Need For Relaparotomy Research Articles

Risk factors for relaparotomy after a cesarean delivery: a case-control study.

Relaparotomy following a cesarean delivery (CD) is an infrequent complication, with inconsistency regarding risk factors and indications for its occurrence. We therefore aimed to determine risk factors and indications for a relaparotomy following a CD at a single large tertiary center. A retrospective case-control single-center study (2013-2023). We identified all women who had a relaparotomy up to six weeks following a CD (study group). Maternal characteristics, obstetrical and surgical data were compared to a control group in a 1:2 ratio. Controls were women with a CD before and immediately after each case in the study group, who did not undergo a relaparotomy. Included were CDs occurring after 24 gestational weeks. CD performed at different centers and indications for repeat surgery unrelated to the primary surgery (e.g., appendicitis) were excluded. Logistic regression was used to adjust for potential confounders. During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD, and 130 patients (0.46%) underwent a relaparotomy. Relaparotomies following a CD occurred during the first 24h, the first week, and beyond the first week, in 59.2%, 33.1%, and 7.7% of cases, respectively. In the multivariable logistic regression analysis, relaparotomy was significantly associated with Mullerian anomalies (aOR 3.33, 95%CI 1.08-10.24, p = 0.036); uterine fibroids (aOR 3.17, 95%CI 1.11-9.05,p = 0.031); multiple pregnancy (aOR 4.1, 95%CI 1.43-11.79,p = 0.009); hypertensive disorders of pregnancy (aOR 3.46, 95%CI 1.29-9.3,p = 0.014); CD during the second stage of labor (aOR 2.54, 95%CI 1.15-5.88, p = 0.029); complications during CD (aOR 1.62, 95%CI 1.09-3.21,p = 0.045); and excessive bleeding during CD or implementation of bleeding control measures (use of tranexamic acid, a hemostatic agent, or a surgical drain) (aOR 2.23, 95%CI 1.29-4.12,p = 0.012). Indications for relaparotomy differed depending on the time elapsed from the CD, with suspected intra-abdominal bleeding (36.1%) emerging as the primary indication within the initial 24h. We detected several pregnancy, intrapartum, and intra-operative risk factors for the need for relaparotomy following a CD. Practitioners may utilize these findings to proactively identify women at risk, thereby potentially reducing their associated morbidity.

Factors influencing outcome in patients with perforated peptic ulcer disease at a South African tertiary hospital.

Perforated peptic ulcer (PPU) is associated with significant morbidity and mortality, particularly in low to middle income countries. This study aimed to scrutinise the clinical course of patients diagnosed with PPU and identify modifiable factors to improve outcomes. A retrospective review of the hybrid electronic medical record (HEMR) database at Grey's Hospital was performed. All patients diagnosed with PPU between January 2013 and December 2020 were entered into the study. The variables collected include age, ethnicity, comorbid profile, Boey score, type of surgery performed and complications. These factors were analysed to determine the factors responsible for morbidity and mortality. One hundred and ninety four patients were diagnosed with PPU during the study period. Six patients were treated non-operatively, all of whom survived. In the surgically treated group, omental patch repair was performed in 159 (84.5%) patients, and primary closure in 26 (13.8%) patients. The leak rate was 32% in the cohort that underwent relaparotomy and the overall mortality was 14%. There was no significant relationship between the type of repair performed and outcome. All patients had a Boey score of 1 or more. The following factors were found to increase the probability of in-hospital mortality: age > 40 years (OR: 8.49, 95% CI 2.46-29.29 p < 0.01), female gender (OR: 2.509, CI 0.98-6.37, p = 0.048), need for relaparotomy (OR: 0.398, CI 0.17-0.91, p = 0.027) and Boey score > 1 (OR: 46.437, CI 6.13-350.28, p < 0.01). A Boey score > 1 was the only variable that increased the likelihood of finding a leaking repair at relaparotomy (p < 0.01). The Boey score was a significant predictor of mortality and leak rate in our patients with PPU. Adding age as a variable may improve the ability to predict mortality in our setting, while the impact of gender and ethnicity needs further investigation.

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience.

To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy. A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture. During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01). Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

Persistent Bowel Loop in the Left Upper Quadrant: An Indication for Relaparotomy in Paediatric Adhesive Intestinal Obstruction: A Retrospective Cohort Study

Introduction: Abdominal surgery in children is known to contribute to Adhesive Small Bowel Obstruction (ASBO). No X-ray findings have been validated for predicting management in ASBO. Various imaging modalities often cannot predict complications or if a conservative line of management would be successful. Aim: To determine if a persistent prominently dilated small bowel loop in the Left Upper Quadrant (LUQ) on plain X-rays (Omega loop) would suggest early operative intervention. Materials and Methods: A retrospective cohort study was conducted in the Department of Paediatric Surgery, IMCH, Government Medical College, Kozhikode, Kerala, India from January 2016 to December 2018. Diagnosis was based on history, clinical features, and radiologic findings. Demographic, clinical, radiologic, and operative data were collected. After exclusions, the study population was divided into two groups: Group A - ASBO patients with the characteristic Omega loop, and Group B - patients without the Omega loop. Appropriate statistical methods were used to compare the groups, with significance defined as p&lt;0.05. Results: Among the 72 cases of ASBO that met the inclusion criteria, 40 (55%) were successfully managed conservatively, and 32 (45%) required non urgent relaparotomy. The median age was 6.9 years (range: 2-12 years), and 55% were male. Group A comprised 16 patients (22.2%), and the remaining patients were in Group B 56 (77.8%). Group A showed higher rates of failure of conservative management (n=14, p=0.0002), with higher rates of single-band obstruction, bowel loss, perforation, matting of bowel loops, and difficult dissection. The Omega loop had a low sensitivity (43.7%) but high specificity (95%) and positive predictive value (87.5%) for the need for relaparotomy. Conclusion: The Omega loop suggests the possibility of more complications, and therefore, earlier operative intervention should be considered.

Observational clinical study of indications and outcome of re-exploration laparotomy in 50 patients

Background: Abdominal surgery that has to be re-done in association with initial surgery (Index surgery), within 60 days of initial surgery, is referred to as re-laparotomy. Redolaparotomies are called, on demand, if laparotomy has to be re-done because of patient condition and planned, if the second laparotomy is decided upon during the course of first surgery itself. Re-laparotomy is associated with increased morbidity and mortality. To find out incidence, indications, morbidity and mortality of re-laparotomy.Methods: This is a retrospective observational study of 50 cases of re-exploratory laparotomy from 2018 to 2020 done at tertiary care teaching hospital of South Gujarat.Results: In this study, majority of cases (56%) were seen in the 21-50 age group; males (37) more than females (13) with 3:1 ratio. Index operation was done in emergency in 78% (n=39) and planned in 22% (n=11) of patients. In our study mean duration between 2 laparotomies was 8 days with range of 3-20 days. It is also observed that mean duration of hospital stay among the discharged patients is 30 days with range of 15-60 days. In this study, mortality was 16% (n=8), out of which 5 patients were having co-morbidity. Out of 50 patients 34 (68%) developed local or systemic post-operative complications.Conclusions: The need for re-laparotomy supersedes risks of severe morbidities and high mortality in view of worsening clinical status of the patient.

Correlation of Different Serum Biomarkers with Prediction of Early Pancreatic Graft Dysfunction Following Simultaneous Pancreas and Kidney Transplantation.

Background: Despite recent advances and refinements in perioperative management of simultaneous pancreas–kidney transplantation (SPKT) early pancreatic graft dysfunction (ePGD) remains a critical problem with serious impairment of early and long-term graft function and outcome. Hence, we evaluated a panel of classical blood serum markers for their value in predicting early graft dysfunction in patients undergoing SPKT. Methods: From a prospectively collected database medical data of 105 patients undergoing SPKT between 1998 and 2018 at our center were retrospectively analyzed. The primary study outcome was the detection of occurrence of early pancreatic graft dysfunction (ePGD), the secondary study outcome was early renal graft dysfunction (eRGD) as well as all other outcome parameters associated with the graft function. In this context, ePGD was defined as pancreas graft-related complications including graft pancreatitis, pancreatic abscess/peritonitis, delayed graft function, graft thrombosis, bleeding, rejection and the consecutive need for re-laparotomy due to graft-related complications within 3 months. With regard to analyzing ePGD, serum levels of white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), pancreatic lipase as well as neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) were measured preoperatively and at postoperative days (POD) 1, 2, 3 and 5. Further, peak serum levels of CRP and lipase during the first 72 h were evaluated. Receiver operating characteristics (ROC) curves were performed to assess their predictive value for ePGD and eRGD. Cut-off levels were calculated with the Youden index. Significant diagnostic biochemical cut-offs as well as other prognostic clinical factors were tested in a multivariate logistic regression model. Results: Of the 105 patients included, 43 patients (41%) and 28 patients (27%) developed ePGD and eRGD following SPKT, respectively. The mean WBC, PCT, NLR, PLR, CRP and lipase levels were significantly higher on most PODs in the ePGD group compared to the non-ePGD group. ROC analysis indicated that peak lipase (AUC: 0.82) and peak CRP levels (AUC: 0.89) were highly predictive for ePGD after SPKT. The combination of both achieved the highest AUC (0.92; p < 0.01) in predicting ePGD. Concerning eRGD, predictive accuracy of all analyzed serological markers was moderate (all AUC < 0.8). Additionally, multivariable analysis identified previous dialysis/no preemptive transplantation (OR 2.4 (95% CI: 1.41–4.01), p = 0.021), donor age (OR 1.07 (95% CI: 1.03–1.14), p < 0.010), donor body mass index (OR 1.32 (95% CI: 1.01–1.072), p = 0.04), donors cerebrovascular cause of death (OR 7.8 (95% CI: 2.21–26.9), p < 0.010), donor length of ICU stay (OR 1.27 (95% CI: 1.08–1.49), p < 0.010), as well as CIT pancreas (OR 1.07 (95% CI: 1.03–1.14), p < 0.010) as clinical relevant prognostic predictors for ePGD. Further, a peak of lipase (OR 1.04 (95% CI: 1.02–1.07), p < 0.010), peak of CRP levels (OR 1.12 (95% CI: 1.02–1.23), p < 0.010), pancreatic serum lipase concentration on POD 2 > 150 IU/L (OR 2.9 (95% CI: 1.2–7.13), p = 0.021) and CRP levels of ≥ 180 ng/mL on POD 2 (OR 3.6 (95% CI: 1.54–8.34), p < 0.01) and CRP levels > 150 ng/mL on POD 3 (OR 4.5 (95% CI: 1.7–11.4), p < 0.01) were revealed as independent biochemical predictive variables for ePGD after transplantation. Conclusions: In the current study, the combination of peak lipase and CRP levels were highly effective in predicting early pancreatic graft dysfunction development following SPKT. In contrast, for early renal graft dysfunction the predictive value of this parameter was less sensitive. Intensified monitoring of these parameters may be helpful for identifying patients at a higher risk of pancreatic ischemia reperfusion injury and various IRI- associated postoperative complications leading to ePGD and thus deteriorated outcome.

Clinical effectiveness of sodium hyaluronate gel usage for prevention of postoperative adhesion in children

It was considered expedient to study the effectiveness of intraoperative prevention of adhesion formation in children based on the results of our own experimental and clinical studies on the effectiveness of using an anti-adhesive gel based on cross-linked sodium hyaluronate. Purpose - to evaluate clinical efficacy and safety of cross-linked sodium hyaluronate gel (SHG) usage as a barrier agent for primary prevention of postoperative peritoneal adhesions formation in children. Materials and methods. This is a prospective, randomized, controlled, patient blinded observational study, which includes 62 children. All patients underwent laparotomy for appendicular peritonitis and were randomly divided into two equal groups. Patients from group A (n=31) received conventional surgical treatment, SHG was additionally applied in group B (n=31) before abdominal closure. Immediate and long-term effects of SHG usage were investigated to evaluate the influence on adhesions reformation. The average period of postoperative observation was 14.0±2.4 months. Results. SHG application was associated with no increase in complications rate: duration of postoperative ileus, need in nasogastric decompression, intensive care unit state, hospital state, the incidence of surgical site infection, and need for relaparotomy did not differ significantly between compared groups. The prevalence of peritoneal adhesions at the end of in-hospital treatment differs significantly between groups according to the ultrasound data (χ2=10.930; p=0.005). The incidence of small bowel obstruction (SBO) developed during the follow-up period in group A (16.1%) was significantly higher than in group B (3.23%) where the anti-adhesive gel was applied (χ2=4.026; p=0.045). Conclusions. Intraoperative use of SHG based on sodium hyaluronate allows reduction of postoperative adhesions formation in children without worsening the postoperative course. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors. Key words: sodium hyaluronate, adhesions, small bowel obstruction.

Role of biliary drainage before pancreatoduodenectomy for pancreatic adenocarcinoma: a retrospective study.

Utilization of preoperative biliary drainage prior to pancreatoduodenectomy for patients with pancreatic ductal adenocarcinoma and obstructive jaundice remains controversial. All patients that underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma at the authors' institution were analyzed retrospectively to evaluate the effect of endoscopic biliary drainage on postoperative outcomes and long-term survival. Age, gender, ASA-Score, operative time, blood loss, intraoperative transfusion rate, and postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, bleeding, bile fistula, wound infections, sepsis, pulmonary and cardiac complications as well as the need for relaparotomy were analyzed. Two hundred eighty-five patients with similar baseline characteristics underwent pancreatoduodenectomy, 151 patients with biliary drainage (group 1) and 134 without drainage (group 2). More than 60% of patients had one or more postoperative complications, without significant difference between the two groups (P=0.140). The overall incidence of pancreatic fistula was 21.75% in both groups (group 1: 19.87% vs. group 2: 23.88%, P=0.659). Wound healing impairment was the only postoperative complication that differed significantly between the two groups (group 1: 24.50% vs. group 2: 8.96%, P<0.001). In multivariate risk analysis, biliary drainage was the only independent risk factor for wound healing impairment (OR 4.126; 95% CI: 1.295-13.143; P=0.017). The median overall survival was similar in both groups. Preoperative endoscopic biliary drainage is associated with an increased risk for wound healing impairment and wound infections. Therefore, biliary drainage should not be used routinely in patients with obstructive jaundice prior to pancreatoduodenectomy.

The effect of surgical procedure on surgical outcomes in patients undergoing emergency peripartum hysterectomy: a retrospective multicenter study

Objective To investigate the effect of surgical procedure on the operation’s results in patients undergoing emergency peripartum hysterectomy (EPH). Methods The records of patients who underwent EPH due to postpartum hemorrhage between 2010 and 2020 in two tertiary centers with a high crude delivery rate were retrospectively analyzed. Surgical data were compared according to the EPH type. Results During the study period, 115,709 births occurred in these two centers. EPH was administered for 181 (1.6%) of these patients. Sixty-seven (37%) of the EPH cases involved subtotal EPH (SEPH), and 114 (63%) were total EPH (TEPH). Surgical time (107.3 ± 17.6 vs. 134.2 ± 32.3 min, p < 0.001), erythrocyte transfusion count (2.6 ± 1.3 vs. 4.3 ± 6.2, p < 0.001), ureter injury (0.0 vs. 7.9%), bladder injury (1.5 vs. 28.1%), disseminated intravascular coagulation (1.5 vs. 9.6%), need for relaparotomy (4.5 vs. 14%), and intensive care unit admission (19.4 vs. 52.6%) were found to be higher in the TEPH group compared to the SEPH group (p < 0.05). In addition, the total length of hospitalization was longer in the TEPH group (4.5 ± 2.3 vs. 6.1 ± 4.6 day, p = 0.011). Conclusion According to the results, if the bleeding in peripartum hemorrhage requiring EPH can be controlled with SEPH, attempting to remove the cervix completely may be associated with increased surgical time, blood transfusion need, and surgical complications.

Intrauterine balloon tamponade combined with temporary abdominal aortic balloon occlusion in the management of women with placenta accreta spectrum:a randomized controlled trial

Objective: To access the effectiveness and safety of the intrauterine balloon tamponade verse gauze packing combined with temporary abdominal aortic balloon occlusion in the management of placenta accreta spectrum (PAS). Methods: This was an open-label, randomized controlled trial conducted in Nanjing Drum Tower Hospital. The patients suspected with PAS for uterine preservation surgery under the multidisciplinary team care were recruited between Aug 2015 and Jan 2018. When bleeding could not be achieved after fetus delivered, and a temporary abdominal aortic balloon occlusion and the compression sutures as needed, the women were randomly allocated 1∶1 into balloon tamponade (n=81) or gauze packing (n=80) group. The primary outcome was successful bleeding arrests by avoiding second line surgeries. The secondary outcomes included the volume of blood loss during and after cesarean section, the rate of PPH, incidence and amount of blood transfusion, hysterectomy, postpartum pain, ICU admission, need for re-laparotomy, and the length of hospital stay, readmission, and interventional radiology complications. Results: All the women [100% (81/81)] in the balloon group were obtained hemostasis without further intervention, significantly higher than 88% (70/80) in the gauze group (P=0.001). Before uterine tamponade, blood loss were 820 ml (620-1 230) ml and 850 ml (605-1 442) ml, while placenta bed were sutured in 96%（78/81, 77/80） respectively (P>0.05).The proportion of blood loss≥1 000 ml was higher in the gauze group than that in the balloon group (P=0.006). Maternal adverse events involving total blood loss, puerperal morbidity and postpartum pain occurred more frequently in the gauze group (P<0.05). The following outcome showed no statistically significant difference between the two groups: the vascular occlusion time, the dose of radiation, and interventional radiology complication (P>0.05). The median volume infused into the lower and upper balloons is 70 ml (50-100 ml) and 180 ml (100-240 ml). Conclusions: Incrauterine balloon tamponade is as effective as gauze packing in hemostasis following the placenta delivery in PAS. Compared with gauze packing, the uterine balloon tamponade is more effective.

The Presence of Hemorrhagic Shock on Admission Is the Strongest Predictor of Mortality in Trauma Patients Who Require Packing

The aim of this study was to evaluate patients who had to be applied with packing because of abdominal trauma and to identify the factors affecting mortality from the findings on admission and the laboratory values that can be immediately examined. A retrospective analysis of 42 patients accepted to our level one trauma center between January 1998 and December 2017 was carried out. The patients were evaluated in respect of demographic characteristics, vital parameters, trauma type, injury severity score (ISS), the presence of additional injuries, transfusion amount, the need for intensive care, mortality rates, complications, the number and types of operations performed, the number of packings, the need for re-laparotomy, imaging methods, and radiological interventions. Of these parameters, the effects on mortality of findings on admission and the laboratory values that could be immediately tested were examined in particular. Packing was applied to 27 patients due to blunt trauma and to 15 patients due to penetrating trauma. Thirty-one patients had hypotension, and 24 of them had hemorrhagic shock status upon admission. Average ISS value was 34.5 ± 9.9 (16–59). Twenty of the 42 patients died (47.6%). ISS level, hypotension, and hemorrhagic shock on admission were found to be significant risk factors of death in univariate analysis. In multivariate analysis however, only the presence of hemorrhagic shock was a statistically significant factor related to mortality. The presence of hemorrhagic shock on admission is a strong predictor of mortality in patients undergoing damage control surgery.

Application of the Kiewiet-Van Ruler model to predict the need for relaparotomy in patients with secondary peritonitis.

It is crucial the timely detection of a new infection or the persistence of it to improve the survival rates, there is no index that can determine the need for relaparotomy. To evaluate the diagnostic certainty of the model elaborated by Kiewiet-Van Ruler. A retrospective, descriptive, cross-sectional study, patients diagnosed with abdominal sepsis who underwent exploratory laparotomy between January 2013 to and May 2015. We included 109 patients, 63 male patients and 46 female patients. Mortality of 16.5%. 68 cases had a score lower than or equal to 19, of which 17 -patients (43%) did need to reoperate. The second group with a score higher than 20 was 41 patients, of which 22 (56%) required reoperation. In the individual analysis of the variables, a significant value was determined in five of them, with p < 0.05. Only one variable (hemoglobin < 8.1 mg/dl) in the chi-square test and confidence interval was not significant and I do not help so much to predict reoperation. The utility of the model proposed by Kiewiet-Van Ruler results in an acceptable prediction value for re laparotomy.

Update on the Management of Morbid Adherent Placenta

&#x0D; Morbid adherent placenta collectively includes placenta accrete, increta, and percreta, according to the depth of invasion through the decidua-myometrial junction. Incidence is increasing due to increase in the incidence of scarred uterus. Scarred either due to caesarean section, myomectomy or repeated D&amp;C. These conditions are responsible for massive obstetrics haemorrhage, associated complications like consumption coagulopathy, multisystem organ failure &amp; death. Also there is a risk for peripartum surgical complication, such as injury to the bladder, ureter &amp; bowel. There is also the need for relaparotomy, complication of blood transfusion, admission in intensive care unit. Indicated or emergency preterm delivery needs admission of the newborn to neonatal intensive care unit. Outcome can be improved by multi disciplinary expertise and experienced approach for delivery, including the conservative management to avoid peripartum hysterectomy. Such team approach by maternal-fetal medicine, gynaecological surgeon, vascular, trauma, urology surgeon, transfusion medicine, intensivist, neonatologist, intervention radiologist, anaesthesiologist, specialized nursing staff and ancillary personnel.&#x0D; J Bangladesh Coll Phys Surg 2019; 37(1): 30-34&#x0D; &#x0D;

Predictor of early post-operative small bowel obstruction in patients undergoing emergency laparotomy and the role of computed tomography in detecting need for re-laparotomy

Background: Early Post-Operative Small Bowel Obstruction (EP-SBO) is common complication following laparotomy. Pathophysiology of early post-operative small bowel obstruction is poorly understood.Methods: This cross-sectional observational study was conducted over a period of 18 month on 180 patients who underwent emergency abdominal laparotomy.Results: EP-SBO developed in 35.55% patients. History of previous surgery, location of disease, degree of peritonitis, operative procedure, wound dehiscence was found to be significantly related with occurrence of EP-SBO.Conclusions: EP-SBO is more likely to develop if patient had history of previous surgery, peritonitis, some operative procedure, ostomy, wound dehiscence. We should have a preventive attitude towards any risk factor at any stage- Before, During and After surgery and CECT-Abdomen is a helpful tool in establishing need of re-laparotomy.

Isolated Roux loop pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: A case-control study

ObjectivesThe aim of this study was to compare the postoperative outcomes of isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD). MethodsData of patients who underwent IPJ were compared with those of a pair-matched equal number of patients undergoing CPJ. The matching was performed according to age, gender, nature of the lesion indicating PD and the texture of the pancreas. The primary outcome was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality. ResultsSeventy patients treated by PD (35 patients in each group) were included in the study. The two groups were comparable with regards to the pre-operative and intra-operative parameters. Postoperative pancreatic fistula developed in 10 out of 35 patients in the CPJ group and 3 out of 35 patients in the IPJ group (p = 0.031). Nine CPJ patients and one IPJ patient had POPF of type B or C (p = 0.006). Re-laparotomy was significantly more frequent in the CPJ group (11.1% versus 34.6%; p = 0.04). Time to resumption of oral feeding was shorter in the IPJ group (p = 0.001). ConclusionsThe use of IPJ is associated with decrease in the rate of postoperative PF in patients undergoing PD. In addition, patients with IPJ reconstruction have lesser need for re-laparotomy and early resumption of oral feeding.

A CLINICAL CASE OF ACTINOMYCOSIS OF THE ABDOMINAL WALL AND SMALL PELVIC ORGANS

The paper describes a clinical case of visceral actinomycosis in a 19-year-old female patient. The complexity of preoperative and intraoperative diagnosis is the similarity of this form of actinomycosis and the neoplastic process and abscess of the abdominal cavity and small pelvis. The disease ran involving the abdominal wall, bladder, right fallopian tube, and parametrium. The diagnosis was based on the histological findings of specimens obtained during the first surgery. On day 18 after the first surgery, there was a need for relaparotomy. Postoperatively, the patient received combination therapy, long-term antibiotic therapy, and immunomodulators (actinolysate). The performed treatment provided a positive effect.

Risk factors for relaparotomy after caesarian section: a study in a tertiary care hospital

Background: Caesarian section ( CS) is one of the most common reasons for the development of puerperal complications. Most of the women are treated conservatively, but sometimes there is a need for relaparotomy. Usually it is performed when the condition of the patient is too critical to withstand the risk of anaesthesia and repeat operation. Methods: Detailed demographic data was collected from the patients such as age, parity, indication for primary caesarian section, indications for relaparotomy and the interval between the two surgeries. Results: Most of the women were in the age group of 20-35 years with 1 case being 38 and most of them were multiparous except 3 for whom this was the first parity. Atonic post-partum haemorrhage was the most common indication for relaparotomy followed by traumatic postpartum haemorrhage and rectus sheath hematoma. Most of the surgeries took place within the first 24 hours of the primary surgery. Conclusions: Since there is a high rate of indications for relaparotomy, immediate action and careful monitoring of the patient is required post caesarian section.

Developing a clinical model to predict the need for relaparotomy in severe intra-abdominal sepsis secondary to complicated appendicitis.

Complex intra-abdominal sepsis secondary to acute appendicitis is common in South Africa, and management frequently involves relaparotomy. The decision to perform relaparotomy is often difficult, and this study aimed to develop a clinical model to aid the decision-making process. The study was conducted from January 2008 to December 2012 at Edendale Hospital, Pietermaritzburg. All patients with intraoperatively confirmed acute appendicitis and all patients in this group who subsequently underwent relaparotomy were included. The clinical course, intraoperative findings and outcome of all patients were recorded until discharge (or death). Using a combination of preoperative and intraoperative parameters, a clinical model was developed to predict the need for relaparotomy. Of the total of 1 000 patients identified, 54.1% were males. The median age for all patients was 21 years. Of 406 relaparotomies, 227 (55.9%) were planned and 179 (44.1%) on demand (expectant treatment). In the relaparotomy group, 367 patients (90.4%) had positive findings. Logistic regression analysis showed that the following four factors accurately predicted the need for subsequent relaparotomy: patients referred from any rural centre, duration of illness >5 days, heart rate >120 bpm, and perforation associated with generalised intraabdominal sepsis. Th is model had a predictive value of >90%. We have constructed a model that uses clinical data available at initial laparotomy to predict the need for subsequent relaparotomy in patients with complicated acute appendicitis. It is hoped that this model can be integrated into routine clinical practice, but further study is first needed to validate this model.

Characterizing the need for re-laparotomy during puerperium after cesarean section

As inconsistency exists concerning the rate and risk factors for re-laparotomy after cesarean section (CS), we aimed to determine the incidence, risk factors and indications for re-laparotomy after CS. This is a retrospective study. Women underwent re-laparotomy following CS were compared to a control group in a 1:3 ratio. Demographic, obstetrical and surgical data were analyzed. CS complications were defined as intra-operative abnormal hemorrhage, summoning surgical personnel, inverted T incision, uterine and/or hypogastric arteries ligation or cesarean hysterectomy. Overall, 35,779 women delivered during the study, of them 7,926 by CS (22.1 %) and 62 patients (0.7 %) underwent re-laparotomy. Re-laparotomies occur during the first 24 h, first week and beyond it, following CS in 64.5, 22.6 and 12.9 %, respectively. Previous abdominal/pelvic surgery (14.5 vs. 8.1 %, p < 0.01), emergent surgery (24.2 vs. 13.4 %, p = 0.04), intra-operative complications (26.8 vs. 0.5 %, p < 0.001), post-operative complication (40.7 vs. 0.5 %, p < 0.001) and adhesions (65.5 vs. 33.3 %, p < 0.001) were significantly increased in the study group. Indications for re-laparotomy varied according to the interval elapsed to the re-laparotomy with post-partum hemorrhage (27.4 %) being the leading indication in the early period. Risk factors for re-laparotomy following CS can be recognized and are mainly associated with previous abdominal and/or pelvic surgeries and intra-operative adhesions.

A decision rule to aid selection of patients with abdominal sepsis requiring a relaparotomy

BackgroundAccurate and timely identification of patients in need of a relaparotomy is challenging since there are no readily available strongholds. The aim of this study is to develop a prediction model to aid the decision-making process in whom to perform a relaparotomy.MethodsData from a randomized trial comparing surgical strategies for relaparotomy were used. Variables were selected based on previous reports and common clinical sense and screened in a univariable regression analysis to identify those associated with the need for relaparotomy. Variables with the strongest association were considered for the prediction model which was constructed after backward elimination in a multivariable regression analysis. The discriminatory capacity of the model was expressed with the area under the curve (AUC). A cut-off analysis was performed to illustrate the consequences in clinical practice.ResultsOne hundred and eighty-two patients were included; 46 were considered cases requiring a relaparotomy. A prediction model was build containing 6 variables. This final model had an AUC of 0.80 indicating good discriminatory capacity. However, acceptable sensitivity would require a low threshold for relaparotomy leading to an unacceptable rate of negative relaparotomies (63%). Therefore, the prediction model was incorporated in a decision rule were the interval until re-assessment and the use of Computed Tomography are related to the outcome of the model.ConclusionsTo construct a prediction model that will provide a definite answer whether or not to perform a relaparotomy seems a utopia. However, our prediction model can be used to stratify patients on their underlying risk and could guide further monitoring of patients with abdominal sepsis in order to identify patients with suspected ongoing peritonitis in a timely fashion.