Morbimortalidad en pacientes con peritonitis apendicular sometidos a cirugía laparoscópica / Morbimortality in patients with appendicular peritonitis undergoing laparoscopic surgery

Objetivo: Describir la morbimortalidad de los pacientes con diagnóstico de peritonitis apendicular, sometidos a cirugía laparoscópica en el Servicio de Cirugía General del Hospital Universitario de Caracas, durante el periodo enero 2013 - diciembre 2018. Métodos: estudio retrospectivo, descriptivo, observacional de corte transversal. Se revisaron las historias clínicas de los pacientes con peritonitis apendicular que fueron sometidos a cirugía laparoscópica en los servicios de Cirugía I, II, III y IV del Hospital Universitario de Caracas, en el período enero 2013-diciembre 2018. Las variables cuantitativas se expresaron en media ± desviación estándar y variables cualitativas en frecuencia y porcentaje; los datos se procesaron en el programa estadístico SPSS 19 (SPSS, inc., Chicago, EEUU). Resultados: la muestra estuvo conformado por 60 pacientes con edades entre 12 y 78 años, con el 78,33% en el grupo etario de 10 a 29 años; el sexo masculino representó el 58,33% de la muestra, con un promedio de edad de 23,90± 11,84 años; las complicaciones se presentaron en el 18,33% de los casos, más frecuente la infección del sitio operatorio con 6,67% (n=4) de los pacientes. La estancia hospitalaria global fue de 4,80 ± 2,58 días. Un paciente falleció. Conclusiones: el abordaje laparoscópico para el tratamiento de la peritonitis apendicular difusa se relaciona con muy baja morbimortalidad postoperatoria. La complicación más frecuente fue la infección del sitio operatorio. La mayoría de los pacientes solo ameritó una intervención quirúrgica(AU)

Objective: To describe the morbimortality ofpatients with a diagnosis of appendicular peritonitis undegoinglaparoscopic surgery in the General Surgery Department of the University Hospital of Caracas, during the period January2013 - December 2018. Methods: A retrospective, descriptive,observational, cross-sectional, descriptive study was performed.the medical records of patients with appendicular peritonitis who underwent laparoscopic surgery in the Surgery I, II, III and IV services of the University Hospital of Caracas were reviewed. Period January 2013-December 2018. Quantitative variables are expressed as mean ± standard deviation and qualitative variablesas frequency and percentage. The data were processed in the SPSS 19 statistical program (SPSS, inc., Chicago, USA). Results: the sample consisted of 60 patients aged between 12 and 78 years, with 78.33% in the age group 10 to 29 years. Male sex represented 58.33% of the sample, with an average age of 23.90 ±11.84 years. Complications occurred in 18.33% of the cases, with6.67% (n=4) of the patients reporting surgical site infection. The overall hospital stays of 4.80 ± 2.58 days. One patientdied. Conclusions: the laparoscopic approach is of choice for the treatment of diffuse appendicular peritonitis. The most frequent complication was surgical site infection. Most of the patients only required one surgical intervention(AU)

Outcomes of peritoneal dialysis in elderly vs non-elderly patients: A systemic review and meta-analysis.

OBJECTIVES: Several studies have compared outcomes of peritoneal dialysis (PD) between elderly and non-elderly patients but with variable results. We hereby designed this review to compare mortality, peritonitis, and technique survival between elderly and non-elderly patients on PD. METHODS: PubMed, Embase, and Google Scholar were searched for studies comparing outcomes of PD between elderly and non-elderly patients. The last search date was 14th July 2021. RESULTS: Fourteen studies were included. 12 studies defined the elderly as ≥65 years of age and these were included in the meta-analysis. Pooled analysis of crude (RR: 2.45 95% CI: 1.36, 4.40 I2 = 97% p = 0.003) and adjusted data (HR: 2.80 95% CI: 2.45, 3.09 I2 = 0% p<0.00001) indicated a statistically significant increased risk of mortality amongst elderly patients as compared to non-elderly patients. Meta-analysis of four studies demonstrated a statistically significant increased risk of peritonitis in the elderly (RR: 1.56 95% CI: 1.18, 2.07 I2 = 76% p = 0.002). Pooled analysis demonstrated no statistically significant difference in technique survival between the two groups (RR: 0.95 95% CI: 0.86, 1.05 I2 = 86% p = 0.32). CONCLUSION: Elderly patients on PD have a significantly increased risk of mortality as compared to non-elderly patients. The risk of peritonitis is also significantly increased in older adults but the increased age has no impact on technique survival. Further studies are needed to strengthen our conclusions.

Caracterización epidemiológica: análisis de tasa de mortalidad e índice de swaroop para peritonitis en el periodo 2017- 2021, en Chile / Epidemiological characterization: peritonitis mortality rate and swaroop Index in the period 2017 - 2021, in Chile

Introducción: La peritonitis alcanza una mortalidad global de hasta un 60%. Dada la falta de estudios epidemiológicos nacionales, se plantea calcular la tasa de mortalidad (TM) por peritonitis entre los años 2017-2021 en Chile. Metodología: Estudio descriptivo, ecológico, sobre defunciones por peritonitis entre los años 2017-2021 en Chile (N=1.741), en población mayor de 15 años según grupo etario, sexo y región con datos obtenidos del departamento de estadística e información en salud. Se utilizó estadística descriptiva, cálculo de TM e índice de Swaroop (IS). No requirió aprobación por comité de ética. Resultados: Se calculó una TM de 2,47/100.000 habitantes entre los años 2017 y 2021, siendo el año 2020 la mayor con 3,07. El sexo femenino presentó una tasa de 2,65. El grupo etario con mayor TM es el de 80 y más con 141,7/100.000 habitantes. Para el IS por región, lideran las regiones XV y XII con 100%, siendo la más baja la XI con 83,3%. Discusión: El pico de TM para el año 2020 coincide con la pandemia por Covid-19, donde se reporta mayor mortalidad postoperatoria en pacientes infectados. El IS se mantiene mayor al 90% en el país, excepto en las Regiones X y XI, probablemente debido a la menor disponibilidad de centros de alta complejidad. Conclusión: Dada la ausencia de datos recientes de mortalidad para peritonitis, se realizó una actualización epidemiológica local, con perspectiva comparativa regional respecto a las TM de la población general y en mayores de 50 años.

Introduction: Peritonitis reaches an overall mortality of up to 60%. Given the lack of national epidemiological studies, it is proposed to calculate the mortality rate (MR) due to peritonitis between the years 2017-2021 in Chile. Methodology: Descriptive, ecological study about deaths by peritonitis between 2017 and 2021 in Chile (N=1,741), in a population older than 15 years old according to age group, sex, and region with data obtained from Departamento de Estadística e Información en Salud. Descriptive statistics were used, MR calculation, and Swaroop Index (SI). It did not require approval by an ethics committee. Results: A MR of 2.47/100,000 was calculated between the years 2017 and 2021, with 2020 being the highest with 3.07. The female sex presented a rate of 2.65. The age group with the highest MR is 80 and over with 141.7/100,000. For the SI by region, the XV and XII regions lead with 100%, the lowest being XI region with 83.3%. Discussion: The peak of MR for the year 2020 coincides with the Covid-19 pandemic and the highest postoperative mortality in infected patients. The SI remains above 90% in the country, except in X and XI regions, probably due to the lower availability of high complexity centers. Conclusion: Given the lack of recent mortality data for peritonitis, a local epidemiological update was carried out, with a regional comparative perspective regarding MR in the general population and in those over 50 years old.

Identifying early indicators of secondary peritonitis in critically ill patients with cirrhosis.

Ascitic fluid infection (AFI) is a life-threatening complication of cirrhosis. We aimed to identify early indicators of secondary peritonitis (SP), which requires emergency surgery, and to describe the outcomes of SP and spontaneous bacterial/fungal peritonitis (SBFP). Adults with cirrhosis and AFI admitted to 16 university or university-affiliated ICUs in France between 2002 and 2017 were studied retrospectively. Cases were identified by searching the hospital databases for relevant ICD-10 codes and hospital charts for AFI. Logistic multivariate regression was performed to identify factors associated with SP. Secondary outcomes were short- and long-term mortality and survivors' functional outcomes. Of 178 included patients (137 men and 41 women; mean age, 58 ± 11 years), 21 (11.8%) had SP, confirmed by surgery in 16 cases and by abdominal computed tomography in 5 cases. Time to diagnosis exceeded 24 h in 7/21 patients with SP. By multivariate analysis, factors independently associated with SP were ascitic leukocyte count > 10,000/mm3 (OR 3.70; 95%CI 1.38-9.85; P = 0.009) and absence of laboratory signs of decompensated cirrhosis (OR 4.53; 95%CI 1.30-15.68; P = 0.017). The 1-year mortality rates in patients with SBFP and SP were 81.0% and 77.5%, respectively (Log-rank test, P = 0.92). Patients with SP vs. SBFP had no differences in 1-year functional outcomes. This multicenter retrospective study identified two indicators of SP as opposed to SBFP in patients with cirrhosis. Using these indicators may help to provide early surgical treatment.

Increased mortality and altered local immune response in secondary peritonitis after previous visceral operations in mice.

Postoperative peritonitis is characterized by a more severe clinical course than other forms of secondary peritonitis. The pathophysiological mechanisms behind this phenomenon are incompletely understood. This study used an innovative model to investigate these mechanisms, combining the models of murine Colon Ascendens Stent Peritonitis (CASP) and Surgically induced Immune Dysfunction (SID). Moreover, the influence of the previously described anti-inflammatory reflex transmitted by the vagal nerve was characterized. SID alone, or 3 days before CASP were performed in female C57BL/6 N mice. Subdiaphragmatic vagotomy was performed six days before SID with following CASP. The immune status was assessed by FACS analysis and measurement of cytokines. Local intestinal inflammatory changes were characterized by immunohistochemistry. Mortality was increased in CASP animals previously subjected to SID. Subclinical bacteremia occurred after SID, and an immunosuppressive milieu occurred secondary to SID just before the induction of CASP. Previous SID modified the pattern of intestinal inflammation induced by CASP. Subdiaphragmatic vagotomy had no influence on sepsis mortality in our model of postoperative peritonitis. Our results indicate a surgery-induced inflammation of the small intestine and the peritoneal cavity with bacterial translocation, which led to immune dysfunction and consequently to a more severe peritonitis.

Immune Resolution Dilemma: Host Antimicrobial Factor S100A8/A9 Modulates Inflammatory Collateral Tissue Damage During Disseminated Fungal Peritonitis.

Intra-abdominal infection (peritonitis) is a leading cause of severe disease in surgical intensive care units, as over 70% of patients diagnosed with peritonitis develop septic shock. A critical role of the immune system is to return to homeostasis after combating infection. S100A8/A9 (calprotectin) is an antimicrobial and pro-inflammatory protein complex used as a biomarker for diagnosis of numerous inflammatory disorders. Here we describe the role of S100A8/A9 in inflammatory collateral tissue damage (ICTD). Using a mouse model of disseminated intra-abdominal candidiasis (IAC) in wild-type and S100A8/A9-deficient mice in the presence or absence of S100A9 inhibitor paquinimod, the role of S100A8/A9 during ICTD and fungal clearance were investigated. S100A8/A9-deficient mice developed less ICTD than wild-type mice. Restoration of S100A8/A9 in knockout mice by injection of recombinant protein resulted in increased ICTD and fungal clearance comparable to wild-type levels. Treatment with paquinimod abolished ICTD and S100A9-deficient mice showed increased survival compared to wild-type littermates. The data indicates that S100A8/A9 controls ICTD levels and antimicrobial activity during IAC and that targeting of S100A8/A9 could serve as promising adjunct therapy against this challenging disease.

Time until treatment initiation is associated with catheter survival in peritoneal dialysis-related peritonitis.

For peritonitis, a serious complication of peritoneal dialysis (PD), we investigated the relation between duration from the sign (PD effluent abnormalities) to treatment with appropriate antibiotics (ST time) and catheter removal. For 62 PD hospital patients, data of PD-related peritonitis (n = 109) were collected retrospectively. We examined ST time and PD catheter removal times using univariate and multivariate analyses. The catheter removal rate in the delayed ST time group (≥ 24 h) was higher than that in early ST time group (< 24 h) (38 vs. 16%, p = 0.02). Concomitant tunnel infection and delayed ST time were associated with catheter removal (OR [95% CI] 32.3 [3.15-329] and 3.52 [1.11-11.1]). Rates of catheter removal and re-development of peritonitis within 1 month after starting treatment were higher in the delayed ST time group (p = 0.02). PD duration at peritonitis and the first peritonitis episode were associated with delayed ST time (1.02 [1.00-1.04] and 3.42 [1.09-10.7]). Significant association was found between PD catheter removal and the start of treatment more than 24 h after appearance of abnormal effluent. Education for patients about prompt visitation at the onset of peritonitis with long PD duration might improve outcomes.

Caracterización del tratamiento quirúrgico de los tumores hepáticos sólidos / Characterization of Surgical Management of Hepatic Tumors

Introducción: La historia de la cirugía del hígado abarca 28 siglos, lo que ha permitido su evolución desde considerar al hígado como un órgano intocable hasta realizar hepatectomías complejas y trasplante hepático. Esta investigación representa el balance de 10 años en la actividad de un grupo de cirugía hepatobiliar. Objetivo: Caracterizar el tratamiento quirúrgico de los tumores hepáticos sólidos en el Centro de Investigaciones Médico-Quirúrgicas entre los años 2009 y 2019. Métodos: Se realizó un estudio de tipo observacional, descriptivo, longitudinal y retrospectivo en el que se analizaron 129 pacientes que fueron tributarios de tratamiento quirúrgico. Resultados: Los tumores malignos representaron el 73 por ciento del total, dentro de este grupo se destacan los metastásicos con 50 casos. La morbilidad de esta cirugía fue del 13 por ciento y la mortalidad operatoria del 2 por ciento. La causa de muerte identificada fue el shock séptico por peritonitis generalizada. Conclusiones: Los tumores malignos fueron los más frecuentes. Se presentó una baja morbilidad encontrándose el derrame pleural como la complicación más usual. Existe una mortalidad acorde a los valores reportados para este tipo de cirugía(AU)

Introduction: The history of liver surgery covers twenty-eight centuries, which has allowed its evolution from considering the liver as an untouchable organ to performing complex hepatectomies and hepatic transplantation. This research describes the ten years' balance in the activity developed by a hepatobiliary surgery team. Objective: To characterize the surgical management of solid hepatic tumors in the Center for Medical-Surgical Research between 2009 and 2019. Methods: An observational, descriptive, longitudinal and retrospective study was carried out, for which 129 patients who underwent surgical treatment were analyzed. Results: Malignant tumors accounted for 73 percent of the total; within this group, metastatic tumors stand out, accounting for fifty cases. Morbidity of this surgery type was 13 percent, while operative mortality was 2 percent. The cause of death identified was septic shock due to generalized peritonitis. Conclusions: Malignant tumors were the most frequent. There was low morbidity, with pleural effusion as the most common complication. Mortality is consistent with the values reported for this type of surgery(AU)

[Comparative assessment of prognostic systems for secondary peritonitis outcome]. / Sravnitel'naya otsenka sistem prognoza iskhoda vtorichnogo peritonita.

OBJECTIVE: To compare the most common prognostic systems in patients with peritonitis. MATERIAL AND METHODS: The study included 352 patients with secondary peritonitis. At admission, sepsis was diagnosed in 15 (4.3%) patients, septic shock - in 4 (1.1%) cases. Mortality was associated with the following main causes: purulent intoxication and/or sepsis - 51 cases (87.9%), cancer-induced intoxication - 4 (6.9%) cases, acute cardiovascular failure - 3 cases (5.2%). We analyzed the efficacy of Manheim Peritoneal Index (MPI), WSES prognostic score, APACHE-II scale, gSOFA score and Peritonitis Prediction System (PPS) developed by the authors. RESULTS: Age of a patient, malignant tumor, exudate nature, sepsis (septic shock) and organ failure not associated with peritonitis are the most important criteria in predicting fatal outcome. ROC analysis was used to assess prognostic value of various prediction systems. Standard error was less than 0.05 for all scales. Therefore, all prediction systems can be considered accurate for prediction of mortality in patients with peritonitis. CONCLUSION: PPS (AUC 0.942) has the greatest accuracy in predicting fatal outcome in patients with advanced secondary peritonitis, APACHE II (AUC 0.840) - minimum accuracy. MPI had predictive accuracy > 90% too.

Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants With Late-Onset Infection.

Importance: Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown. Objective: To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites. Design, Setting, and Participants: A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants. Exposures: Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis. Main Outcomes and Measures: The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset. Results: In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks' completed gestation did not reduce the association of the nSOFA score with infection-related mortality. Conclusions and Relevance: The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.

Baseline serum triglyceride predicts early-onset peritonitis and prognosis in incident CAPD patients.

ABSTRACT: We aimed to investigate the hypothesis that serum triglyceride (TG) may be an independent predictor of early-onset peritonitis and prognosis in incident continuous ambulatory peritoneal dialysis (CAPD) patients.In this retrospective, observational study, we screened 291 adults admitted to the PD center of the Wuhan No. 1 hospital from August 1, 2013 to November 31, 2017. All biochemical data were collected at the first 1 to 3 months after the initiation of CAPD. Early-onset peritonitis was defined as peritonitis occurring within 6 months after the initiation of PD. All of PD patients were followed up to July 31, 2018. The primary endpoint was the incidence of early-onset peritonitis while the second endpoints included overall mortality and technical failure.A total of 38 patients occurred early-onset PD peritonitis and the Lasso logistic regression selected TG and age in the final model for early-onset peritonitis. We divided patients into two groups based on the median baseline TG levels: TG ≥ 1.4mmo/L group (n = 143) and TG < 1.4mmol/L group (n = 148). There were 34 (11.7%) patients died and 33 (11.3%) patients transferred to hemodialysis during the follow-up, Moreover, a level of TG ≥ 1.4mmol/L at the initiation of CAPD was associated with a significantly increased probability of technical failure (hazard ratio, HR, 1.30; 95% confidence interval, 95% CI, 1.09 to 2.19, P = .043) and overall mortality (HR, 2.33; 95% CI, 1.16-4.72, P = .018).Serum TG levels measured at the initiation of PD therapy is an independent predictor of early-onset peritonitis and prognosis of CAPD patients.

Oligosaccharides from Polygonatum Cyrtonema Hua: Structural characterization and treatment of LPS-induced peritonitis in mice.

Fructooligosaccharide was isolated from Polygonatum Cyrtonema Hua (PFOS) for the first time. Structure characterized using FT-IR, MALDI-TOF-MS, NMR, AFM, and TEM, indicated that PFOS was graminan-type fructan with a degree of polymerization ranging from 5 to 10. A murine model of lipopolysaccharide (LPS)-induced peritonitis was used to evaluate the in vivo anti-inflammatory and lung protective efficacy of PFOS. The result shown that pretreatment with PFOS (1.0 mg/mL) in peritonitis-induced mice could significantly inhibit the level of pro-inflammatory cytokines (TNF-α, IL-1ß) in serum (P < 0.001), increase mice survival rate from 12.5 % to 54 % (P < 0.05), and alleviated lung injury through ameliorating the damage of the pulmonary cellular architecture and reducing inflammatory monocyte accumulation in lung tissue. This effect of oligosaccharides could explain the traditional usage of P. cyrtonema as a tonic medicine for respiratory problems and it could be used as a potential natural ingredient with anti-inflammatory activity.

Outcome of community- versus hospital-acquired intra-abdominal infections in intensive care unit: a retrospective study.

BACKGROUND: To compare patients hospitalised in the intensive care unit (ICU) after surgery for community-acquired intra-abdominal infection (CA-IAI) and hospital-acquired intra-abdominal infection (HA-IAI) in terms of mortality, severity and complications. METHODS: Retrospective study including all patients admitted to 2 ICUs within 48 h of undergoing surgery for peritonitis. RESULTS: Two hundred twenty-six patients were enrolled during the study period. Patients with CA-IAI had an increased 28-day mortality rate compared to those with HA-IAI (30% vs 15%, respectively (p = 0.009)). At 90 days, the mortality rates were 36.7 and 37.5% in the CA-IAI group and HA-IAI group, respectively, with a similar APACHE II score on admission (median: 21 [15-25] vs. 21 [15-24] respectively, p = 0.63). The patients with HA-IAI had prolonged ICU and hospital stays (median: 17 [7-36] vs. 6[3-12] days, p < 0.001 and 41 [24-66] vs. 17 [7-32] days, p = 0.001), and experienced more complications (reoperation and reintubation) than those with CA-IAI. CONCLUSION: CA-IAI group had higher 28-day mortality rate than HA-IAI group. Mortality was similar at 90 days but those with HA-IAI had a prolonged ICU and hospital stay. In addition, they developed more complications.

Abdomen agudo quirúrgico en el paciente geriátrico / Surgical Acute Abdomen in the Geriatric Patient

RESUMEN Introducción: El abdomen agudo es causa frecuente de ingreso hospitalario en pacientes geriátricos. Objetivo: Caracterizar el comportamiento del abdomen agudo quirúrgico en el paciente geriátrico en un servicio de cirugía general. Métodos: Se realizó un estudio observacional descriptivo longitudinal de corte transversal en 169 pacientes. Los datos procedieron de las historias clínicas del Hospital Universitario "Manuel Ascunce Domenech" de Camagüey, desde enero de 2014 a diciembre de 2016 y se procesaron mediante estadística descriptiva, relacionándose algunas variables de manera no inferencial. Resultados: El 52,2 por ciento de los pacientes eran hombres. El 42,6 por ciento tenía edades entre 60 y 69 años. El 28,9 por ciento presentaron la oclusión intestinal como etiología. Hubo un 39,5 por ciento de complicaciones, el 54,5 por ciento de ellas fueron infecciosas. La mortalidad fue de un 22,5 por ciento. El 26,6 por ciento de los fallecidos presentaba oclusión intestinal. Conclusiones: Casi una décima parte de los pacientes fallecieron, la peritonitis fibropurulenta y el choque séptico fueron las causas más frecuentes de los decesos. La oclusión intestinal como causa de abdomen agudo pareció influir en la mortalidad de la muestra estudiada(AU)

ABSTRACT Introduction: Acute abdomen is a frequent cause of hospital admission in geriatric patients. Objective: To characterize the occurrence of acute surgical abdomen in the geriatric patient in a general surgery service. Methods: An observational, descriptive, longitudinal and cross-sectional study was carried out with 169 patients. The data were obtained from the medical records of Manuel Ascunce Domenech University Hospital in Camagüey, from January 2014 to December 2016, and were processed using descriptive statistics, relating some variables in a noninferential way. Results: 52.2 percent of the patients were men. 42.6 percent were aged between 60 and 69 years. 28.9 percent presented intestinal occlusion as an etiology. There were 39.5 percent of complications, 54.5 percent of which were infectious. Mortality was 22.5 percent. 26.6 percent of the deceased had intestinal obstruction. Conclusions: Almost one tenth of the patients died, with fibrinopurulent peritonitis and septic shock being the most frequent causes of death. Intestinal occlusion as a cause of acute abdomen appeared to influence mortality in the sample studied(AU)

Peritonitis por fusarium en paciente en diálisis peritoneal domiciliaria / Fusarium peritonitis in a patient on home peritoneal dialysis

Introducción: La peritonitis fúngica es una complicación infrecuente pero grave para un paciente en diálisis peritoneal domiciliaria. Objetivo: Describir un caso de peritonitis fúngica en un paciente en diálisis peritoneal continua ambulatoria (DPCA). Métodos: Se presenta un paciente masculino de 53 años de edad, con antecedentes de hipertensión arterial, 9 años en diálisis peritoneal continua ambulatoria, con una desnutrición proteico energética moderada. Durante su tratamiento presentó varios episodios de peritonitis bacterianas, infecciones del orificio de salida y una recolocación de catéter peritoneal con cuff extruido. Se trabajó con sus antecedentes, cuadro clínico, agente etiológico y tratamiento. El diagnóstico se estableció por la presencia de líquido peritoneal turbio, conteo celular con más de 100 leucocitos/ul y cultivo con la presencia del hongo filamentoso. Resultados: En diciembre de 2017 se le diagnostica una peritonitis por fusarium, sin leucocitosis ni anemia, sí presentaba una hipoalbuminemia, se cultiva además pared de la habitación donde el paciente se realizaba los intercambios y se encuentra hongo filamentoso. En principio se comienza tratamiento con vancomicina y ceftacidima, posteriormente se cambia la ceftazidima por amikacina y finalmente, al tener resultado de cultivo y se muestra el patógeno, se inicia tratamiento con itraconazol, lamentablemente el paciente fallece a los 20 días. Conclusiones: Con esta investigación se analizan aspectos clínicos y microbiológicos de la peritonitis por fusarium, los cuales son poco conocidos en diálisis peritoneal domiciliaria(AU)

Introduction: Fungal peritonitis is an infrequent but serious complication for a patient on home peritoneal dialysis. Objective: To describe a case of fungal peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD). Methods: A 53-year-old male patient is reported, with a history of arterial hypertension, 9 years on continuous outpatient peritoneal dialysis, moderate protein-energy malnutrition. During his treatment, he had several episodes of bacterial peritonitis, exit-site infections, and repositioning of a peritoneal catheter with an extruded cuff. We worked with his antecedents, clinical status, etiological agent and treatment. The diagnosis was established by the presence of cloudy peritoneal fluid, cell count higher than 100 leukocytes / ul, and culture with the presence of the filamentous fungus. Results: In December 2017, he was diagnosed with fusarium peritonitis, with no leukocytosis or anemia, he did present hypoalbuminemia. A culture was performed on the wall of the room where the patient had his exchanges and filamentous fungus was found. Initially, treatment started with vancomycin and ceftazidime, followed by amikacin. Finally, after having a culture showed the pathogen, treatment with itraconazole started. Unfortunately the patient died 20 days later. Conclusions: This research analyzes clinical and microbiological aspects of fusarium peritonitis, which are poorly understood in home peritoneal dialysis(AU)

Difficult-to-treat ascitic fluid infection is a predictor of transplant-free survival in childhood decompensated chronic liver disease.

OBJECTIVE: To study the clinico-bacteriological profile of ascitic fluid infection (AFI) and its impact on outcome in childhood chronic liver disease (CLD). METHODS: It was a retrospective study on pediatric CLD patients requiring an ascitic tap. Logistic regression was performed to study the predictive factors for AFI. RESULTS: Two hundred and fifty-two (30.9%) of 814 children with CLD underwent ascitic tap on suspicion of AFI of whom 79 (31.3%) had AFI, culture negative neutrocytic ascites being the commonest. Younger age (p = 0.002), male gender (p = 0.007), new onset/rapid increase in ascites (p = 0.032), fever (p = 0.012), and blood total leukocyte count (TLC) (p = 0.001) were found to be independently associated with AFI. Twenty-three children had positive ascitic fluid culture: 15 Gram negative; 11 (52.3%) were multidrug resistant organism. Hepatic encephalopathy (HE) (p = 0.001), Model for End-stage Liver Disease/Pediatric End-stage Liver Disease (MELD/PELD) (p < 0.0005), and difficult-to-treat AFI (p = 0.007) were found to be independently associated with death and or LT. CONCLUSION: Children with ascites should undergo a diagnostic paracentesis in presence of fever, increasing or new-onset ascites, and/or increased TLC. Death or liver transplant are more likely due to advanced liver disease (high PELD /HE) and in those with difficult-to-treat AFI.

Transverse vs. median laparotomy in peritonitis and staged lavage: a single center case series.

Background: Staged lavage was first introduced in the 1970s and now serves as a therapeutic option for septic patients with peritonitis. A central aspect of this treatment concept is leaving the abdomen open after a wide incision. To evaluate the influence of transverse vs. median access to the abdomen in staged lavage, data from the authors' patients were analyzed. Methods: To evaluate patients with peritonitis, prospective intensive care data were examined together with data on the surgical details. The main aspects covered here were the surgical details of the lavage (namely, transverse vs. median laparotomy), number of lavages, fascia closure, wound-healing disorders, and observed lethality, in combination with the preoperatively evaluated SAPS-II score, expected hospital lethality, patient age, and the Mannheim Peritonitis Index. Results: Between January 2008 and December 2018, 522 patients were treated with open abdomen and staged lavage. The mean age of the patients was 66.0 years (standard deviation (SD) 15.9 years). A median incision was used in 140 cases, and transverse laparotomy was performed in 382. The mean SAPS-II score was 46.5 (SD 15.7), expected lethality was 39.6% (SD 26.3%), and observed lethality was 19.9%. On average, two lavages were performed after the index operation. Transverse incision was significantly less likely to cause wound-healing disorder (p=0.03), and fascial dehiscence was observed less frequently in the transverse laparotomies group than in median incisions in the statistical trend (p=0.06). Conclusion: In summary, staged lavage reduced expected lethality in patients with peritonitis. Transverse incision caused wound-healing disorders and fascial dehiscence less often. Therefore, the indication for transverse laparotomy should be generous, as this form of treatment is advantageous in case of peritonitis.

Comparative study between P- POSSUM and Apache II scores in predicting outcomes of perforation peritonitis: Prospective observational cohort study.

BACKGROUND: Scoring systems are needed to prognosticate, compare and audit surgical procedures. Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and morbidity (P-POSSUM) and Acute Physiological and Chronic Health Evaluation II (APACHE II) are well known and validated scores to predict surgical outcomes. The objective of this study was to compare P-POSSUM and APACHE II scores in predicting morbidity and mortality of patients who underwent emergency surgery for perforation peritonitis. MATERIALS AND METHODS: A prospective single-center cohort study was conducted with a sample size of 56 patients of perforation peritonitis from November 2018 to March 2020. All patients were followed up prospectively for a period of 30 days to monitor the primary outcome variable mortality and secondary outcome variables such as wound infection, wound dehiscence, anastomotic leak, respiratory complications, Intensive Care Unit (ICU) stay and hospital stay. RESULTS: Mean age of patients was 37.1 years and 67.86% were males. Ileum was the most common site of perforation followed by the stomach. The most common post-operative complication was wound infection (71.43%) followed by respiratory complications (64.29%) and wound dehiscence (35.71%). ICU stay was required for a majority of patients (74.42%). The mean hospital stay was 8.93 days and the mortality rate was 23.21% in this study. P-POSSUM and APACHE II scores had a good association with mortality, post-operative wound dehiscence, respiratory complications, ICU stay and hospital stay. However, there was no statistical difference between the two scores in predicting the above outcomes. Post-operative wound infection and anastomotic leak had no association with P-POSSUM or APACHE II scores. CONCLUSION: As the APACHE II score is based only on preoperative parameters and is easier to calculate we recommend its use for patients of perforation peritonitis over the P-POSSUM score as both have similar predictability.

Abdominal sepsis patients have a high incidence of chronic critical illness with dismal long-term outcomes.

BACKGROUND: As hospital sepsis mortality has decreased, more surgical ICU survivors are progressing into chronic critical illness (CCI). This study documents the incidence of CCI and long-term outcomes of patients with abdominal sepsis. We hypothesized that patients developing CCI would have biomarker evidence of immune and metabolic derangement, with a high incidence of poor 1-year outcomes. METHODS: Review of abdominal sepsis patients entered in a prospective longitudinal study of surgical ICU sepsis. RESULTS: Of the 144 study patients, only 6% died early, 37% developed CCI (defined as ICU days ≥14 with organ dysfunction) and 57% were classified rapid recovery (RAP). Compared to RAP, CCI patients a) were older (66 vs 58), males who were sicker at baseline (Charlson Comorbidity Index 4 vs 2), b) had persistently elevated biomarkers of dysregulated immunity/metabolism (IL-6, IL-8, sPDL-1, GLP1), c) experienced more secondary infections (4.9 vs 2.3) and organ failure (Denver MOF frequency 40 vs 1%), d) were much more likely to have poor dispositions (85 vs 22%) with severe persistent disabilities by Zubrod Score and e) had a notably higher 1-year mortality of 42% (all p < 0.05). CONCLUSION: Over 1/3rd surgical ICU patients treated for abdominal sepsis progress into CCI and experience dismal long-term outcomes.

Predictors of immediate and short-term mortality in spontaneous bacterial peritonitis.

BACKGROUND: There is scarce data from the Indian subcontinent on the outcomes following spontaneous bacterial peritonitis (SBP). AIM: To study the immediate (within 30 days) and short-term mortality (31-90 days) associated with SBP and to determine the predictors of the same. METHODS: This prospective observational study was done among patients with liver cirrhosis who underwent paracentesis. Patient data included age, gender, co-morbidity, cirrhosis-related complications, model of end-stage liver disease (MELD), and Child-Turcotte-Pugh (CTP) scores. SBP was diagnosed based on ascitic fluid polymorphonuclear leukocyte count > 250/mm3 with or without ascitic fluid culture positivity. RESULTS: Of the 870 patients with cirrhosis and ascites registered during the study period, 610 fulfilled the criteria for inclusion. Altogether, 122 patients with SBP were identified: 52 (42.6%) died, 40 (32.8%) survived without liver transplant, and 30 (24.6%) underwent liver transplantation within 3 months. Thirty-two patients (26.2%) were blood culture posi tive for bacteria and 7 (5.7%) demonstrable bacterial growth in ascitic fluid. Blood culture positivity was significantly higher in the group with immediate mortality (p < 0.0001) and was also significantly associated (p 0.005) with mortality at 3 months. CONCLUSION: Nearly two-fifths (42.6%) of the study cohort died within 3 months of an episode of SBP. Four-fifths of these patients died within 30 days. Blood culture positivity was significantly associated with immediate and short-term mortality.