Abdominal Re-exploration Research Articles

Management of severe pancreatitis by high risk protocol and staged abdominal Re-explorations

Management of severe pancreatitis by high risk protocol and staged abdominal Re-explorations

Management of severe pancreatitis by high risk protocol and staged abdominal Re-explorations

Management of severe pancreatitis by high risk protocol and staged abdominal Re-explorations

A Fifteen-Year Experience with Open Drainage for Infected Pancreatic Necrosis

Advances in the understanding of the pathophysiologic factors of acute pancreatitis, combined with several recent technologic breakthroughs, have led to the establishment of infected pancreatic necrosis as the most common, the most severe and the most lethal of the infectious complications of acute pancreatitis. In this report, a single institutional experience in the surgical management of infected pancreatic necrosis during a 15 year period is chronicled. Using open drainage with scheduled abdominal re-explorations, the overall mortality rate was 15 percent in 71 consecutive patients with infected pancreatic necrosis. In the most recent 25 instances, sequential re-explorations were performed until retroperitoneal granulation occurred, at which time the abdomen was closed over lesser sac lavage catheters. Compared with the original 46 patients permitted to heal entirely by secondary intention, patients undergoing delayed secondary closure and lavage had a significant decrease during the hospitalization period (48.8 versus 30.1 days; p < 0.05), without a significant change in the mortality rate. In the most recent patients, dynamic pancreatography and fine needle aspiration bacteriologic factors were accurate in the preoperative prediction of pancreatic necrosis and microbial infection in 95 and 97 percent of the patients, respectively. Preoperative endoscopic retrograde cholangiopancreatography demonstrated leakage of contrast material from necrotic pancreatic ducts in seven of eight patients, while postoperative pancreatograms revealed abrupt truncation or other abnormalities in 11 of 13 patients. These observations establish that necrotizing pancreatitis involves pancreatic parenchyma as well as peripancreatic adipose tissue. Open drainage with contingent secondary closure and high volume lavage deserves a place in the management of patients with extensive infected pancreatic necrosis.

Sequential abdominal reexploration with the zipper technique

Frequently, several multiple abdominal reexplorations are needed in patients with acute necrotizing hemorrhagic pancreatitis (ANP) or with persistent intraabdominal sepsis (PIAS). Residual undrained necrotic and septic foci lead to multiple organ failure. To provide wide-open drainage of the abdominal cavity, since 1985 we have performed sequential abdominal reexploration with the zipper technique (SARZT) in 24 patients. Apache II score was used to evaluate expected mortality. In the pancreatic necrosis group, with a mean Apache II score of 31, the expected and the observed mortality were 70% and 29%, respectively. In the PIAS group, with a mean Apache II score of 30, the expected and observed mortality were 60 and 28%, respectively. These results are attributed to the sequential reexploration of the abdominal cavity that permits excision and drainage of necrotic and septic foci.

Injuries Missed at Operation

Injuries missed at initial operation have the potential to cause the most disastrous complications in trauma patients. Over the past 5 years, 12 patients have required re-operation for 14 injuries missed at initial laporatomy and/or thoracotomy. Six missed injuries were vascular, two each in the thorax, pelvis, and retroperitoneum. The other eight were visceral: three small bowel (one patient), two pancreatic, and one each of the heart, ureter, and diaphragm. Five patients (42%) died, three with missed vascular and two with missed visceral injuries. Three died due to complications directly related to their missed injuries, while the unrecognized injury did not play a significant role in the other two. Indications for re-operation in patients with vascular injuries were hypotension in two patients, persistent output from drains in three, and refractory acidosis in one. Re-exploration in visceral injuries was for clinical sepsis in three patients, DIC in one, cardiac tamponade in one, and persistent chest tube drainage in one. Eleven of the 12 patients presented to the E.D. in shock. All patients had multiple injuries with a mean of 3.25 organ systems injured. Hypotension, coagulopathy, and/or hypothermia (T < 92$dG) were felt to have contributed to missing the injury in five of the patients with vascular, and three of the patients with visceral injuries. In the four other patients, injuries were missed due to inadequate exploration or a low index of suspicion in the presence of multiple injuries. Mean time to re-exploration was significantly less in survivors for both vascular (4.4 vs. 11.2 hr) and visceral injuries (4.3 vs. 9 days). In nonsurvivors, the delays in re-exploration were due to incorrectly ascribing blood loss to coagulopathy in four and intra-abdominal sepsis to pneumonia in one. Missed injuries, although rare following surgical exploration for serious trauma, result in preventable morbidity and mortality. Patients with clinical indications of ongoing bleeding should be re-explored within 4 hours, and those with clinical sepsis or early multiple organ failure should undergo abdominal re-exploration within 4 days to detect undiagnosed injuries.

Re-operation for intra-abdominal sepsis. Indications and results in modern critical care setting.

In a 2-year period (1981-1983), 87 abdominal re-explorations (1.6% of total laparotomies) were performed on 77 patients for sepsis in five Downstate hospitals. Fifty-one patients were re-explored solely on clinical grounds, 21 on clinical plus radiographic criteria, four solely on radiographic grounds, and 11 for multiple organ failure. The overall mortality rate was 43%. As expected, the most common laparotomy finding was intra-abdominal abscess (47); other findings included anastomotic leak (14), necrotic bowel (10), evidence of technical error (five), and acalculous cholecystitis (two). The most common clinical findings were localized tenderness, fever, and absent bowel sounds (85%). Fifty-four special studies were performed with an overall accuracy rate of 76%. CAT scans and contrast radiographs were most accurate (92% and 81%) while sonography and gallium scans were less useful (59% and 60%). Seven patients had negative laparotomies. While all were distended and six were febrile, only one patient had focal tenderness. In the 11 patients explored solely for multiple organ failure, six patients had drainable pus despite negative radiographic studies, and two survived. The other five patients had negative laparotomies, and all died. Factors correlated with mortality were age over 50, peritonitis at the primary operation, and multiple organ failure. The approach to these seriously ill patients should be governed by a high index of suspicion. Clinical findings are at least as reliable as sophisticated radiographic modalities of which CAT scan appears to be the most accurate. Re-exploration for multiple organ failure alone will yield a significant group of patients with drainable septic foci and some survivors; thus, exploration for this indication appears to be defensible.

Secondary surgical intervention in acute renal failure.

In a series of 118 patients postoperative acute renal failure was usually the result of a severe, but occult, surgical complication. Abdominal reexploration was often required. Postoperative hypotension, even without abdominal signs, commonly indicated an intraabdominal complication. Pancreatitis with abscess formation was a particularly serious complication. Peritoneal lavage was thought to have an important role in the management of diffuse intraabdominal sepsis.

Scanning bremsstrahlung of yttrium-90 microspheres injected intra-arterially.

Scanning internally deposited beta particle emitters which have been administered in therapeutic doses has useful clinical application. The procedure of scanning is generally used to detect and map the distribution of gamma-emitting internally deposited isotopes. Beta-particle emitters are ordinarily considered impractical for scanning, since the emitted radiation is absorbed by only a few millimeters of tissue. Bremsstrahlung or “braking rays” however, resulting from the interaction of beta particles with tissue, are sufficiently penetrative for detection outside the body. This conversion of energy from beta particle to bremsstrahlung is quite inefficient, but, when therapeutic doses of beta particles are administered, sufficient radiation escapes from the body to permit useful scanning (1). Our experience with the scanning of internally deposited yttrium 90 and phosphorus 32 will be described. We have injected yttrium 90 intra-arterially into brain, kidney, liver, and lung. The radioactive material is in the form of plastic microspheres suspended in dextran and incorporating the Y90 within the plastic microspheres. In our cases, the microspheres were 15 microns in diameter. Carcinoid Tumor of Liver Three cases of carcinoid tumor of the liver were treated with these microspheres of Y90. The common hepatic artery was catheterized percutaneously through the brachial or femoral artery. The position of the catheter was checked by opacifying the vessel with radiopaque material before injecting the radioactive microspheres. Further check on the position of the catheter was made by repeat angiography directly following the injection of the isotope. The patients were scanned within a few hours after the procedure to observe the distribution of the beta-emitting Y90 within the liver and also any “leakage” of the radioactive material into the lungs or extremities. In a 50-year-old housewife nodules of carcinoid tumor had been found in the liver at the time of resection of an adenocarcinoma of the transverse colon three years ago (1963). Subsequently, carcinoid attacks developed with diarrhea and flushing. These were controlled medically by Dr. Richard Warner until 1965 when the patient's liver became massive. At this time an abdominal re-exploration was carried out, and the common hepatic artery was catheterized for prolonged intra-arterial injection of fluorouracil for a period of five weeks. The patient's condition improved, although the early result of this chemotherapy was an exacerbation of the attacks. In January 1966, when the carcinoid attacks returned even more severely than before, external irradiation with cobalt teletherapy was administered to a dose of 3,000 rads to the right lobe of the liver. The patient's condition again deteriorated, the liver became enlarged, and a gold-198 diagnostic scan showed large "cold spots" corresponding to huge deposits of carcinoid tumor in the right lobe of the liver (Fig. 1).