 84%, respectively. RBC counts >15,000/mm3 in abdominal wounds and >25,000/mm3 in lower chest wounds were the best cut-off points in distinguishing patients with and without need of operation, with a sensitivity and specificity of 94% and 96%, respectively. CONCLUSION: New cut-off points of RBC count in DPL effluent may promote management of patients with thoracoabdominal stab wounds and no obvious indication for operation.

Utility and relevance of diagnostic peritoneal lavage in trauma education.

OBJECTIVES: During the last 2 decades, the advent of new technologies in trauma patient care may have resulted in a decreased number of diagnostic peritoneal lavage (DPL) evaluations. In this study, it is hypothesized that fewer DPL are being performed at a midwestern trauma center. Such negative trends may make the inclusion of DPL in current trauma education potentially outdated and no longer universally appropriate in trauma evaluation algorithms. DESIGN, SETTING, AND PARTICIPANTS: This retrospective observational study of a level I trauma center includes patients from January 1998 through September 2010. The total number of trauma-related DPL procedures performed annually during the study period was determined along with accompanying facility and trauma patient level data. RESULTS: A total of 24 DPLs were performed at the target trauma center during the study period. There was a significant decrease (p = 0.0018) in the use of DPL despite a significant increase (p < 0.0001) in the proportion of trauma patients with an injury severity score > 15. CONCLUSIONS: Study data demonstrated a decrease in the use of DPL as a diagnostic modality in the evaluation of blunt abdominal trauma patients at a medium-sized midwestern center. These data provide historic facility-level evidence of a practice change. Such information may support a recommendation that the American College of Surgeons revisit its current curriculum for Advanced Trauma Life Support (ATLS). Specifically, we propose the American College of Surgeons consider changing DPL instruction to an optional component of ATLS. COMPETENCIES: Patient Care, Medical Knowledge, Practice Based Learning and Improvement.

[Open abdomen 2009. A national survey of open abdomen treatment in Germany]. / Offenes Abdomen 2009. Umfrage zu Behandlungsstrategien des offenen Abdomens in Deutschland.

BACKGROUND: Open abdomen (OA) treatment has been established worldwide. This survey examines the current status of OA treatment in Germany. MATERIAL AND METHODS: A national survey was conducted between October 2008 and September 2009 by questionnaires sent to 1,219 surgical departments. Data were evaluated descriptively. RESULTS: The response rate was 38% overall and 69% for university departments. Open abdomen treatment is used by 94% of all respondents. Most commonly used are staged abdominal lavage (87%), a commercial abdominal dressing system (82%), planned ventral hernia (69%), and other intra-abdominal dressings (e.g. vacuum pack 15%, Bogotá bag 5%). Nearly half of the respondents (46%) indicated a modification of their strategy towards vacuum techniques during the last 5 years. CONCLUSIONS: Open abdomen procedures are widely used in German surgical departments. This survey indicates a shift of treatment strategies towards vacuum techniques but even though predominant, the effectiveness and safety of these techniques must still be confirmed by prospective controlled trials. This survey helps to identify relevant clinical questions and enables focused trial networking.

Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds.

BACKGROUND: Recent guidelines do not support local wound exploration (LWE) or diagnostic peritoneal lavage (DPL) in the evaluation of patients with anterior abdominal stab wounds (AASWs), favoring computed tomography scanning or serial examinations. In patients without immediate indications for laparotomy, we hypothesized that LWE/DPL would identify patients requiring surgery while limiting unnecessary hospital admissions. METHODS: Patients sustaining penetrating trauma at our level I trauma center over a 3-year period were reviewed. RESULTS: During the study period, 139 patients with AASW followed our LWE/DPL algorithm. Fifty-six patients had LWE without fascial penetration: 46 were discharged immediately, 10 required admission. Fifty-eight patients had fascial penetration on LWE but negative DPL: 37 were observed for less than 24 hours, 19 were observed for more than 24 hours, and 2 patients developed peritonitis requiring exploration. Twenty-five patients had positive LWE/DPL: 13 had therapeutic laparotomy, 12 had nontherapeutic laparotomy. CONCLUSIONS: Only 11% of patients with AASWs without overt indication for laparotomy require surgical care. LWE remains a valid method to exclude intra-abdominal injury and to eliminate hospitalization in more than one third of AASW patients.

Is peritoneal drainage necessary in childhood perforated appendicitis?--a comparative study.

PURPOSE/BACKGROUND: In this study, we aimed to evaluate the effect of peritoneal drainage (PD) on postoperative infective complications in cases with perforated appendicitis. METHOD: One hundred nine patients (with PD) were evaluated retrospectively and 117 cases (with no drainage [ND]) were evaluated prospectively regarding complications like wound infection (WI), intraabdominal abscess (IAA), and small bowel obstruction caused by adhesions (SBO) in perforated appendicitis cases. The abdomen was irrigated with isotonic NaCl solution and the wounds were closed primarily in all patients. RESULTS: The total number of patients was 226 (male, 66.4%; female, 33.6%), with a mean age of 8.6 +/- 3.4 years (range, 1-15 years). The WI rates in PD and ND groups were 28.4% to 16.2%, respectively. The ratio of IAA in the PD group was 12.8% which decreased to 3.4% in the ND group. The difference was statistically significant (P < .05). The postoperative hospitalization period in the PD and ND groups were 10.2 +/- 6.5 and 8.3 +/- 3.3 days, durations of antibiotic use were 9.5 +/- 5.5 and 7.7 +/- 2.7 days, durations of NG tube usage were 3.2 +/- 1.5 and 2.2 +/- 1.2 days, time to oral feeding was 3.7 +/- 1.7 and 2.5 +/- 1.4 days, and time to normalization of the body temperatures was 3.7 +/- 2.3 vs 2.3 +/- 1.7 days. All differences were statistically significant (P < .05). The ratio of SBO increased from 2.8% to 3.4% in the ND group, but this result was not statistically significant. CONCLUSIONS: As a result of this study, we recommend that peritoneal drainage should be abandoned in childhood appendicitis.

Intra-operative peritoneal lavage--who does it and why?

INTRODUCTION: Intra-operative peritoneal lavage (IOPL) is widely practised but its benefits are unclear. The frequency and pattern of its use amongst general surgeons is investigated. METHODS: A postal questionnaire was sent to 153 general surgical consultants and registrars enquiring about their use of IOPL. The surgeon was asked the volume and type of lavage fluid used, under various circumstances. RESULTS: 118 (77%) questionnaires were returned. 115 (97%) surgeons used IOPL. The majority of surgeons (61%) lavaged until the fluid was clear, 20% used more than 1 l and 17% used between 500-1000 ml. In the case of the dirty abdomen (i.e. gross pus or faecal peritonitis), 47% used saline as the lavage fluid, 38% aqueous betadine, 9% water and 3% antibiotic lavage. Similar results were found in the case of a contaminated abdomen (i.e. a breached hollow viscus). 34% of surgeons used IOPL during clean cases. 36% used water lavage during intra-abdominal cancer surgery; 21% lavaged with saline and 17% with betadine. More registrars (47%) than consultants (29%) lavaged with water during cancer surgery. Consultants, however, used more aqueous betadine. CONCLUSIONS: The frequency of use and choice of lavage fluid varies widely. The successful management of the septic abdomen rests on at least 3 tenants - systemic antibiotics, control of the source of infection and aspiration of gross contaminants. There is little good evidence in the literature to support IOPL in the management of the septic abdomen. The use of IOPL during cancer surgery is supported by in vitro evidence. The current use of IOPL, as shown by this study, appears not to be evidence based.

Evaluation of blunt abdominal trauma: current practice in Taiwan.

OBJECTIVE: To gain an overview of the current practice of different major institutions in Taiwan in the evaluation of abdominal injuries. A further comparison was made between general surgeons and emergency physicians in this aspect. METHOD: A telephone survey was conducted of all emergency departments of 58 major institutions (14 medical centres, 44 district hospitals) that are capable of providing definitive care for trauma victims in Taiwan in June 2002. Respondents were asked to select the diagnostic modality of choice in the evaluation of a haemodynamically abnormal blunt trauma victim with suspected intra-abdominal injuries. In the same study period, this particular telephone scenario was also used to survey 109 individual doctors (45 emergency physicians, 64 general surgeons). RESULTS: Most respondents preferred ultrasound (also known as focused assessment with sonography for trauma or "FAST") instead of diagnostic peritoneal lavage (DPL) because DPL is invasive and most doctors in Taiwan have limited experience in performing DPL or interpreting the results. CONCLUSIONS: It seems reasonable to devote greater resources for emergency departments to incorporate a FAST based algorithm into their initial management of trauma victims, and to improve training in its use. It is also suggested that future ATLS teaching in Taiwan should include didactic material on FAST.

The resident experience on trauma: declining surgical opportunities and career incentives? Analysis of data from a large multi-institutional study.

PURPOSE: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). METHODS: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). RESULTS: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. CONCLUSION: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Laparostomía contenida en manejo de sepsis abdominal: uso de mallas versus ventrofil como forma de contención / Contained laparostomy in the management of abdominal sepsis: use of meshs versus ventrofil as contention method

En un intento de disminuir la mortalidad de los cuadros sépticos peritoneales graves, se han introducido nuevos enfoques quirúrgicos, entre ellos la laparostomía y su variante la laparostomía contenida o semiabierta. Existen diversas formas de contención, entre ellas el uso de ventrofil y de mallas. El objetivo de este trabajo es comparar ambos tipós de contención en relación a los resultados y complicaciones observadas. Para ello se estudiaron retrospectivamente 35 pacientes en los cuales se realizó laparostomía contenida. De ellos en 22 casos se uso ventrofil y en 13 pacientes (6 hombres y 7 mujeres con edad promedio de 50 años) mallas suturadas a pared abdominal. Se clasificó a los pacientes según su gravedad al ingreso mediante puntaje APACHE II, subdividiéndose en tres grupos para facilitar su análisis. Se observó una distribución similar de los pacientes en relación al índice de gravedad. Las causas que llevaron a la laparostomía en ambos grupos fueron proporcionales, encontrándose en más del 50 por ciento como etiología la perforación de tracto gastrointestinal. El tiempo promedio de laparostomía fue de 11,8 días de los casos con ventrofil y de 20,1 días en los con malla, con un promedio de 3,9 aseos en el primer caso y 4,8 en el otro. En cuanto a las complicaciones intraabdominales observadas derivadas del método, en los pacientes en que se usó ventrofil hubo 8 fístulas intestinales (36,3 por ciento). En los que se utilizó malla las complicaciones intraabdominales fueron 3 casos (23 por ciento) de fístula intestinal. La mortalidad fue de 27 por ciento en pacientes con ventrofil y 23 por ciento en uso de malla, estando ésta dada por la gravedad de la sepsis abdominal y no por el tipo de laparostomía. Se concluye que para el manejo de la laparostomía contenida, el uso de mallas como forma de contención sería la mejor opción, permitiendo un fácil manejo y un menor índice de complicaciones