Intraperitoneal Sepsis Research Articles

Risk factors and predictors of mortality in cases of on-demand relaparotomy due to complicated intraperitoneal Sepsis: a prospective study

Risk factors and predictors of mortality in cases of on-demand relaparotomy due to complicated intraperitoneal Sepsis: a prospective study

INFLAMMATORY RESPONSES TO POLYMICROBIAL INTRA-ABDOMINAL SEPSIS ARE HIGHLY VARIABLE BUT STRONGLY CORRELATED TO ENTEROBACTERIACEAE OUTGROWTH.

Sepsis is a common, heterogeneous, and frequently lethal condition of organ dysfunction and immune dysregulation due to infection. The causes of its heterogeneity, including the contribution of the pathogen, remain unknown. Using cecal slurry, a widely used murine model of intraperitoneal polymicrobial sepsis, as well as 16S ribosomal RNA sequencing and measurement of immune markers, we performed a series of translational analyses to determine whether microbial variation in cecal slurry composition (representing intra-abdominal pathogens) mediated variation in septic response. We found wide variation in cecal slurry community composition that changed markedly over the 24-h course of infection. This variation in cecal slurry bacteria led to large variation in physiologic and inflammatory responses. Severity of inflammatory response was positively correlated with intraperitoneal enrichment with Enterobacteriaceae. Likewise, in a human cohort of patients with intra-abdominal abscesses, Enterobacteriaceae was also associated with increased inflammatory markers. Taken together, these data demonstrate that intra-abdominal Enterobacteriaceae drives inflammation in sepsis both in animal models and human subjects. More broadly, our results demonstrate that pathogen identity is a major driver of the host response in polymicrobial sepsis and should not be overlooked as a major source of phenotypic heterogeneity.

The Gut Microbiota Contributes to Systemic Responses and Liver Injury in Gut-Derived Sepsis.

The gut microbiota, as a major source of opportunistic pathogens, poses a great threat to systemic infection, whereas the role of the gut microbiota in sepsis is underestimated. Here, we aimed to explore the effects of different gut microbiota patterns (namely, enterotypes) in cecal ligation and puncture (CLP)-induced murine sepsis. To achieve this purpose, we built four kinds of enterotypes by exposing mice to different types of antibiotics (azithromycin, amoxicillin, metronidazole, and levofloxacin). The results showed that antibiotic exposure induced different enterotypes, which, in turn, led to varying levels of systemic inflammation in septic mice, with amoxicillin-associated enterotypes exhibiting the most severe inflammation, followed by metronidazole, azithromycin, and levofloxacin. Specifically, the amoxicillin-associated enterotype was characterized by an abundance of intestinal opportunistic pathogens, including Enterobacteriaceae, Sutterellaceae, and Morganellaceae. This enterotype played a significant role in promoting the pathogenic potential of the gut microbiota, ultimately contributing to the development of severe systemic inflammation. Furthermore, the amoxicillin-associated enterotype exaggerated the sepsis-related liver injury, as evidenced by higher levels of alanine aminotransferase, aspartate transaminase, and hepatic malondialdehyde. The results of the RNA sequencing and the fecal suspension intraperitoneal injection sepsis model indicated that the amoxicillin-associated enterotype provoked acute hepatic immune responses and led to more significant metabolic compensation in the event of sepsis. Collectively, we concluded that the gut microbiota was one crucial factor for heterogeneity in sepsis, where the modulated gut microbiota likely prevented or reduced the serious consequences of sepsis, at least in gut-derived sepsis.

Crosstalk in the Abdomen: The Interface of the Omentum and the Microbiome in Sepsis.

Previously considered inert, the greater omentum is now thought to play a central role in intra-peritoneal immune defense. The intestinal microbiome has recently become a target for potential therapeutic interventions. A narrative review of the immune functions of the omentum was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Articles were selected from domains including surgical history, immunology, microbiology, and abdominal sepsis. Evidence suggests the intestinal microbiome may be responsible for some maladaptive physiologic responses in disease states, particularly intra-peritoneal sepsis. Elaborate crosstalk exists between the gut microbiome and the omentum, given its innate and adaptive immune capabilities. We summarize current knowledge, provide examples of how normal and abnormal microbiomes interface with the omentum, and illustrate their impact on surgical disease and its management.

421. In vitro and in vivo synergistic antimicrobial activities of the combinations of meropenem, colistin, tigecycline, and ceftolozane/tazobactam against carbapenem-resistant Klebsiella pneumoniae

Abstract Background The aim of this study was to evaluate the in vitro and in vivo activities of various antimicrobial combinations against carbapenem-resistant Klebsiella pneumoniae (CRKP). Methods The in vitro activity of six two-drug combinations against CRKP isolates collected from the rectal swab samples of patients with intestinal CRKP colonization was evaluated using the checkerboard method and time-kill assay to identify potential synergistic and bactericidal two-drug combinations against CRKP isolates. The in vivo efficacy of the combinations of colistin, meropenem and ceftolozane/tazobactam (C/T) as therapeutic options, was assessed in a mouse model of intraperitoneal CRKP sepsis. Antimicrobial susceptibility and genotypes of carbapenem-resistance were also analyzed. Results A total of 5 clinical isolates of CRKP were collected from nonduplicate patients with CRKP infection. Of 5 CRKP isolates, 4 carried the blaKPC-2-type carbapenem-hydrolyzing enzymes except 1 blaNDM-1-type. Antimicrobial susceptibility rates were tigecycline 80%, colistin 40%, and C/T 0%, respectively. The checkerboard assay showed that in vitro synergistic activity against CRKP isolates was 90% for the meropenem-tigecycline combinations and 20% for colistin-C/T combinations. None of the various combinations of the six antibiotics showed a synergistic effect in the time-kill assay. However, the meropenem-colistin (100%) and colistin-C/T (100%) combinations showed bactericidal effects in the time-kill assay (using an antibiotic concentration of 1× MIC) (Table). The survival rates of the mice was 80% (4/5) at 48 h in the treated group using low dose combinations of colistin (10 mg/kg) and C/T (25 mg/kg), unlike both antibiotics, which were 60% in a monotherapy with the same dose (Figure). Comparison of checkerboard assay and time-kill assay Comparison of checkerboard assay and time-kill assay associated with the bactericidal activity of two-drug combinations (1 × MIC) against each carbapenem-resistant Klebsiella pneumoniae isolate In vivo survival tests for antimicrobial combinations Comparison of the survival rates of the mice in the treated group using antimicrobial combinations Conclusion In conclusion, the present in vivo study demonstrated that the low-dose combination of colistin and C/T may be a promising alternative to nephrotoxic high-dose colistin alone for treating CRKP infections. However, it was difficult to predict this possibility in in vitro tests, and even there is great discordance of antimicrobial synergistic activities between the checkerboard microdilution and time-kill assays. Disclosures All Authors: No reported disclosures.

The impact of maternal protein restriction during perinatal life on the response to a septic insult in adult rats.

Although abundant evidence exists that adverse events during pregnancy lead to chronic conditions, there is limited information on the impact of acute insults such as sepsis. This study tested the hypothesis that impaired fetal development leads to altered organ responses to a septic insult in both male and female adult offspring. Fetal growth restricted (FGR) rats were generated using a maternal protein-restricted diet. Male and female FGR and control diet rats were housed until 150-160 d of age when they were exposed either a saline (control) or a fecal slurry intraperitoneal (Sepsis) injection. After 6 h, livers and lungs were analyzed for inflammation and, additionally, the amounts and function of pulmonary surfactant were measured. The results showed increases in the steady-state mRNA levels of inflammatory cytokines in the liver in response to the septic insult in both males and females; these responses were not different between FGR and control diet groups. In the lungs, cytokines were not detectable in any of the experimental groups. A significant decrease in the relative amount of surfactant was observed in male FGR offspring, but this was not observed in control males or in female animals. Overall, it is concluded that FGR induced by maternal protein restriction does not impact liver and lung inflammatory response to sepsis in either male or female adult rats. An altered septic response in male FGR offspring with respect to surfactant may imply a contribution to lung dysfunction.

2-Chlorofatty acids are biomarkers of sepsis mortality and mediators of barrier dysfunction in rats

Sepsis is defined as the systemic, dysregulated host immune response to an infection that leads to injury to host organ systems and, often, death. Complex interactions between pathogens and their hosts elicit microcirculatory dysfunction. Neutrophil myeloperoxidase (MPO) is critical for combating pathogens, but MPO-derived hypochlorous acid (HOCl) can react with host molecular species as well. Plasmalogens are targeted by HOCl, leading to the production of 2-chlorofatty acids (2-CLFAs). 2-CLFAs are associated with human sepsis mortality, decrease in vitro endothelial barrier function, and activate human neutrophil extracellular trap formation. Here, we sought to examine 2-CLFAs in an in vivo rat sepsis model. Intraperitoneal cecal slurry sepsis with clinically relevant rescue therapies led to ∼73% mortality and evidence of microcirculatory dysfunction. Plasma concentrations of 2-CLFAs assessed 8 h after sepsis induction were lower in rats that survived sepsis than in nonsurvivors. 2-CLFA levels were elevated in kidney, liver, spleen, lung, colon, and ileum in septic animals. In vivo, exogenous 2-CLFA treatments increased kidney permeability, and in in vitro experiments, 2-CLFA also increased epithelial surface expression of vascular cell adhesion molecule 1 and decreased epithelial barrier function. Collectively, these studies support a role of free 2-CLFAs as biomarkers of sepsis mortality, potentially mediated, in part, by 2-CLFA-elicited endothelial and epithelial barrier dysfunction.

Superiority of Somatostatin Analog in Comparison With Drugs for Treating Pancreatic Fistula in Rats

Objective This study aims to identify the most effective individual drug in an established triple-drug therapy (TDT) using a postoperative pancreatic fistula (POPF) rat model. Summary of background data POPF is the major complication of pancreatectomy that causes intraperitoneal abscess, sepsis, and pseudoaneurysm rupture, all of which may prolong hospital stays and cause potentially serious events or death. We previously demonstrated that TDT with a somatostatin analog, gabexate mesilate, and imipenem/cilastatin effectively prevents POPF, especially in high-risk patients. Methods POPF-induced rats were killed on postoperative day 3 after control (C), gabexate mesilate (G), imipenem/cilastatin (I), and somatostatin analog (S) treatments. Levels of serum amylase and lipase, or ascitic amylase and lipase were measured. Intraperitoneal adhesion between the abdominal wall and pancreas and pancreatic inflammation were evaluated. Results Serum amylase levels did not significantly differ among the groups. Serum lipase level was significantly higher in group I than in the other groups (P < 0.01). Both ascitic amylase and lipase levels were significantly lower in group S than in the other groups (P < 0.01). Median inflammation scores were significantly lower in groups G, I, and S than in group C (P < 0.01). Moreover, adhesion score was lower in group S than in the other groups (groups C, G, I, and S with scores 3, 2, 3, and 1, respectively, P < 0.01). Conclusion Among the 3 drugs, the somatostatin analog was the most effective against POPF.

Continuous Subcutaneous Delivery of Proline-Rich Antimicrobial Peptide Api137 Provides Superior Efficacy to Intravenous Administration in a Mouse Infection Model.

Apidaecins are cationic, proline-rich antimicrobial peptides originally isolated from honeybees and exhibit high Gram-negative activity by inhibiting bacterial protein translation. Pharmacokinetics of apidaecin derivative Api137 was studied using single and multiple intravenous or subcutaneous injections as well as continuous subcutaneous infusion and correlated to its efficacy in a lethal murine Escherichia coli infection model. Survival rates of infected CD-1 mice were monitored and Api137 and its metabolites were quantified in plasma of uninfected CD-1 mice and Sprague Dawley rats using reversed-phase chromatography coupled online to mass spectrometry. The highest Api137 plasma levels of 23 mg/L were obtained after a single intravenous injection of 20 mg/kg body weight, which declined fast over the next 120 min (half-life time < 30 min). In contrast, continuous subcutaneous infusion of a similar dose over an hour (19.2 mg/kg/h) lead to stable plasma levels of ∼6 mg/L, which was above the minimal inhibitory concentration against E. coli ATCC 25922 (4 mg/L). The increased exposure by continuous subcutaneous administration of Api137 at 19.2 mg/kg/h over 48 h improved efficacy in the murine intraperitoneal sepsis model with survival rates of 67% over 5 days compared to 33% after intravenous and subcutaneous administration in different dosing schemes. To the best of our knowledge, continuous subcutaneous infusion using osmotic pumps was successfully utilized for delivery of an antimicrobial peptide for the first time. Additionally, the potential of apidaecin analogs as novel antibiotics is demonstrated even in a scenario where the infection site is clearly separated from the route of administration.

Novel Endothelial Cell Targeted Peptide Nanoformulation for Inhibiting von Willebrand Factor Secretion to Reduce Thrombotic Complications in Sepsis

RationaleMicrovascular thrombosis and disseminated intravascular coagulation (DIC) are primary determinants of ischemia, organ failure and mortality/morbidity in sepsis. Interestingly, elevated plasma level of von Willebrand factor (vWF), the glue to which platelets adhere to form a clot, is associated with reduced survival and poor outcome in septic patients. Previously, we demonstrated that endothelial cell (EC) Gα12 is required for soluble N‐ethylmaleimide‐sensitive‐fusion factor attachment protein α (αSNAP)‐dependent vWF secretion from Weibel Palade bodies. Here, we report that sterically stabilized simple micelles (SSM) containing cell‐permeable myristoylated αSNAP binding domain (Myr‐SBD) peptide based on the unique N‐terminal Gα12 sequence that binds to αSNAP, inhibits vWF secretion.MethodsStructural complex of αSNAP/SBD was determined by blind‐ and data‐driven docking using AutoDock and HADDOCK, respectively. After incorporating Myr‐SBD into SSM (Myr‐SBD‐SSM) by film hydration method, micelle size and shape were confirmed by dynamic light scattering and transmission electron microscopy (TEM), respectively. Intracellular delivery of Myr‐SBD‐SSM was evaluated by fluorescence microscopy and fluorometry in cultured ECs. Cecal ligation and puncture (CLP) in C57BL/6 mice (14–16 wks, 25 g) was used to induce severe inflammation, microvascular thrombosis and DIC, and blood was collected 6 h and 24 h post CLP. The effect of Myr‐SBD‐SSM on plasma vWF, platelet count and inflammatory cytokines was assessed following addition of 0, 2 or 4 μmol Myr‐SBD/kg given i.v. at the time of surgery. Bleeding was assessed by tail‐snip assay. Glomerular fibrin deposition was scored by IHC analysis at 24 h post CLP.ResultsThe αSNAP/SBD structure showed the potential interaction between Arg of SBD peptide and Glu139 of αSNAP by H‐bond. Spherical shape of Myr‐SBD‐SSM (14.1 ± 2.7 nm in diameter) was confirmed by negative staining TEM. Addition of Myr‐SBD‐SSM to ECs resulted in the intracellular accumulation of Myr‐SBD which blocked thrombin‐induced vWF secretion. Intravenous delivery of Myr‐SBD‐SSM to mice at the time of CLP blunted the increase in plasma vWF and associated microvascular thrombosis in the kidney glomerulus. Importantly, Myr‐SBD‐SSM treatment resulted in increased platelet and WBC counts 6 h after surgery and improved survival compared to untreated or scrambled peptide treated mice with severe vascular inflammation suggesting Myr‐SBD‐SSM reduced clotting, platelet consumption and systemic inflammation in intraperitoneal sepsis. Moreover, Myr‐SBD‐SSM treatment did not increase tail‐snip bleeding time suggesting it did not prevent hemostasis.ConclusionOur studies demonstrate that Myr‐SBD‐SSM nanoformulation reduces vWF secretion and attenuates the thrombotic complications of severe inflammation.Support or Funding InformationThis work was supported by MPI R01 HL125356 (RDM, XD), Michael Reese Research and Education Foundation (RDM) and American Heart Association (MB, LR).This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Interrupted Midline Fascial Closure to Prevent Burst Abdomen in Emergency Laparotomy: Comparison between Continuous and Interrupted closure

Burst abdomen represents one of the most frustrating and difficult postoperative complication that concerns every abdominal surgeon. It occurs because of various predisposing factors which can be prevented to some extend by having knowledge regarding them. Despite many years of experience, the optimal technique of laparotomy closure remains controversial. The varieties of surgical excess as well as the varieties of abdominal closure techniques are the main difficulties in the proper standardization of this procedure. In this paper a randomized prospective study was designed to compare with a interrupted and continuous technique for closing a midline abdominal fascia in emergency laparotomy. A total of 300 patients of acute abdominal condition who underwent laparotomy were randomized into two groups of 150 patients in each group. Total 22(7.33%) of 300 patients developed burst in the postoperative period. Fourteen (14) (9.33%) in continuous arms and eight (08) (5.33%) patients in interrupted arms developed burst. Burst abdomen occurring mostly 40-60 years age group with a male to female ratio of 1.68: 1. Cough, anemia, malnutrition, DM, intraperitoneal sepsis, wound infection, uremia and abdominal distension were the important predisposing factors for the incidence of burst abdomen. Interrupted suturing was associated with significantly reduced the burst abdomen when comparing with continuous closure.TAJ 2017; 30(2): 69-75

Acinetobacter baumannii Gastrointestinal Colonization Is Facilitated by Secretory IgA Which Is Reductively Dissociated by Bacterial Thioredoxin A.

ABSTRACTMultidrug-resistant Acinetobacter baumannii is among the most common causes of infectious complications associated with combat-related trauma in military personnel serving overseas. However, little is currently known about its pathogenesis. While the gastrointestinal (GI) tract has been found to be a major reservoir for A. baumannii, as well as to potentially contribute to development of multidrug resistance, no studies have addressed the mechanisms involved in gut colonization. In this study, we address this critical gap in knowledge by first assessing the interaction between secretory IgA (SIgA), the principal humoral immune defense on mucosal surfaces, and the A. baumannii clinical isolate Ci79. Surprisingly, SIgA appeared to enhance A. baumannii GI tract colonization, in a process mediated by bacterial thioredoxin A (TrxA), as evidenced by reduction of bacterial attachment in the presence of TrxA inhibitors. Additionally, a trxA targeted deletion mutant (ΔtrxA) showed reduced bacterial burdens within the GI tract 24 h after oral challenge by in vivo live imaging, along with loss of thiol-reductase activity. Surprisingly, not only was GI tract colonization greatly reduced but the associated 50% lethal dose (LD50) of the ΔtrxA mutant was increased nearly 100-fold in an intraperitoneal sepsis model. These data suggest that TrxA not only mediates A. baumannii GI tract colonization but also may contribute to pathogenesis in A. baumannii sepsis following escape from the GI tract under conditions when the intestinal barrier is compromised, as occurs with cases of severe shock and trauma.

A Challenging Case of Retroperitoneal Abscess in a Post-Partum Crohn’s Disease Patient

Patient: Female, 29Final Diagnosis: Retroperitoneal abscessSymptoms: Flank bruising • flank painMedication: —Clinical Procedure: Incision • drainage • debridement of the necrotizing soft-tissue infectionSpecialty: Infectious DiseasesObjective:Unusual clinical courseBackground:Crohn’s disease (CD) is an inflammatory bowel disease affecting approximately 1 in 3000 people in the United States. Since the inflammation of CD is transmural, patients are at risk for fistula and abscess formation. Retroperitoneal abscesses are one type of which physicians must be aware.Case Report:We present the case of a 29-year-old woman with CD who complained of right hip and flank pain that began when she was 6-months pregnant. After delivery, she continued to complain of severe right flank pain and was admitted to the hospital 1 month later. CT scan imaging revealed a complicated retroperitoneal and right flank abscess, possibly due to a colonic intramural fistula. She developed severe acute necrotizing soft-tissue infection requiring 13 days of intensive care. She required debridement of the necrotizing infection of the right flank, drainage of the abscess, and washout for intraperitoneal sepsis. The patient tolerated the procedures well and was discharged 1 month later.Conclusions:Given that the clinical manifestation of retroperitoneal fistula with abscess is insidious and its formation is less common than intraperitoneal abscesses, we hope healthcare providers learn from this case to avoid morbidity and mortality. When presented with a pregnant CD patient complaining of nonspecific abdominal symptoms, providers should consider fistulization and/or abscess formation. The option to evaluate pregnant patients using noninvasive methods, such as ultrasound or low-dose CT scan, can decrease radiation exposure to the fetus and prevent delays in diagnosis and treatment.

Comparison of efficacy and complications of endoscopic and percutaneous biliary drainage in malignant obstructive jaundice: a systematic review and meta-analysis

BackgroundMalignant obstructive jaundice is a common problem in the clinic. Currently, the generally applied treatment methods are percutaneous transhepatic biliary drainage (PTBD) and endoscopic biliary drainage (EBD). Nevertheless, there has not been a uniform conclusion published on either efficacy of the two types of drainage or the incidence rate of complications. Therefore, we conducted a systematic review and meta-analysis of studies comparing endoscopic versus percutaneous biliary drainage in malignant obstructive jaundice, to determine whether there is any difference between percutaneous and endoscopic biliary drainage, with respect to efficacy and incidence rate of overall complications.MethodsThe enrolled studies contain a total of three randomized controlled trials and eleven retrospective studies, which together encompass 2246 patients with PTBD and 8100 patients with EBD.ResultsOur analysis indicates that there is no difference between PTBD and EBD with regard to therapeutic success rate (%), overall complication (%), intraperitoneal bile leak, 30-day mortality, sepsis, or duodenal perforation (%). Cholangitis and pancreatitis after PTBD were lower than after EBD, with odds ratios (OR) of 0.48 (95% confidence interval (CI), 0.31 to 0.74) and 0.16 (95% CI, 0.05 to 0.52), respectively. Incidences of bleeding and tube dislocation for PTBD were higher than EBD, OR of 1.81 (95% CI, 1.35 to 2.44) and 3.41 (95% CI, 1.10 to 10.60).ConclusionsThis meta-analysis indicates certain advantages for both PTBD and EBD. In the clinical practice, it is advised to choose specifically either PTBD or EBD, based on location of obstruction, purpose of drainage (as a preoperative procedure or a palliative treatment) and level of experience in biliary drainage at individual treatment centers.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3-2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2-3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

Recurrent perinephric and intra-peritoneal sepsis from dropped gall stones at laparoscopic cholecystectomy

Recurrent perinephric and intra-peritoneal sepsis from dropped gall stones at laparoscopic cholecystectomy

Successful interventional radiological management of postoperative complications of laparoscopic distal pancreatectomy

During the past decade, laparoscopic distal pancreatectomy (LDP) has gained increasing acceptance in the surgical community as a viable treatment option for distal pancreatic lesions. However, the possible complication of post-LDP pancreatic leakage remains a challenge, because it may lead to a series of events resulting in intraperitoneal abscess formation, sepsis, pseudoaneurysm formation, and occasional fatal hemorrhage. Dealing with these complications is extremely difficult and not much experience has been reported to date. We report a case involving the aforementioned post-LDP complications successfully managed by interventional radiological techniques while avoiding reoperation. We conclude that these management options are attractive, safe and minimally invasive alternatives to standard protocols.

Repair of a postappendectomy massive ventral hernia using tissue expanders

Reconstruction of large abdominal wall defects is a challenging problem. Various reconstructive techniques have been described in the surgical literature each with its advantages and disadvantages. In this report we describe our experience in treating a patient with large abdominal wall defect by staged abdominal wall reconstruction utilizing prosthetic mesh in conjunction with tissue expanders. A 41-year-old male presented with abdominal pain. Exploratory laparotomy showed perforated appendicitis with intraabdominal abscess of 1,500 mL. Postoperatively, he developed intraperitoneal sepsis. To prevent abdominal compartment syndrome, he was reoperated and left with "open abdomen". After several open abdomen lavages, his abdominal wall defect was allowed to granulate. After epithelization of the defect, the abdominal wall was reconstructed using prosthetic mesh and tissue expanders. The tissue expansion process was well tolerated. We suggest that the use of tissue expanders provides reliable and well-vascularized soft-tissue coverage in abdominal wall reconstruction.

Résultats radiologiques et évolution des segments adjacents dans un essai clinique randomisé (FDA) : prothèse de disque cervical versus arthrodèse sur deux étages

Infections due to extraintestinal pathogenic E. coli (ExPEC) are very common in humans as well as in animals. In humans ExPEC infections include urinary tract infections (UTI), septicemia, and wound infections, which result in significant morbidity, mortality, and substantial healthcare costs. In view of the increasing number of ExPEC infections caused by more and more resistant strains, effective prevention would be desirable. Given the rising treatment costs, a vaccine may be cost-effective in selected patient groups, such as women with recurrent UTI, patients with neurologic disorders impairing bladder function and men with prostate hyperplasia. Previous vaccine studies used single target proteins or whole inactivated ExPEC cells. Here, we describe a vaccine system for oral application based on artificial multiple subunit vaccine proteins. Those multi-epitope proteins are composed of predicted epitopes derived from ExPEC virulence-associated proteins. As ExPEC are known to form intracellular biofilms in the urothelium and can also resist killing by non-activated macrophages, T-cell responses are supposed to be an important measure to counteract these stages of ExPEC during infection. Therefore, a live bacterial antigen delivery system based upon the Salmonella type-III secretion system (T3SS) was used in this study to directly deliver the vaccine proteins into the cytoplasm of the host cells. Epitope-rich domains of the proteins FyuA, IroN, ChuA, IreA, Iha, and Usp were expressed in an attenuated Salmonella enterica serovar Typhimurium strain and translocated into target cells for extended periods of time inducing a strong T-cell response. No significant antibody titre increase against the secreted vaccine proteins could be detected in vaginal wash or serum. Despite that, one of the vaccine proteins was able to significantly reduce bacterial load in the challenge model of intraperitoneal sepsis. This study shows that a vaccine encompassing distinct epitopes of virulence-associated ExPEC proteins (i) can be applied for a T3SS-dependent vaccination strategy, (ii) elicits T-cell responses and (iii) confers protection after a single application.

Comparison between one stage operation for obstructed left colon cancer and Hartmann's procedure

Background: Although acute obstruction of the right colon is usually dealt with by primary anastomosis following resection, many surgeons are reluctant to offer one stage resection and anastomosis to patients with obstructive lesions of the left colon. Aim: The aim of the study is to compare the result of one stage resection and anastomosis for patients with acute complete obstruction due to left colon cancer versus Hartman's procedure. Patients and methods: Eighty four patients with acute left colonic obstruction presented to Sohag University Hospital between march 2008 and February 2012. The diagnosis was based on clinical evidence of obstruction and radiological features of left colonic obstruction on plain x-ray abdomen. No pre-operative histopathological confirmation of the diagnosis was done for all patients. Thirty eight patients were managed by one stage left colectomy without intra­ operative lavage (only manual evacuation of colon and mobbing of the two ends of anastomosis). Hartmann's procedure was performed in thirty four patients. Twelve patients were excluded from the study according to the following criteria: 1- patients with inoperaple tumors (liver metastasis, peritoneal seedling, haemorrhagic ascitis or unresectable). 2-medically unfit or haemodynamiclly unstable patients. 3- colonic perforation or peritonitis. Results: As regards the post operative complications related to left sided colonic surgery (wound sepsis, intra-peritoneal sepsis, anastomotic leakage), there were no significant difference between the two techniques