Peritoneal Fluid Culture Research Articles

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.

Intraoperative peritoneal fluid culture: A retrospective study evaluating its relationship with survival and short‐term postoperative complications in horses undergoing emergency exploratory laparotomy

Intraoperative peritoneal fluid culture: A retrospective study evaluating its relationship with survival and short‐term postoperative complications in horses undergoing emergency exploratory laparotomy

#2355 Eradication of Staphylococcus aureus carriage in patients undergoing peritoneal dialysis

Abstract Background and Aims Peritonitis is a common and serious complication of peritoneal dialysis (PD). A single episode of severe peritonitis or multiple peritonitis episodes frequently leads to diminished peritoneal ultrafiltration capacity, hospitalization, and a switch to hemodialysis. Prevention of infection is the mainstay for the reduction of peritonitis rate. According to the current guidelines, we use nasal antibiotic prophylaxis if patients are identified as nasal Staphylococcus aureus carriers on screening prior to PD beginning. Eradication of S. aureus Regular with nasal mupirocin reduces the rate of exit-site infections but has uncertain effects on the risk of peritonitis. The aim of this study was to evaluate the rate of S. aureus peritonitis in our cohort of patients receiving PD. Method A retrospective single-center study was conducted in a large Italian PD center. We reviewed all cases of bacterial peritonitis from 1999 to 2023. Demographic and clinical characteristics of the patients and microbiological features of the bacteria identified in cultures were extracted from electronic health record. From 2011, all patients were screened before surgery for Methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) with nares swabs. All patients with positive nasal colonization for MSSA and MRSA were treated with nasal mupirocin (nasal ointment twice daily for 5 consecutive days every 4 weeks) until eradication was confirmed by a nasal swab. According to our protocol, from 2011, screening for S. aureus carriage along peritoneal fluid culture was performed in all patients on PD with an episode of peritonitis to verify nasal colonization with S. aureus. The study was approved by the regional ethical committee of Emilia Romagna (507/2021/OSS/AOUMO SIRER ID 2845). Results Overall, 345 cases of peritonitis were reviewed in 214 patients who received peritoneal dialysis. In our center, the rate of peritonitis was 0.23 episodes/patient-year. After the introduction of nasal screening for S. aureus carriage, the episodes of S. aureus peritonitis decreased in frequency (0.0093 episodes/patient-year vs. 0.034 episodes/patient-year) and as absolute number (17.8% vs 3.6%; p = 0.001). No differences were observed in the rate of catheter removal in the two populations (p = 0.99). The age of 109 patients screened for S. aureus carriage was 64.1 ± 17 years. Males accounted for 58.9% and automated PD (APD) was chosen by 66% of the subjects. After an average period of 1.6 years from the start of PD, 7 patients experienced S. aureus peritonitis in the absence of exit-site or tunnel catheter infection. Nasal screening at the time of peritonitis showed that half of them were carriers of S. aureus and half were negative (one patient was not screened). Colonization from S. aureus was found in another 9 patients whose peritonitis was caused by a different type of bacteria (44% S. epidermidis, 33.3% Enterobacteriaceae, 11.1% Acinetobacter, and 11.1% culture-negative peritonitis). Conclusion Our data document that screening for S. aureus, along with other preventive measures, contributes to significantly reducing the rate of S. aureus peritonitis in patients screened and treated for S. aureus carriage at the time of PD start. Routine screening and the use of a mask during connection are required because recolonization occurs frequently in this population.

#1217 Reinsertion of peritoneal dialysis catheter in a patient with Nocardial peritonitis: a case report

Abstract Background and Aims Peritonitis is a major drawback in patients on PD leading to technique failure, change in modality to hemodialysis, mortality. Nocardia infections are rare and occur mainly in immunocompromised individuals. Eleven cases of Nocardial peritonitis only have been reported. Given the rarity of the condition, duration of medical treatment, time at which catheter reinsertion can be done after treatment are not clear. We describe a case of nocardial peritonitis which presented with tunnel abscess and septic shock. Method Our patient is a 65 yr/M, DM & HT, initiated on CAPD due to multiple access failure elsewhere. He was also on treatment with directly acting antiviral for HCV infection. He presented with fever, abdominal pain and cloudy peritoneal fluid. Vitals were HR 98/min, BP 90/ 60 mmHg, temperature 100 F. Abdominal examination showed insertion and exit site pus with tenderness (Fig. 1a,b). USG screening showed tunnel abscess. Labs showed hemoglobin 7.2 g/dL, white blood cell count 6200 cells/cu mm, platelet count 1.4 lakh/cu mm, SGOT 23 U/L, SGPT 15 U/L and peritoneal dialysis fluid count 1570. CT abdomen showed no intraabdominal abscess. He was started on intravenous antibiotic and ionotropic support. Emergent PD catheter removal was done in view of septic shock & was dialysed via femoral tunneled catheter. Pus and peritoneal fluid culture grew Nocardia spp after six days of incubation. Intravenous cotrimoxazole was given for 2 weeks and intravenous ceftriaxone was given for 4 weeks followed by oral cotrimoxazole 960 mg thrice weekly. Results Following 7 months of treatment with cotrimoxazole, PD catheter was inserted laparoscopically after omentectomy and adhesiolysis. Peritoneal biopsy was taken at the time of catheter insertion, histopathology showed fragments of peritoneal tissue with scattered chronic inflammatory cells, culture was negative for Nocardia. PD catheter outflow dysfunction was noted after initiation of exchanges. CT abdomen showed migration of PD catheter tip following which catheter tip repositioning was done laparoscopically. During procedure, nodules were noted over peritoneum and bowel. Biopsy of the nodules were revealed foreign body granuloma and culture did not grow Nocardia (Fig. 2). Patient was initiated on three exchanges with 2.5% dextrose per day after a break-in period of 14 days. He continues to be on PD with good ultrafiltration. Conclusion There is not much data on reinsertion of PD catheter after nocardial peritonitis. One case of Nocardial peritonitis reported in literature, in which PD catheter was reinserted. Jamie Kendrick-Jones et al. [1] reported a case of Nocardial peritonitis in which catheter was reinserted after 1 year. To our knowledge this is the first case of Nocardial peritonitis which presented with tunnel abscess. Catheter was removed due to septic shock. Patient was treated with cotrimoxazole for seven months after which PD catheter insertion was done. Return to PD is feasible if Nocardial infection is identified and treated appropriately.

Blastocystis hominis -associated Acute Appendicular Peritonitis in a 9-Year-old Boy: A Case Report and a Comprehensive Review of the Literature.

Although Blastocystis sp. has been classically considered a commensal parasite with limited pathogenicity, recent studies suggest that its pathogenic potential is high. We report the case of a 9-year-old Spanish male who presented with peritonitis secondary to acute appendicitis with abundant intra-abdominal turbid-free fluid. A standard appendectomy was performed, and a sample of the fluid was taken for microbiological culture. Multimicrobial flora was isolated in peritoneal fluid culture. The antibiotic resistance study showed that all the microorganisms were sensitive to meropenem. On the 5th postoperative day, a control blood test showed relative eosinophilia and a persistently elevated C-reactive protein. A stool parasitological study showed abundant cysts morphologically compatible with Blastocystis hominis . The hematoxylin & eosin and Giemsa study identified abundant parasitic cysts in the appendix. The patient evolved favorably and is currently asymptomatic and under follow-up. Regarding acute appendicitis, there is only one report in the literature of peritonitis of appendiceal origin associated with Blastocystis sp. In conclusion, although infrequent, parasitosis should be considered as a potential etiological agent of acute appendicitis, even in nonendemic areas. Relative eosinophilia or persistently elevated acute phase reactants despite adequate antibiotic coverage should help to establish diagnostic suspicion.

Microbiological etiology and current resistance patterns in acute calculous cholecystitis

IntroductionThe current treatment for acute calculous cholecystitis (ACC) is early laparoscopic cholecystectomy, in association with appropriate empiric antibiotic therapy. In our country, the evolution of the prevalence of the germs involved and their resistance patterns have been scarcely described. The aim of the study was to analyze the bacterial etiology and the antibiotic resistance patterns in ACC. MethodsWe conducted a single-center, retrospective, observational study of consecutive patients diagnosed with ACC between 01/2012 and 09/2019. Patients with a concomitant diagnosis of pancreatitis, cholangitis, postoperative cholecystitis, histology of chronic cholecystitis or carcinoma were excluded. Demographic, clinical, therapeutic and microbiological variables were collected, including preoperative blood cultures, bile and peritoneal fluid cultures. ResultsA total of 1104 ACC were identified, and samples were taken from 830 patients: bile in 89%, peritoneal fluid and/or blood cultures in 25%. Half of the bile cultures and less than one-third of the blood and/or peritoneum samples were positive. Escherichia coli (36%), Enterococcus spp (25%), Klebsiella spp (21%), Streptococcus spp (17%), Enterobacter spp (14%) and Citrobacter spp (7%) were isolated. Anaerobes were identified in 7% of patients and Candida spp in 1%. Nearly 37% of patients received inadequate empirical antibiotic therapy. Resistance patterns were scrutinized for each bacterial species. The main causes of inappropriateness were extended-spectrum beta-lactamase–producing bacteria (34%) and Enterococcus spp (45%), especially in patients older than 80 years. ConclusionsUpdated knowledge of microbiology and resistance patterns in our setting is essential to readjust empirical antibiotic therapy and ACC treatment protocols.

Atypical Influx: Navigating Invasive Group A Streptococcus Cases in Emergency General Surgery

Abstract Aim To highlight the rising national incidence of iGAS infections, particularly during the post emergency phase of the COVID-19 pandemic, and emphasise its significance as a differential diagnosis in acutely unwell emergency surgical patients. Methods Data was gathered retrospectively from December 2022 - August 2023. Inclusion criteria were emergency surgical patients testing positive for GAS isolated from sterile sites, or non-sterile sites in case of septic shock. Results Six cases (four females, two males), with a mean age of 55 (36-67) were identified. Four had necrotizing fasciitis, one bacterial peritonitis in the presence of a ventriculo-peritoneal shunt, and one streptococcal bacteremia. All presented in septic shock, with metabolic acidosis and multiorgan impairment. The initial diagnosis was clinical in 66% of cases. iGAS was confirmed via wound, peritoneal fluid, tissue or blood culture in five patients and via genital swab in one. 50% of cases were sensitive to clindamycin and amoxicillin. Two received IV immunoglobulins. All cases were managed according to Sepsis 6 protocols, involving multidisciplinary teams. Five patients underwent immediate surgery for debridement and washout. The mortality rate was 16.6%. Three patients were transferred to tertiary centres once stabilised (1 for neurosurgical input, and 2 for plastics grafting). Conclusion It is crucial for frontline doctors to consider iGAS as a differential when encountering critically ill surgical patients. Simultaneous systemic resuscitation, early surgical intervention, multidisciplinary care, tailored antibiotic therapy and immunoglobulins are essential to minimise morbidity and mortality.

Post-Operative Increase in Serum Interleukin-6 Is Associated With Longer Hospital Stay in Children Operated on for Acute Appendicitis: A Pilot Study.

Background: Pediatric acute appendicitis (PAA) involves a substantial consumption of health and economic resources. The identification of serum biomarkers that may help predict the post-surgical evolution of these patients is a field of great interest. Patients and Methods: This was a prospective, observational substudy within the Biomarkers for the Diagnosis of Appendicitis in Pediatrics (BIDIAP) cohort aimed at evaluating the association between post-surgical increase in serum IL-6 and different outcomes related to the clinical evolution of children operated on for PAA. Sixty-nine children with a confirmed diagnosis of acute appendicitis and both pre-operative and post-operative serum IL-6 were included in the study. Three multivariable-adjusted linear regression models were fitted to analyze the association between an increase of >10% in post-operative serum IL-6 level with the length of stay, the number of post-operative emetic episodes, and the onset of oral feeding. Two multivariable-adjusted logistic regression models were fitted to assess the association of the same exposure with the indication of antibiotherapy at discharge and with positivity in peritoneal fluid culture. Results: Thirteen children showed an increase of >10% in the post-operative serum IL-6 value (group 1) whereas 56 showed only a minor increase, or no change (group 2). After accounting for potential confounders, children in group 1 had a mean of three-day longer hospital stay (difference, 3.33; 95% confidence interval [CI], 0.57-6.09) and higher odds of a positive result in peritoneal fluid culture (odds ratio [OR], 37.43; 95% CI, 1.02-1361.28) than children in group 2. Conclusions: An increase of >10% in post-operative serum IL-6 value could predict longer hospital stay and higher odds of positive peritoneal fluid culture. Future prospective studies are needed to replicate these findings and to broaden the range of biomarkers that could predict the post-operative evolution of children operated on for PAA.

414 Has Routine Purulent Peritoneal Fluid Aspirate Culture Results During Appendicectomy Helped in Patients’ Management?

Abstract Background Intra-operative purulent peritoneal fluid aspirate for microscopy, culture and sensitivity during appendicectomy is routinely practiced aiding post-operative management of patients if the patients get unwell requiring a change of the prescribed pre-operative antibiotics. As at the time of this audit, there was no guideline in the NHS regarding the routine purulent peritoneal aspirate for culture during appendicectomy. This necessitated the need to carry out this audit. Aim To evaluate if there is/ are benefit(s) from the routine purulent peritoneal fluid aspirate culture results during appendicectomy. Method This was a retrospective review of medical records with operation notes of all the patients who had appendicectomy with purulent peritoneal fluid that were aspirated for microscopy culture and sensitivity in the last 3 years (May 2019 to April 2022). The data were analysed using SPSS version 22. Results There were 127 patients that had appendicectomy and 73 (57.5%) patients had purulent peritoneal fluid culture results. Seventy-one (71.2%) of the patients had positive culture result from the purulent peritoneal fluid while there was no growth in the culture result in 28.8% of the remaining patients. Re-operation and ultrasound drainage were avoided in 13 patients out of 17 patients with post-operative intra-abdominal collections due to the change of the pre-operative antibiotics following the routine peritoneal fluid culture results. Conclusions The routine purulent peritoneal fluid culture results during appendicectomy was beneficial in 28.8% of the patients that required change of the pre-operative antibiotics due to the culture results.

Development of a clinical risk score system for peritoneal dialysis-associated peritonitis treatment failure

ObjectiveThis study aimed to construct a clinical risk score system for peritoneal dialysis-associated peritonitis (PDAP) treatment failure to provide a theoretical basis for clinical workers.MethodsA total of 161 PDAP individuals admitted to our hospital were included, among whom 70 cases were in the treatment-improved group and 87 cases were in the treatment failure group. We compared the general condition, clinical manifestations, and laboratory examination indicators of the two groups of individuals, used multivariate logistic regression analysis to identify the factors influencing PDAP treatment failure, and developed a clinical risk score system. The diagnostic performance of the risk score system was evaluated utilizing the receiver operating characteristic (ROC) curve.ResultsSignificant differences (P < 0.05) were observed between the two groups in terms of contamination, peritoneal fluid culture results, blood urea nitrogen (BUN) level, C-reactive protein (CRP) level, B-type natriuretic peptide (BNP) level, average residual urine (RU) volume, and urea clearance rate (UCR). Multivariate logistic regression analysis showed that BUN level, CRP level, BNP level, average RU volume, and UCR were independent risk factors affecting PDAP patient treatment outcomes (P < 0.05). The ROC curve analysis of the risk score system for predicting treatment failure in PDAP individuals showed an area under the curve of 0.895 [95% confidence interval (0.847–0.943)]. The optimal cut-off point was 2.5 points, with corresponding sensitivity and specificity of 88.5% and 74.3%, separately.ConclusionBUN level, CRP level, BNP level, average RU volume, and UCR are independent risk factors for PDAP treatment failure. The clinical risk score system based on these five independent risk factors can accurately predict the risk of treatment failure in PDAP individuals.

#6921 INFECTIOUS PERITONITIS DURING PEDIATRIC PERITONEAL DIALYSIS

Abstract Background and Aims Peritoneal dialysis (PD) is the dialysis treatment modality of choice used to treat pediatric patients with end-stage kidney disease (ESKD), thanks to its various benefits. However, infectious complications, mainly infectious peritonitis (IP), can occur, leading to morbidity, mortality and technique's failure. In this study, we aimed to describe the deferent infectious complications observed in children on PD and to investigate the risk factors for the occurrence of IP. Method In this study, we retrospectively collected the records of 99 patients who were treated with PD within the last eleven years (2010-2020) in the department of pediatrics of the University Hospital Charles Nicolle in Tunis. We adopted the terminology of the International Society of Peritoneal Dialysis (ISPD) to define peritonitis and its outcome. Analysis examining possible predictive factors of IP were performed using parametric and non-parametric tests and multivariate logistic regression in multivariate analysis. Results Ninety-nine patients were on PD during our study period, of which 65 patients had a total of 120 episodes of IP. The incidence of IP was 0.41 episodes per patient/year. The average time to onset of the first episode of IP was 1.2 years [3 days – 5.54 years]. Clinical signs of IP were dominated by abdominal pain (78.3%) and fever (50.4%). The PD effluent was cloudy in 78.3% of cases. Peritoneal dialysis fluid culture was positive in 33.3% of episodes with a predominance of gram-positive germs (62.8%). The evolution of this IP was favourable in 91.5% of cases with a response to antibiotics. 7% of episodes were relapsing of which five were during the first episode of IP. IP recurrence occurred in one patient. A catheter change was required over 16 episodes of IP, and hemodialysis sessions were necessary in 27 patients, temporary in 10 patients. The multivariate study identified the following predictive factors of IP: poor adherence to treatment (OR=3.851; 95%CI: 1.369-10.837; P = .011) and weight less than 15 Kg (OR=6.314; 95%CI: 1.333- 29.897; P = .02). Conclusion Considering the high risk of peritonitis in children on PD, it is imperative to establish a primary prevention based on training of the child's caregivers and families. Continous quality improvement program and PD technique must systematically reviewed in every peritonitis episode. Nutritional management of children prior to the start of PD is necessary to limit the risk of IP.

Tuberculous peritonitis in patients on peritoneal dialysis: a 35-year experience from a large medical center in Northern Taiwan

Introduction Tuberculous peritonitis (TBP) is a rare but fatal complication in patients on peritoneal dialysis (PD). In this study, we aimed to determine the demographic features, clinical features, laboratory parameters, and clinical outcomes of PD patients with TBP and to clarify possible risk factors for mortality. Materials and methods We retrospectively reviewed 2084 PD patients from January 1985 to December 2019. The diagnosis of TBP was established by positive peritoneal fluid culture for Mycobacterium tuberculosis. Results 18 patients were diagnosed with TBP. The incidence was 2.029 episodes per 1000 patient-years. The most common symptom was fever (94.4%), followed by cloudy effluent (83.3%) and abdominal pain (83.3%). The average peritoneal dialysis effluent (PDE) white blood cell (WBC) count was 172.7 cells/μL. Nine patients (50%) had WBC counts lower than 100 cells/μL and 13 patients (72.2%) had neutrophilic predominant WBC counts. Acid fast stain (AFS) was positive in 7 patients (38.9%). Only 2 patients (11.1%) continued with PD after TB infection, while 10 patients (55.6%) changed to hemodialysis. Seven patients (38.9%) died within 1 year. Significant differences were observed in sex (p = 0.040), the presence of diabetes mellitus (p = 0.024), and PD catheter removal (p < 0.001) between TBP patients with and without mortality. However, none of them was a significant factor for 1-year mortality in multivariate Cox regression model. Conclusion Physicians should pay attention to the unusual presentations of peritonitis, especially if symptoms include fever or an initial low PDE WBC count. Catheter removal is not mandatory if early diagnosis and appropriate therapy are available.

S3253 A Case of Recurrent Ascites Secondary to Ventriculoperitoneal Shunt in a Patient With Idiopathic Intracranial Hypertension

Introduction: Idiopathic Intracranial Hypertension (IIH) is a rare diagnosis affecting approximately 0.9–3/100,000 adults, mostly females of childbearing age with obesity. Surgical intervention is usually indicated in cases that prove refractory to conservative measures (such as weight loss and acetazolamide) or in cases of progressive papilledema and visual deficit. Ventriculoperitoneal shunt (VPS) is the preferred internalized cerebrospinal fluid diversion method. Here, we present a case of VPS causing ascites in a woman with IIH. Case Description/Methods: A 33-year-old female smoker with obesity, hypertension, and IIH with VPS (Medtronic strata valve, set to 1.0., placed six years ago for headache and visual problems) presents to the ED with increased abdominal distention and discomfort along with shortness of breath. She underwent a paracentesis two weeks prior for new ascites. Paracentesis showed no malignant cells. She had no family history of gastrointestinal pathology, no risk factors for viral hepatitis, and negative hepatitis serologies. She started noticing re-accumulation of fluid that did not improve with prescribed furosemide. She had no other symptoms including fevers, chills, or neurological symptoms. Physical exam showed ascites with a normal neurologic exam. Liver function tests were normal. CT abdomen and pelvis showed an unremarkable liver and VPS catheter without kinking. Pelvic ultrasound was unrevealing except for an ovarian cyst. Repeat paracentesis showed SAAG (Serum Ascites Albumin Gradient) 0.8, WBC 650 cells/ul, and only 10% polymorphonuclear cells (PMN). Culture of peritoneal fluid was positive for Cutibacterium acnes. The patient completed an antibiotics course and underwent a removal of the distal (peritoneal) catheter of the VPS that led to resolution of her ascites. Discussion: We present a case of recurrent ascites resolution following VPS removal. Cerebrospinal fluid (CSF) ascites is one of the rarest intra-abdominal complications of VPS. Only 29 cases have been described in the literature and only six of them were in adults. In such cases, VPS are removed and Ventriculo-pleural or Ventriculo-atrial shunts are placed. While pathophysiology behind IIH is hypothesized to be due to inability of CSF to be reabsorbed by arachnoid granulations and extracranial lymphatics, there is no satisfactory explanation in the literature regarding the pathophysiology of CSF ascites due to VPS. It is suspected that our patient’s infected VPS caused device malfunction leading to ascites.

Bacterial and Antibiotic Sensitivity Pattern in Secondary Peritonitis.

Peritonitis is inflammation of the peritoneum usually as a result of a localized or generalized infection. Secondary peritonitis which is the most common type follows an infective process in a visceral organ. The role of peritoneal cultures and use of antibiotics effective against culture results remain controversial. This study was conducted to determine the bacterial and antibiotic sensitivity pattern in patients with secondary peritonitis. It also compared the use of empirical antibiotics and culture-sensitive antibiotics with outcomes of patients with secondary peritonitis. A prospective randomized clinical study was conducted. Five millilitres of peritoneal fluid was sampled intra-operatively, and microscopy, culture, and sensitivity testing was performed in patients with secondary peritonitis. The patients, randomized into two groups, had antibiotics administered for 7 days. The first group had empirical antibiotics throughout (Ceftriaxone + Metronidazole), whereas the second group had empirical antibiotics (Ceftriaxone + Metronidazole) for the first 2 days and antibiotics according to the sensitivity report for the remaining 5 days. The post-hoc analysis was also done on a third group, who, even though were randomized to either groups, had no growth on culture of peritoneal fluid. The commonest pathogens identified from the peritoneal culture of the participants were Escherichia coli, Klebsiella pneumonia, Anaerococcus group, and Bacteroides fragilis. Complications including mortality were significantly higher in those who received empirical antibiotics than those who received culture-sensitive antibiotics. The outcome of antibiotics administration in patients with secondary peritonitis with a positive culture was better in those who received culture-sensitive antibiotics than those who received empirical antibiotics.

S3084 Metastatic Pancreatic Tail Adenocarcinoma Presenting With Multiple Hepatosplenic Abscesses: A Case Report

Introduction: Pancreatic cancer is the third leading cause of cancer-related deaths in the United States. It is often detected in advanced stages and may present in unusual ways such as pyogenic liver abscesses (PLA) or splenic abscesses which may be a diagnostic and therapeutic challenge. Case Description/Methods: A 78-year-old dialysis-dependent man with a history of end stage renal disease, hypertension and cerebrovascular accident was evaluated for diffuse abdominal pain and altered mental status for one day. The examination was pertinent for generalized weakness and altered sensorium. Laboratory tests revealed transaminitis and leukocytosis. Computed tomography (CT) of the abdomen and pelvis showed multiple hypoattenuating hepatic foci with hepatosplenomegaly. A set of blood cultures grew Clostridium inoculum. A pyogenic liver abscess was diagnosed, drained percutaneously and the culture grew pansensitive Escherichia coli. A follow up CT of the abdomen and pelvis revealed a large splenic abscess. Exploratory laparotomy, splenectomy, liver biopsy and peritoneal lavage were performed. Immunostaining of the sample was positive for CK7, CK20 and CDX2. Pancreaticobiliary adenocarcinoma metastatic to the spleen and liver was confirmed by pathology. CA 19-9 and CA 125 were elevated. A repeat CT of the abdomen with pancreatic protocol showed a pancreatic tail mass. Vancomycin resistant Enterococcus faecium grew on peritoneal fluid culture. Daptomycin and ceftriaxone were started. The patient improved clinically but he was deemed unsuitable for further invasive procedures or chemotherapy. (Figure) Discussion: Uncommon presentations of pancreatic adenocarcinoma include gastrointestinal (GI) bleeding from metastasis and acute abdomen from splenic infarct. PLA is associated with GI malignancies including pancreatic cancer. Some experts recommend cancer evaluation for GI malignancies in patients with PLA. Mucosal barrier breach by cancer cells, translocation of bacteria into the circulation and inoculation at metastatic sites are possible explanations for developing liver and splenic abscesses. Dialysis is also a risk factor for hepatosplenic abscess. In an elderly patient with hepatosplenic abscess and elevated tumor markers, a thorough evaluation for GI malignancies including pancreatic cancer should be done.Figure 1.: Image 1 shows cancer in the spleen. Images 2-3 show positive immunostains for CK7 in image 2, CK20 in image 3. Image 4 shows the cancer in the liver biopsy (no normal liver is present). Image 5 shows non-enhancing hypoattenuated foci in the right and left lobes of the liver most consistent with multifocal liver abscesses. Image 6 shows splenomegaly with multiple hypoattenuated foci and a mass within the tail of the pancreas.

Clinical presentation and surgical management of perforated peptic ulcer in a tertiary hospital in Mogadishu, Somalia: a 5-year retrospective study

BackgroundPerforated peptic ulcer is a common surgical emergency condition worldwide, which is associated with significant morbidity and mortality if early diagnosis and immediate surgical management were not carried out. Perforation occurs in roughly 5% of PUD patients during their lifetime; this study aimed to explore the wide range of clinical presentations, associated risk factors, complications, and surgical management of perforated peptic ulcer patients.MethodsA 5-year retrospective observational study on the clinical presentation and surgical management of perforated peptic ulcer is carried out in a tertiary hospital in Mogadishu, Somalia, Department of General Surgery, from January 2017 to December 2021. We included all patients undergoing operations with an intraoperative confirmed diagnosis of perforated peptic ulcer at the general surgery department. For operated patients, follow-up evaluation was performed in the outpatient department.ResultsFifty-one patients underwent an emergency operation for perforated peptic ulcer during the study period. The sociodemographic distribution of patients was 45 (88.2%) males and 6 (11.8%) females, giving a male-to-female ratio of 7.5:1. The mean age of patients was 35.5 ± 16.8 years, and the peak frequency was in the third decade. The commonest presenting symptoms were sudden onset of severe epigastric pain in 42 (82.4%) patients. Patients who presented perforated peptic ulcer within 24 h of initiation of symptoms were free from complications. Age-group and delayed presentation > 48 h after onset of symptoms were linked to postoperative complications and were statistically significant (P 0.032 and P 0.005), respectively. Four patients died (mortality rate of 7.8%). Two patients were reoperated because of the failed primary repair, and 4 patients had > 5 cm intra-abdominal abscess image-guided percutaneous drainage, and the rest were given antibiotic therapy according to peritoneal fluid culture and sensitivity results. The most common microorganism isolated was E. coli 22% and Klebsiella 11%. Other rare microorganisms (pseudomonas, Staphylococcus aureus, and Candida spp.) were identified. In half (51%) of the patients with peritoneal fluid culture, no microorganism growth was seen.ConclusionThe distribution of perforated peptic ulcer is common in the young age-group in the third decades of life. Delayed presentation of the disease is linked because most patients arrived from remote areas where proper facilities of health care and health education are not available and the patient might come to the hospital in an advanced stage of the disease. We suggest conducting further researches, health awareness related to complications over-the-counter drugs self-medication, and bad habit including smoking, and to improve health-seeking behaviors of society.

Peritoneal contamination and associated post-operative infectious complications after natural orifice specimen extraction for laparoscopic colorectal surgery.

Peritoneal contamination is a major concern during natural orifice specimen extraction after laparoscopic colorectal resection (LCR-NOSE), but few data are available. We explored the prevalence, risk factors, and association between clinical outcomes and infectious complications in patients with positive peritoneal drain fluid culture (PDFC) after LCR-NOSE. We retrospectively analyzed patient records in our prospectively maintained registry database who underwent LCR-NOSE between 2011and 2020. Peritoneal drain fluid was collected within 12h post-operative and cultures for microorganisms were obtained. The relationships between PDFC, clinical variables, and infectious complications were examined by univariate and multivariable analysis. Of 241 consecutive patients who underwent LCR-NOSE and drainage fluid culture, 59 (24.5%) had PDFC. Anterior resection (Odds ratio OR 2.40) was identified as an independent predictor for PDFC. Twenty-eight patients (11.6%) developed infectious complications. Multivariable analysis identified low anterior resection (OR 2.74), prolonged operative time (OR 3.20), and PDFC (OR 5.14) as independent risk factors. Pseudomonas aeruginosa was the most frequently found microorganism (OR 5.19) responsible for infectious complications. Microorganisms are commonly present in the peritoneum after LCR-NOSE and play a critical role in the development of infectious complications and related morbidity. Specific caution is warranted in patients contaminated with specific types of microorganisms.

Is Natural Orifice Specimen Extraction Surgery Really Safe in Radical Surgery for Colorectal Cancer?

BackgroundThe main feature of natural orifice specimen extraction (NOSE) is its avoidance of an auxiliary abdominal incision. The safety of NOSE remains controversial. This study aimed to investigate the early safety of transanal NOSE in the treatment of sigmoid colon and upper rectal cancer from the follow aspects: clinical and pathological characteristics, inflammatory and immune indicators and postoperative complications.MethodsData from 125 patients diagnosed with sigmoid colon, and upper rectal cancer by gastrointestinal surgery in the First Affiliated Hospital of Wannan Medical College from January 2017 to June 2020 were analyzed. Patients were assigned to two surgical groups: Conventional laparoscopic-assisted radical resection for CRC (CLA, 75cases) and laparoscopic-assisted radical resection for CRC with NOSE (La-NOSE, 50 cases). The following were compared: clinical and pathological characteristics; intraoperative, bacteriological, and oncological results; postoperative inflammation and immune response indexes. Bacteriological results were obtained by aerobic and anaerobic bacterial culture of peritoneal wash fluid and oncology results by cytological analysis of peritoneal wash liquid exudation. Inflammation indicators included postoperative C-reactive protein (CRP) and procalcitonin (PCT) trend reactions. The immune index was the level of postoperative T lymphocytes (CD3, CD4/CD8). All data were analyzed by using SPSS statistical version 18.0 for windows. Measurement data are presented as the means ± standard deviations, and two-group comparisons were performed using the t-test. Comparisons of count data were performed using the chi-square test. p <0.05 indicates that the difference was statistically significant.ResultsThe bacterial culture positive rate was not significant in the La-NOSE group (15/50 vs 19/75) than in the CLA group. The exfoliative cytology (EC) rate of the peritoneal wash fluid was 0 in both groups.The La-NOSE group had a significantly higher postoperative day 2(POD2) CRP and PCT level than the CLA group. The POD2 CD3 and CD4/CD8 levels were higher in the La-NOSE group than in the CLA group. There was no significant difference in the incidence of postoperative complications between the two groups (La-NOSE group vs CLA group: 3/50 vs 6/75) (p>0.05).ConclusionsAlthough the incidence of intra-abdominal contamination is high, it does not develop into a severe infectious disease, and does not lead to the implantation of free tumor cells into the abdominal cavity. Therefore, it is safe for the NOSE to treat colorectal cancer.

Risk factors for death in elderly patients admitted to intensive care unit after elective abdominal surgery: a consecutive 5-year retrospective study

To investigate the risk factors that were associated with the death of elderly patients who were admitted to the intensive care unit (ICU) after elective abdominal surgery, and to find reliable and sensitive predictive indicators for early interventions and reducing the mortality. A retrospective case-control study was conducted. The clinical data of elderly (age ≥ 65 years old) patients after elective abdominal surgery admitted to the ICU of the Affiliated Hospital of Guizhou Medical University from January 1st 2016 to December 31st 2020 were collected, including the patient's gender, age, body mass index (BMI), medical history, American Society of Anesthesiologists (ASA) grades, surgical classification, intraoperative blood loss, duration of operation, interval time between end of operation and admission to the ICU, acute physiology and chronic health evaluation II (APACHE II) score and the worst laboratory examination results within 24 hours of ICU admission, the first blood gas analysis in ICU, the duration of invasive mechanical ventilation, and the length of ICU stay. Postoperative abdominal infection was evaluated by the pathogenic culture of peritoneal drainage fluid and clinical symptoms and signs. The patients were divided into death group and survival group based on clinical outcomes, and clinical data were compared between the two groups. Binary multivariate Logistic regression analysis was used to screen the risk factors of death, and the receiver operator characteristic curve (ROC curve) was plotted to analyze the predictive values of these risk factors. A total of 226 elderly patients with elective abdominal surgery were admitted to the ICU of our hospital during the past 5 years, of whom, two patients who did not undergo laboratory examinations within 24 hours of admission to the ICU were excluded. Finally, 224 patients met the criteria, with 158 survivors and 66 deaths. Univariate analysis showed that: compared with survival group, APACHE II score, blood lactate acid (Lac) and the proportion of postoperative abdominal infection were higher in death group [APACHE II score: 27.5 (25.0, 31.3) vs. 23.0 (18.0, 27.0), Lac (mmol/L): 2.9 (1.8, 6.6) vs. 1.8 (1.1, 2.8), the proportion of postoperative abdominal infection: 65.2% (43/66) vs. 35.4% (56/158), all P < 0.01], prothrombin time (PT), activated partial thromboplastin time (APTT) and interval time between end of surgery and admission to ICU were longer [PT (s): 17.20 (14.50, 18.63) vs. 14.65 (13.90, 16.23), APTT (s): 45.15 (38.68, 55.15) vs. 39.45 (36.40, 45.70), interval time between end of surgery and admission to ICU (hours): 39.2 (0.7, 128.9) vs. 0.7 (0.3, 2.0), all P < 0.01], postoperative hemoglobin (Hb), platelet count (PLT), prealbumin (PA), mean arterial pressure (MAP) and oxygenation index (PaO2/FiO2) were lower in death group [Hb (g/L): 95.79±23.64 vs. 105.58±19.82, PLT (×109/L): 138.5 (101.0, 177.5) vs. 160.5 (118.5, 232.3), PA (g/L): 80.88±43.63 vs. 116.54±50.80, MAP (mmHg, 1 mmHg = 0.133 kPa): 76.8±19.1 vs. 91.6±19.8, PaO2/FiO2 (mmHg): 180.0 (123.5, 242.5) vs. 223.5 (174.8, 310.0), all P < 0.05]. Binary multivariate Logistic regression analysis showed that APACHE II score [odds ratio (OR) = 1.187, 95% confidence interval (95%CI) = 1.008-1.294, P < 0.001], interval time between end of operation and admission to ICU (OR = 1.005, 95%CI = 1.001-1.009, P = 0.016) and postoperative abdominal infection (OR = 2.630, 95%CI = 1.148-6.024, P = 0.022) were independent risk factors for prognosis in these patients. MAP (OR = 0.978, 95%CI = 0.957-0.999, P = 0.041) and PaO2/FiO2 (OR = 0.994, 95%CI = 0.990-0.998, P = 0.003) were protective factors for the patients' prognosis. Lac, Hb, PLT, PA, PT and APTT had no predictive value for the prognosis of elderly patients admitted to ICU after elective abdominal surgery [OR value and 95%CI were 1.075 (0.945-1.223), 1.011 (0.99-1.032), 1.000 (0.995-1.005), 0.998 (0.989-1.007), 1.051 (0.927-1.192) and 1.003 (0.991-1.016), respectively, all P > 0.05. ROC curve analysis showed that APACHE II score, interval time between end of operation and admission to the ICU and the postoperative abdominal infection had certain predictive values for the prognosis of elderly patients, the area under ROC curve (AUC) were 0.755, 0.732 and 0.649 respectively, all P < 0.001; When the cut-off of APACHE II score and interval time between end of operation and admission to the ICU were 24.5 scores and 2.15 hours, the sensitivity were 78.8% and 66.7%, respectively, and the specificity were 62.0% and 76.6%, respectively. The combined predictive value of the three variables was the highest, which AUC was 0.846, the joint prediction probability was 0.27, the sensitivity was 83.3%, and the specificity was 75.3%. APACHE II score, interval time between end of surgery and admission to ICU, and postoperative abdominal infection may be independent risk factors for the death of elderly patients who were admitted to the ICU after elective abdominal surgery, there would be far greater predictive values when the three variables were combined.

Analysis of 190 Female Patients after Appendectomy.

This study is a retrospective cohort review carried out at a single, private tertiary center. We included 190 female patients who underwent surgery for acute appendicitis between January 2016 and December 2018. Two groups of patients were analyzed based on the pregnancy. The main outcome measures were complication rate and risk of abortion during or after surgery. Out of 190 female patients, eight of them were pregnant (4.2%). The pregnant group more significantly underwent ultrasound investigation compared to the nonpregnant group. Complicated appendicitis present in two pregnant patients at advanced gestational age was not statistically significant from nonpregnant. Laparoscopic appendectomy was performed in 6/8 (75%) of pregnant compared to 158/182 (87%) in nonpregnant (p = 0.415). Compared to the nonpregnant, the pregnant group has a more fecolith, positive peritoneal fluid culture, and wound infection, with E. coli more frequently isolated in 25%. None of the pregnant patients had an abortion, preterm labor, or mortality during or after surgery. In conclusion, laparoscopic appendectomy is a low-risk operation for pregnant with acute appendicitis.