Perforation Peritonitis Research Articles

Simulation of intestinal perforation in experiment

The current problem of neonatal and pediatric surgery remains the tactics of surgical treatment and postoperative management of patients with perforated peritonitis. Mortality with perforation of the stomach and intestines in children in the newborn period reaches about 40-80 %. The combination of the syndrome of increased intra-abdominal pressure and multiple organ failure causes the extremely serious condition of patients. In this connection, new approaches to the surgical treatment of such patients are currently being actively developed. For this, new medical devices are tested in experimental practice, but the problem of such studies, first of all, lies in the lack of an adequate model of the pathological process. The aim of the work is to analyze the methods of experimental modeling of intestinal perforations described in the public domain. For this, a study was conducted of the most significant scientific publications of such databases as Google Scholar, PubMed, Scopus, eLIBRARY. The present work provides a detailed description of existing options for modeling perforations of various parts of the gastrointestinal tract (stomach, small intestine and colon), depending on the goals of the experiment. Several rather rare techniques based on the introduction of microorganisms are also presented. In addition, the article describes the method proposed by the authors for modeling perforation using laparoscopic access.

Spectrum of exploratory laparotomy for acute abdomen in a central Gujarat tertiary care centre

Background: Exploratory laparotomy is one of commonest emergency surgeries performed in the world. Despite technological advance imaging, the fundamental technique of exploratory laparotomy has remained unchanged over years. Studies quantifying the spectrum of laparotomy in central Gujarat are lacking. Methods: A retrospective study of 249 patients of emergency exploratory laparotomy for acute abdomen in SSG Hospital Baroda from May 2022 to May 2024 was done and data involving clinical presentation, imaging, operative findings and post- operative course were studied and analysed. The cases were divided into gastro-intestinal perforation, gastro-intestinal obstruction and miscellaneous cause. Results: The most common cause of exploratory laparotomy in study was perforation peritonitis including 59 ileal, 16 jejunal, 49 pre-pyloric, 29 duodenal, 1 body of stomach, 17 appendicular and 8 colon. With post op major complications like burst-11%, leak-5%, pneumonia-5%, multi-organ failure-6.5% and ileus 5%, wound infection 18%. The overall mortality was 15%. Out of 58 cases of laparotomy for obstruction including adhesions (29.3%), obstructed inguinal hernia (12%), tuberculosis (32%), malignancy (13.8%), internal hernia (12.6%). The miscellaneous causes were ruptured liver abscess (9), rupture ectopic pregnancy (2), twisted ovarian tumour (1). Conclusions: Acute abdomen remains a significant surgical problem. Peptic perforation remains a common cause of acute abdomen with high morbidity and mortality, despite improves medical management, though there is a declining trend in incidence, tuberculosis remains an important cause.

Epidemiology and Long-term Outcomes of Acute Kidney Injury in Adult Patients with Perforation Peritonitis Undergoing Emergency Laparotomy.

Reported incidence of acute kidney injury (AKI) is around 5.0-7.5% of all hospitalized patients, and 40% of them are postoperative patients. Major abdominal surgeries account for 3.1-35% of cases of postoperative AKI in various series. The aim of the study was to identify the incidence and risk factors of AKI in peritonitis patients undergoing emergency laparotomy. Adult patients aged 18-65 years undergoing emergency laparotomy for perforation peritonitis were included in this prospective observational study. Baseline clinical and laboratory data, intraoperative details and postoperative outcome data (AKI at day 7, length of intensive care unit and hospital stay, and mortality) were recorded. Logistic regression model was constructed to predict AKI at day 7. N = 140 patients were included in this study and 69 patients (49.3%) developed AKI within day 7. Larger volume of crystalloid [OR (95% CI) 1.00 (1.00-1.00); p = 0.012], intraoperative vasopressor use (OR 7.42 (2.41-22.83); p < 0.001), intraoperative blood loss [OR 1.004(1.00-1.01); p = 0.003] and the presence of chronic liver disease (CLD) [OR 22.44 (1.68-299.26); p = 0.019] were risk factors for the development of AKI. Acute kidney injury patients had increased mortality at day 90 (24.6% vs 1.4%; p < 0.001), length of ICU stay (3 days vs 0 days, p < 0.001), and length of hospital stay (11 days vs 7 days; p < 0.001). In peritonitis patients undergoing emergency laparotomy, as many as 49% of patients develop AKI within 1 week. The presence of CLD, intraoperative blood loss, and the use of crystalloids and vasopressor increase the odds of developing AKI. Priya P, Baidya DK, Anand RK, Ray BR, Khanna P, Krishna A, et al. Epidemiology and Long-term Outcomes of Acute Kidney Injury in Adult Patients with Perforation Peritonitis Undergoing Emergency Laparotomy. Indian J Crit Care Med 2024;28(9):854-858.

Microbiological Profiles of the Anatomical Sites of Perforation Peritonitis: A Cross-Sectional Study.

Introduction One of the most frequent emergencies that a general surgeon deals with is perforation peritonitis. The anatomical site of the perforation, which in turn affects the source of infection, has a major impact on the mortality rate due to perforation peritonitis. Early and suitable antibiotic therapy can be started in the postoperative period with the aid of knowledge about the microbiological profile and sensitivity of peritoneal fluid culture with respect to the anatomical sites of perforation peritonitis. Methods A cross-sectional study was conducted from June 2021 to November 2021 where peritoneal fluid samples were collected intraoperatively from patients with perforation peritonitis. This was subjected to culture and sensitivity, and results were analyzed with respect to anatomical sites of perforation. Results Forty cases were investigated. The ileum (30%) was the most common site of perforation, followed by the stomach (22.5%), appendix (20%), duodenum (12.5%), caecum (5%), jejunum (5%), transverse colon (2.5%), and rectum (2.5%). Escherichia coli (E. coli) and Klebsiella spp. were the most frequently found organisms in all sites of perforation peritonitis. The most sensitive antibiotics covering all isolated organisms were amikacin and meropenem. Sensitivity to amikacin was found in 85.18% of cases of E. coli and 84.6% of cases of Klebsiella. Sensitivity to meropenem was found in 76.9% of cases of E. coli and 80% of cases of Klebsiella. Conclusion In patients with perforation peritonitis, the peritoneal fluid cultures did not reflect the major differential normal flora according to the region of the gastrointestinal tract. The most prevalent organism isolated among all the sites of perforation peritonitis was E. coli. Antimicrobial activity against organisms isolated from perforation peritonitis patients was significantly demonstrated by aminoglycosides, piperacillin and tazobactam, and meropenem and colistin, with considerable resistance to third-generation cephalosporins.

Tuberculous peritonitis after conservative treatment for acute perforated appendicitis: a case report.

Interval appendectomy is widely recommended for patients with abscesses due to perforated appendicitis. A concomitant malignancy-related problem was reported after conservative treatment of acute appendicitis with abscess, but perforated appendicitis-associated tuberculous peritonitis was never reported. A 67-year-old male patient with a laryngeal cancer history presented to our hospital with an acute appendicitis-associated ileal abscess. He was scheduled for an interval appendectomy after conservative treatment. Fortunately, the symptoms subsided, and the patient was discharged for a later scheduled appendectomy. However, after 3months, he was readmitted to our hospital with fever and abdominal pain, and emergency surgery was performed, which was suspected to be peritonitis. Intraoperative results revealed numerous white nodules in the abdominal cavity. The condition was diagnosed as tuberculous peritonitis based on macroscopic results, later pathological findings, and positive T-SPOT.TB. The antituberculosis medications were effective, and the patient recovered and was discharged from the hospital 8days thereafter. Patients, particularly those immunocompromised, may develop tuberculous peritonitis after conservative treatment for acute perforated appendicitis.

Disseminated Talaromyces marneffei infection initially presenting as cutaneous and subcutaneous lesion in an HIV-Negative renal transplant recipient: a case report and literature review

BackgroundThe incidence of Talaromyces marneffei (T. marneffei) infection has increased in recent years with the development of organ transplantation and the widespread use of immunosuppressive agents. However, the lack of clinical suspicion leading to delay or misdiagnosis is an important reason for the high mortality rate in non-human immunodeficiency virus (HIV) and non-endemic population. Herein, we report a case of disseminated T. marneffei infection in a non-HIV and non-endemic recipient after renal transplant, who initially presented with skin rashes and subcutaneous nodules and developed gastrointestinal bleeding.Case presentationWe describe a 54-year-old renal transplantation recipient presented with scattered rashes, subcutaneous nodules and ulcerations on the head, face, abdomen, and right upper limb. The HIV antibody test was negative. The patient had no obvious symptoms such as fever, cough, etc. Histopathological result of the skin lesion sites showed chronic suppurative inflammation with a large number of fungal spores. Subsequent fungal culture suggested T. marneffei infection. Amphotericin B deoxycholate was given for antifungal treatment, and there was no deterioration in the parameters of liver and kidney function. Unfortunately, the patient was soon diagnosed with gastrointestinal bleeding, gastrointestinal perforation and acute peritonitis. Then he rapidly developed multiple organ dysfunction syndrome and abandoned treatment.ConclusionsThe risk of fatal gastrointestinal bleeding can be significantly increased in kidney transplant patients with T. marneffei infection because of the long-term side effects of post-transplant medications. Strengthening clinical awareness and using mNGS or mass spectrometry technologies to improve the detection rate and early diagnosis of T. marneffei are crucial for clinical treatment in non-HIV and non-endemic population.

Effectiveness of Mannheim's Peritonitis Index in Patients With Peritonitis Secondary to Hollow Viscus Perforation in a Tertiary Care Hospital in Jharkhand, India.

Introduction Peritonitis refers to the inflammation of the peritoneum and peritoneal cavity. Causes of peritonitis can be bacterial (gastrointestinal or non-gastrointestinal), chemical, traumatic, or ischemic. Peritonitis can be localized or diffuse, acute or chronic. Peritonitis can be primary, secondary, or tertiary, according to the pathogenesis. Peritonitis developed secondary to hollow viscus perforation is a life-threatening condition and a common cause of emergency surgery in India. The Mannheim peritonitis index (MPI) is a simple scoring system that can accurately predict the outcome of peritonitis.This study aimed to evaluate the effectiveness of MPI in predicting mortality risk or prognosis in patients with peritonitis due to hollow viscus perforation. Materials and methods This observational cross-sectional study at the Department of General Surgery, Rajendra Institute of Medical Sciences, Ranchi, involved 111 patients with peritonitis due to hollow viscus perforation from December 2021 to March 2022. Detailed history, clinical examination, relevant blood tests, and radiological investigations established a diagnosis of perforation peritonitis, followed by a score assessment. Data were analyzed using SPSS software (IBM Corp., Armonk, NY, USA). Results Patients >50 years had higher mortality (i.e., 18/43) than patients <50 years (i.e., 13/68). Overall mortality was 31, which included one in low risk, 12 in intermediate risk, and 18 in the high-risk group. Mortality was lowest in the low-risk group (i.e., 1/30), highest in the high-risk group (i.e., 18/40), and 12/41 in the intermediate-risk group; the p-value was <0.05, which was highly significant. Mortality was higher in patients presenting after 24 hours, having organ failure, and non-colonic sepsis. Conclusion The MPI scoring system is simple, easy to calculate, cost-effective, precise, and effective in assessing mortality and morbidity risk in patients with peritonitis due to hollow viscus perforation. It can also guide further management strategies.

Effect of chewing gum in reducing postoperative ileus after gastroduodenal perforation peritonitis surgery: A prospective randomised controlled trial.

Chewing gum reduces the duration of postoperative ileus and early recovery of bowel function following elective abdominal surgery. However, its role has not been studied in cases of gastroduodenal perforation peritonitis, prompting us to conduct this study. Patients were randomised into two groups, 39 patients received chewing gum (study group) and 43 patients were in the control group. Sensation of hunger, appearance of first bowel sound, and passages of flatus and faeces were significantly early in the study group; their hospital stay was also shorter. Chewing gum reduces the duration of postoperative ileus in cases of gastroduodenal perforation peritonitis.Registration number: IEC/2020-23/3359 dated 13 December 2020, Institutional Ethics Committee, Netaji Subhash Chandra Bose Medical College, Jabalpur, India.

Effect of in-hospital delay on acute appendicitis severity: does time really matter?

Appendicitis is one of the most common abdominal emergencies. Evidence is controversial in determining if the in-hospital time delay to surgery can worsen the clinical presentation of appendicitis. This study aimed to clarify if in-hospital surgical delay significantly affected the proportion of complicated appendicitis in a large prospective cohort of patients treated with appendectomy for acute appendicitis. Patients were grouped into low, medium, and high preoperative risk for acute appendicitis based on the Alvarado scoring system. Appendicitis was defined as complicated in cases of perforation, abscess, or diffuse peritonitis. The primary outcome was correlation of in-hospital delay with the proportion of complicated appendicitis. The study includes 804 patients: 278 (30.4%) had complicated appendicitis and median time delay to surgery in low-, medium-, and high-risk group was 23.15h (13.51-31.48), 18.47h (10.44-29.42), and 13.04 (8.13-24.10)h, respectively. In-hospital delay was not associated with the severity of appendicitis or with the presence of postoperative complications. It appears reasonably safe to delay appendicectomy for acute appendicitis up to 24h from hospital admission. Duration of symptoms was a predictor of complicated appendicitis and morbidity. Timing for appendicectomy in acute appendicitis should be calculated from symptoms onset rather than hospital presentation.

Comparison of Accuracy between Mannheim Peritonitis Index and Jabalpur Score in Predicting the Mortality in Perforative Peritonitis Patients Presenting for Emergency Surgery at a Tertiary Care Setup of Eastern India

Abstract Background and Objective: Peritonitis following hollow viscus perforation is commonly encountered in surgical emergency, which needs prompt and aggressive management. Unlike foreign nations, no score is routinely used in most tertiary medical colleges of India for prognostication of these patients preoperatively, leading to delay in adequate management and poor outcome. The aim of this research is to compare the accuracy of Mannheim peritonitis index (MPI) and Jabalpur score in prediction of mortality of patients presenting with perforative peritonitis. Materials and Methods: Fifty-one patients presenting with perforative peritonitis between November 2022 and April 2024 were scored using the two scoring systems and patients followed up over 30 days. Mortality based on scores of the scoring systems was analyzed. Results: Both scores had a significant P value, suggesting that both are efficient scoring systems. Receiver operating characteristic curves for both scores were plotted, and the area under the curve was calculated. Chi-square test showed no significant difference between the two scoring systems. Conclusion: Jabalpur score and MPI are both efficient scoring systems. Utilization of either of the scoring systems depends on the availability of resources in the health-care setup.

Endoscopic and clinicopathological features of segmental colitis associated with diverticulosis.

Segmental colitis associated with diverticulosis (SCAD) has close endoscopic and pathological similarities to ulcerative colitis (UC) and Crohn's disease. Clinical data on SCAD are limited in Japan. We examined the endoscopic and clinicopathological features of patients with SCAD. This single-center retrospective study included 13 patients with SCAD between 2012 and 2022. Endoscopic findings were categorized as follows: type A (swollen red patches 5-10 mm at the top of mucosal folds), mild and moderate type B (mild-to-moderate UC-like findings), type C (aphthous ulcers resembling Crohn's disease), and type D (severe UC-like findings). Overall, six, five, and two patients were diagnosed with type A, mild type B, and moderate type B disease, respectively. Among the type A cases, two spontaneously progressed to moderate type B and one escalated to type D, necessitating an emergency sigmoidectomy owing to perforation peritonitis, despite repeated antibiotic treatments. Histopathologically, diffuse neutrophil and lymphocyte infiltration with cryptitis were noted in all type A cases, whereas UC-like alterations were observed in type B and D cases. Seven type B cases were treated with oral 5-aminosalicylic acid and/or salazosulfapyridine. Clinical remission was achieved in three mild type B cases and one moderate type B case, while clinical relapse and remission were noted in three moderate type B cases. No anti-inflammatory treatment was required in three type A and two mild type B cases. Aggressive anti-inflammatory treatment should be considered for SCAD with UC-like findings due to the potential risk of severe ulceration, stenosis, and/or perforation.

‘To Drain or Not’ in Abdominal Surgery

The use of drains in abdominal surgeries is a matter of debate, especially the prophylactic use of a drain. In present times, the prophylactic use of drain is reducing due to some studies not supporting it. We are, in this study, discussing the pros and cons of using drains in abdominal operations. We are stressing through this study that drain helps in prevention and early detection of complications like bleeding, collection (pus, blood, bile, infected fluids) and anastomotic leaks. It also helps in early detection of the kind of fluid, which would be otherwise difficult even by radiological investigations, if drain has not been placed. Total of 50 cases of various abdominal surgeries, open and laparoscopic, are included in this study where drains were used. Informed written consent was taken. None of the patients had residual collections. Drains helped in prevention of post operative fluid collection. We advise placing a drain routinely, in cases of acute or chronic inflammation, or in cases with extensive dissection, in cases with risk of post op collection is high, cases with pus present in cavity, perforation peritonitis, trauma. Drains can always be removed early if they have a low output. But not placing a drain when it should have been placed, can result in preventable complications and add to the morbidity of the patient, sometimes significant.

Ileal perforation-etiopathology and outcome – An observational study

Background: Ileal perforations have a diverse etiology and often present with perforative peritonitis in the surgical emergency. This study is based on the scenario of management of ileal perforation encountered in a tertiary teaching hospital in West Bengal. Aims and Objectives: The aim and objective of this study is to document and evaluate the post-operative outcome based on the diverse etiopathology, clinical presentation, and surgical management performed in patients having ileal perforation. Materials and Methods: A prospective cross-sectional observational study was conducted in the Deben Mahata Government Medical College, Purulia, West Bengal, for a period of 2 years from February 2020 to January 2022 with 60 patients introperatively diagnosed with ileal perforation. Emergency exploratory laparotomy was done in all the cases presenting with perforative peritonitis. Ileal perforation was identified and an edge biopsy was taken. Appropriate surgical treatment in the forms of primary repair/resection-anastomosis/resection-ileostomy was done. The histopathological report was reviewed following surgery. The patients were evaluated in the post-operative period for post-operative morbidity and mortality. Results: Typhoid fever (68.33%) was the predominant cause in our study. The most common symptoms were abdominal pain (93%), fever (85%), and abdominal distension (75%). Widal test was performed preoperatively and was positive in 41 cases (68.33%). In our study, primary repair (58.33%), resection-anastomosis (15%), and resection-ileostomy (26.67%) were the main surgical treatment performed. Sepsis, surgical site infections (SSIs), fecal fistula, and wound dehiscence were the common post-operative complications found. Among them, SSI (51.67%) was the most common post-operative complication (P&lt;0.0001) found and fecal fistula was the most dreaded post-operative complication with 50% mortality. Histopathological reports following surgery showed cases were mainly due to enteric fever (51.67%) and tuberculosis (25%). Conclusion: Early surgical intervention was the mainstay of treatment of ileal perforation. Delayed presentation of perforation is responsible for the development of surgical site infections (SSIs). Uncontrolled generalized sepsis, wound dehiscence, and fecal fistula were the main causes of post-operative mortality.

Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) scoring system in predicting postoperative mortality in patients undergoing emergency laparotomy: A retrospective study.

There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy. This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study's primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients. The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer-Lemeshow (H-L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H-L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively. Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

Gallbladder volvulus: Putting a spin on acute cholecystitis

First reported in 1898, gallbladder volvulus is rare. It occurs when the gallbladder twists on its longitudinal axis greater than 180 degrees, resulting in occlusion of the cystic vessels and duct. Herein, we describe the case of a 73-year old woman who was diagnosed with acalculus gallbladder volvulus, with the aid of computerised tomography. This was managed by urgent laparoscopic cholecystectomy and the patient continues to do well 15 months postoperatively. Although rare, a high index of suspicion of the condition must remain and a low threshold for imaging is needed to prevent the complications of gallbladder necrosis, perforation and biliary peritonitis.

Endoscopic ultrasound-guided antegrade treatment versus balloon enteroscopy endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients with Roux-en-Y gastric bypass: a systematic review and meta-analysis.

The safety and technical success of endoscopic ultrasound-guided antegrade treatment (EUS-AG) compared to balloon enteroscopy-assisted endoscopic cholangiopancreatography (BE-ERCP) for choledocholithiasis in Roux-en-Y gastrectomy has not been well documented. We performed a systematic review and meta-analysis to assess the safety and efficacy of the 2 procedures. A systematic search of multiple databases was undertaken through January 25, 2024, to identify relevant studies comparing the 2 procedures. Standard meta-analysis methods were employed using a random-effects model. For each outcome, risk-ratio (RR), 95% confidence interval (CI), and P-values were generated. P<0.05 was considered significant. Heterogeneity was assessed using the I 2 statistic. Three studies with 795 patients (95 in the EUS-AG group and 700 in the BE-ERCP group) were included. The technical success rate was similar between EUS-AG and BE-ERCP (RR 1.08, 95%CI 0.84-1.38; P=0.57; I 2=56%). The overall rate of adverse effects was higher in the BE-ERCP group than in the EUS-AG group (RR 1.95, 95%CI 1.21-3.15; P=0.006; I 2=0 %). Rates of clinical success, pancreatitis, perforation, and bile peritonitis were similar between the 2 procedure techniques. Our analysis showed no distinct advantage in using one technique over the other for patients with Roux-en-Y anatomy in achieving technical and clinical success. However, the incidence of adverse effects was greater in the BE-ERCP group than in the EUS-AG group.

Corrugated Rubber Drains Versus Closed Suction Drain in Reducing Superficial Surgical Site Infection in Laparotomy Wounds

Background: Surgical site infections (SSI) remain a substantial problem for patients. Surgery for perforation peritonitis is associated with the highest rate of infective complications, especially surgical site infections because there is contamination of the operative field with microorganisms from endogenous sources. Subcutaneous drains are commonly placed in the operative setting to prevent hematoma or abscess formation in surgical wounds. In contrast to open drains, closed suction drains establish a pressure gradient between the wound and the external environment.Objectives: To evaluate the role of wound drainage in preventing surgical site infections (SSI) in patients undergoing emergency laparotomy and draw comparison between the efficacy of open corrugated rubber drainage and closed suction drainage.Methods: A prospective study was conducted on 50 patients admitted under Department of Surgery, Government Medical College, Jammu, India, between January and July of 2020, who underwent emergency laparotomy for various indications, within 24 hours of admission. All investigations for requisite anaesthesia were conducted on emergency basis. Patients received either corrugated rubber drain (group A), closed suction drain (group B) or no drain (group C) for wound drainage. Patients were followed in the post operative period for development of wound infection.Results: Mean age was 39.2 years with median age of 35 years. Male to female ratio was 1.94:1. 8 out of 19 patients from group A developed wound dehiscence, while only 1 out of 20 patients in group B developed wound dehiscence. 6 out of 11 patients in group C developed wound dehiscence. The difference was statistically significant (P&lt;0.05).Conclusion: Placement of subcutaneous drains in emergency laparotomy wounds is associated with lower incidence of wound infection. Closed suction drains appear to be more effective than open corrugated drains in reducing the risk of SSIs.International Journal of Human and Health Sciences Vol. 08 No. 01 Jan’24 Page: 75-78

Strategy of stage treatment for patients with perforated diverticulitis: first experience

BACKGROUND: The results of surgical treatment of patients with perforative diverticulitis of the colon are still unsatisfactory today. Since the majority of patients undergo Hartmann surgery, the main problem is a large number of stoma patients. Three quarters of them live with a stoma for a long time, which negatively affects their quality of life and increases the cost of treatment.&#x0D; AIM: The purpose of this research work is to improve the immediate results of treating patients with perforative diverticulitis and peritonitis by using staged surgical tactics.&#x0D; MATERIALS AND METHODS: The reaserach included 14 patients with perforative diverticulitis Hinchey grade II-III. The average value of the Mannheim peritoneal index is 18.9 ± 6.3 points. At the first stage of surgical treatment, all the patients underwent colon resection with a zone of perforation of the diverticulum and leaving its muffled ends in the abdominal cavity. After lavage and drainage, temporary closure of the anterior abdominal wall was performed. After 24–48 hours, all the patients underwent colon reconstraction.&#x0D; RESULTS: The average age of the patients was 52.3 ± 12.4 years with 4 women (28.6%) and 10 men (71.4%). The average duration of the first stage was 105.7 ± 27.2 minutes, the second one — 113.2 ± 40.5 minutes. The average hospital-stays were 16.4 ± 7.2 days. There were no anastomosis failures and no lethal outcomes. Complications were noted in 9 patients (64.3%), grade I according to Clavien – Dindo — 83.4%.&#x0D; CONCLUSIONS: The tactics of early surgical treatment is a promising concept for patients with perforative diverticulitis. It provides rapid elimination of the septic focus during the first surgical operation, assumes early reconstruction of the intestine without increasing the number of complications and mortality, and can be used in patients with peritonitis.

Comparison of Enhanced Recovery after Surgery Protocols with Conventional Treatment Protocols in Patients Undergoing Emergency Laparotomy: A Randomised Controlled Study

Introduction: Enhanced Recovery After Surgery (ERAS) is a multimodal and multidisciplinary approach intended to reduce the length of stay, postoperative complications, and readmission rates. The benefits of ERAS protocols in elective surgery are well established; however, the evidence to support their safety and efficacy in emergency surgery is rare. Aim: To compare the modified ERAS protocol with conventional management protocol following emergency laparotomy regarding the time taken to recover bowel function and the incidence of postoperative complications, duration of postoperative hospital stay, need for readmission, and 30 day mortality. Materials and Methods: The present study was a randomised controlled study conducted in the Department of General Surgery, Pt BD Sharma Institute of Medical Sciences, Rohtak, Haryana, India over a period of two years from June 2017 to May 2019. It included a total of 70 patients who presented in an emergency with perforation peritonitis. A total of 10 patients were excluded based on the exclusion criteria, and the remaining 60 patients were randomised into the Group-A (case group/ERAS group) and the control Group-B (control group/conventional group), with 30 patients in each group. Postoperative outcomes like postoperative complications, time of appearance of bowel sounds, time to first flatus, time to first defaecation, time to resumption of normal diet, and length of hospital stay were noted in both groups. Results: The length of hospital stay was shorter in the case group (8.83±4.69 days) compared to the control group (12.23±8.65 days); however, the difference was not statistically significant (p=0.064). Similarly, the difference in the time taken for the recovery of bowel sounds, postoperative complications, and 30 day mortality was also statistically insignificant between the two groups. No patient required readmission in either group. Conclusion: The use of ERAS protocols in emergency surgery is feasible, but all the elements of ERAS are difficult to apply in an emergency setting. Hence, a tailored approach to the ERAS protocols has to be used in emergency surgery. However, no significant benefit was noted in the group following modified ERAS protocols compared to the group following conventional protocols.

Ileo-sigmoidien knot: Case report

The ileosigmoid knot, also known as double volvulus, is a surgical emergency characterized by a double obstruction of the small intestine and sigmoid colon, Our patient have 62-year-old, chronic smoker, operated on at age 30 for ulcer perforation peritonitis and pyloric stenosis. Admitted to the emergency department with intestinal obstruction evolving for 3 days prior to admission, vomiting and generalized abdominal pain. Abdominal examination revealed generalized abdominal distension and defense. CT, distension of the colonic frame measuring 64mm at the coecum, producing the coffee-bean sign, with distension of some distal ileal loops measuring 33mm at the ileum, and a transitional level located at the pelvic level, producing the double-beak sign with visualization of the whirlpool sign, aeromesenteria and copious peritoneal effusion, the main treatment is a surgical intervention usually involves bowel resection with or without primary anastomosis.