Secondary Peritonitis Research Articles

Open abdomen in secondary peritonitis: time for closure.

Open abdomen in secondary peritonitis: time for closure.

The Dynamics of Platelet Content in Patients with Diffuse Peritonitis as a Predictor of Disease Outcome

BACKGROUND. Absolute numbers of platelets are of key importance for determining the severity of multiple organ failure in sepsis, while their fluctuations within normal values are not taken into account. At the same time, early detection of a downward trend in this parameter may have greater predictive value in predicting disease outcomes. AIM OF STUDY. To identify trends in changes in platelet levels in patients with widespread peritonitis and determine the possible relationship of these changes with the outcome of the disease. MATERIAL AND METHODS. The basis of the work was an analysis of the results of treatment of 220 patients with diffuse secondary peritonitis who were treated at the Elizavetinskaya Hospital in 2013–2019. A correlation analysis was conducted to identify relationships between disease outcomes, assessed according to the severity of postoperative complications, and the degree of platelet reduction, expressed in platelet ratio. The further ROC analysis allowed us to identify a threshold value of the platelet ratio, which excess indicated a high risk of an unfavorable outcome. RESULTS. Based on the data obtained, the threshold value of the platelet ratio in the first two days has no clinical significance. At the same time, starting from the third 3rd day of the postoperative period, the quality of the resulting classifier increased, which confirms the prognostic significance of the threshold value of the platelet ratio, which was 1.72 on the third 3rd day after surgery. In other words, a decrease in platelet levels more than 1.72-fold on the 3rd day indicates a high risk of an unfavorable outcome, which may be associated primarily with intra-abdominal complications. This provision also indirectly confirms the fact that among patients with platelet ratio (PR) values exceeding 1.72 on the 3rd day, 68.7 % ultimately underwent repeated surgical interventions (33 patients out of 48 with high PR values, and the overall mortality rate was 72.1 %.Similar indicators in the subgroup with low PR values were 27.6 % of reoperated patients (29 of 105) and 26.7 % of unfavorable outcomes. CONCLUSION. The results obtained indicate that the degree of platelet reduction, rather than their absolute levels, has greater predictive value in patients operated on for diffuse peritonitis.

Intraabdominal Urokinase for the Treatment of Secondary Bacterial Peritonitis in Cirrhosis.

Bacterial peritonitis with loculated ascites in patients with liver cirrhosis can be a therapeutic challenge. We present the case of a patient with liver cirrhosis undergoing pre-transplant evaluation, diagnosed with bacterial peritonitis secondary to urgent surgical intervention Imaging studies identified markedly loculated ascites, with a poor response despite broad-spectrum antibiotic therapy. The use of intraabdominal urokinase was a safe and effective adjuvant treatment for the resolution of this complication.

Giant hepatic hemangioma in a patient with cirrhosis: challenging to manage.

Giant hepatic hemangiomas are occasional in patients with cirrhosis. It remains a challenge to decide on the need for treatment and choose the most appropriate intervention. A 62-year-old woman was recently diagnosed with cirrhosis and complained of upper abdominal fullness, reduction in oral food intake, and weight loss of 6 kg over the last three years. Upper digestive endoscopy evidenced thin-caliber esophageal varices and significant extrinsic compression of the lesser gastric curvature. Abdominal computed tomography revealed an exophytic tumor in the left hepatic lobe, measuring 11.5 cm, which had progressive centripetal contrast enhancement from the arterial phase, compatible with hepatic hemangioma. Serum tumor markers were negative, and her liver function was unimpaired. The patient underwent surgical resection (non-anatomical hepatectomy of segments II and III) which had no immediate complications, and the histopathological evaluation confirmed cavernous hepatic hemangioma. Two weeks later, she was admitted to the emergency room with jaundice, signs of hepatic encephalopathy, and moderate ascites, and was further diagnosed with secondary bacterial peritonitis. As no perforations, abscesses, or fistulas were observed on subsequent imaging tests, clinical management was successfully carried out. This case highlights that giant hepatic hemangiomas may be symptomatic and warrant treatment. In the setting of cirrhosis and portal hypertension, physicians should be aware of the risk of hepatic decompensation following surgical resection, even in patients with Child-Pugh class A.

SPONTANEOUS BACTERIAL PERITONITIS

Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid, posing a severe complication in patients with portal hypertension (PH). Hospital mortality rates are exceedingly high, sometimes surpassing 85%. Only timely diagnosis and treatment can mitigate mortality and morbidity levels. Purpose. Through literature analysis and review, demonstrate the necessity, appropriateness, and efficacy of SBP treatment in patients with decompensated portal hypertension. Additionally, highlight the potential development of ascites and subsequent infections, which may not always be linked to liver cirrhosis. Materials and methods. This article conducts a literature review and assesses recommendations, findings from randomized controlled trials, meta-analyses, and other review articles published in databases such as PubMed, Scopus, Web of Science, and Google Scholar between 2000 and 2023. Outcome. Diagnostic paracentesis is recommended for all ascites patients requiring emergency care or hospitalization to ascertain SBP presence. Accurate differentiation between SBP and secondary bacterial peritonitis is crucial, as treatment approaches differ for each condition. Conclusions. Standard SBP treatment entails promptly administering broad-spectrum antibiotics, considering the potential for community-acquired or nosocomial SBP, and factoring in microbial antibiotic resistance. Given SBP's annual mortality rate surpassing 50%, liver transplantation is recommended for SBP survivors.

The impact of direct inoculation of ascites into blood culture bottles on ascites culture positivity

Abstract Objective: Assess whether direct inoculation of ascites into blood culture bottles would improve ascites culture yield. Design: Pre-post-study. Setting: The study was performed at a quaternary academic medical center in Houston, Texas, including all inpatient and emergency department encounters. Patients: Ascites cultures collected from November 2020 to December 2022 were reviewed and screened for spontaneous bacterial peritonitis. Patients were excluded if a prior ascites culture from the same patient was already included in the study or if there was evidence of secondary bacterial peritonitis. Intervention: In the pre-intervention period, ascites cultures were collected into a sterile container and inoculated onto/into solid and liquid media. In the post-intervention period, ascites cultures were instead directly inoculated into bioMérieux© blood culture bottles at the bedside. Results: 114 patients met inclusion and exclusion criteria, 61 pre-intervention and 53 post-intervention. Overall ascites culture positivity was 15.8% (18/114), 11.5% (7/61) pre-intervention vs 20.8% (11/53) post-intervention. After adjusting for confounders, the intervention had a trend toward a significant effect on ascites culture positivity (P = 0.077). No significant differences were seen in time to positivity, hospital length of stay, or 30-day readmission. Conclusions: Direct inoculation of ascitic fluid into blood culture bottles led to a small increase in culture yield but lacked statistical significance. This lack of significance may be due to the study being underpowered. Further studies are required to investigate if this is due to procedural inefficiencies (eg, inadequate inoculation volumes) or pragmatic clinical practice considerations (ie, high rates of pre-culture antibiotics).

Vacuum-assisted laparostomy for advanced peritonitisis

To evaluate the efficacy of negative pressure therapy in patients with peritonitis. The study included 127 patients with advanced secondary peritonitis between 2019 and 2022. All patients were divided into 2 groups. All ones underwent staged sanitation of the abdominal cavity. In the first group (n=76), re-laparotomies were accompanied by skin suture only and passive abdominal drainage. The second group included patients (n=51) with open abdominal cavity strategy and negative pressure therapy (vacuum-assisted laparostomy). We analyzed the number of surgeries, postoperative complications, duration of hospital-stay and mortality. In the second group, there were significantly lower morbidity, mean number of surgeries and hospital-stay. In addition, incidence of fascial closure of abdominal cavity was higher and mortality rate was lower in the same group. Vacuum-assisted laparostomy in patients with advanced peritonitis can reduce the number of secondary purulent complications and mortality, as well as increase the incidence of fascial closure of abdominal cavity. This approach reduces the number of surgical interventions and duration of in-hospital treatment.

The Incidence of Acute Peritonitis Secondary to Different Sites of Viscus Perforation.

Objective The incidence of peritonitis secondary to viscus perforation will be examined to determine the most common sites of perforation and associated comorbidities. Methods This is a retrospective observational study based on data collected from the King Fahad Hospital of the University (KFUH). This research targeted patients who had viscus organ perforation and the relation of peritonitis secondary to it. The sample was taken from patients under the care of the General Surgery Department from the first of Feb 2016 to the 12th of Sep 2022. The final sample consisted of 450 patients. The method of diagnosis of peritonitis was mainly clinical, and the surgical approach was either through an exploratory laparotomy or a diagnostic laparoscopy. Incidental findings of viscus organ perforation were noted in addition to certain postoperative complications (e.g., adhesions) and hospital stay. Results Analysis of the results showed a significant relation (p<0.001) between viscus organ perforation and peritonitis. The most common comorbidities associated with secondary peritonitis were hypertension (12, 24.5%), diabetes mellitus (10, 20.4%), any abdominal mass (3, 6.1%), and inflammatory bowel disease (1, 2%). However, a chi-square analysis has shown no significant association between peritonitis and the targeted associated comorbidities. Conclusion Perforation of the small intestine carries the biggest association with peritonitis incidence, in addition to comorbidities such as hypertension and diabetes mellitus. Further study to establish the value of these factors might contribute to decreasing the morbidity and mortality of secondary peritonitis.

Prediction of mortality in secondary peritonitis: a prospective study comparing p-POSSUM, Mannheim Peritonitis Index, and Jabalpur Peritonitis Index

BackgroundRisk scoring systems are required to allow accurate prognostication, compare outcomes of surgery, and allow patients to make informed decisions about their health. This prospective study compares the p-POSSUM (Portsmouth Modification to Physiological and Operative Severity Score for Enumeration of Mortality), Mannheim Peritonitis Index, and Jabalpur Peritonitis Index for their utility in predicting mortality in patients with peritonitis.MethodsPerioperative data was collected from 235 patients with secondary peritonitis and used to calculate p-POSSUM, MPI, and JPI scores. The accuracy of the 3 scores was compared using receiver operator characteristic curves.Resultsp-POSSUM and Mannheim Peritonitis Index were similar in their accuracy with area under the curve (AUC) values of 0.756 and 0.757. Jabalpur Peritonitis Index had an AUC of 0.665.Conclusionp-POSSUM and Mannheim Peritonitis Index can be used to predict mortality in patients with secondary peritonitis. Jabalpur Peritonitis Index is not suited for this purpose. Further studies are required to improve the diagnostic performance of p-POSSUM and MPI in patients with secondary peritonitis.

A comparative analytical study on outcome of secondary peritonitis using Mannheim's peritonitis index in geographically diverse Indian patients.

Secondary peritonitis is caused by infection of the peritoneal cavity due to perforation of the alimentary tract. Mannheim's peritonitis ındex (MPI) is a prognostic scoring system that predicts outcomes in peritonitis. Increasing MPI scores correlate with poor outcomes and mortality. The objective of this study is to evaluate the effectiveness of MPI-based prognosis and its impact on Indian patients with secondary peritonitis. For understanding the effectiveness of the MPI scoring system, a cross-sectional data analysis of published studies on secondary peritonitis from 10 geographical locations in India was performed. The 10-site study results were compared with unpublished in-house study data for individual MPI parameters to analyze any variations of MPI score-based predictions across a diverse Indian population. Patients were divided into risk groups on the basis of MPI scores: <21 mild, MPI= 21-29 moderate, MPI> 29 severe risk. We observed a significant correlation between mortality with age and gender as reported worldwide. Site of perforations were prevalent in the upper alimentary tract with the majority being gastro-duodenal for the Indian population as opposed to distal parts in the western population. Higher lethality in India is often associated with evolution time, organ failure, and sepsis due to delayed presentation and poor management. MPI scoring is effective in predicting risk across geographically diverse Indian populations. The sensitivity and specificity of MPI scores are more reliable and a score >29 specifically recommends aggressive resuscitation & monitoring of patients, initiation of broad-spectrum antibiotics, and intensive care support to reduce mortality and morbidity.

Combination of serum and peritoneal 1.3-beta-d-glucan can rule out intra-abdominal candidiasis in surgical critically ill patients: a multicenter prospective study

BackgroundIntra-abdominal candidiasis (IAC) is difficult to predict in critically ill patients with intra-abdominal infection, leading to the overuse of antifungal treatments. Serum and peritoneal 1.3-beta-d-glucan (sBDG and pBDG) have been proposed to confirm or invalidate the diagnosis of IAC, but clinical studies have reported inconsistent results, notably because of heterogeneous populations with a low IAC prevalence. This study aimed to identify a high-risk IAC population and evaluate pBDG and sBDG in diagnosing IAC.MethodsThis prospective multicenter noninterventional French study included consecutive critically ill patients undergoing abdominal surgery for abdominal sepsis. The primary objective was to establish the IAC prevalence. The secondary objective was to explore whether sBDG and pBDG could be used to diagnose IAC. Wako® beta-glucan test (WT, Fujifilm Wako Chemicals Europe, Neuss, Germany) was used for pBDG measurements. WT and Fungitell® beta-d-glucan assay (FA, Associate of Cape Cod, East Falmouth, USA) were used for sBDG measurements.ResultsBetween 1 January 2020 and 31 December 2022, 199 patients were included. Patients were predominantly male (63%), with a median age of 66 [54–72] years. The IAC prevalence was 44% (87/199). The main IAC type was secondary peritonitis. Septic shock occurred in 63% of cases. After multivariate analysis, a nosocomial origin was associated with more IAC cases (P = 0.0399). The median pBDG level was significantly elevated in IAC (448 [107.5–1578.0] pg/ml) compared to non-IAC patients (133 [16.0–831.0] pg/ml), P = 0.0021. For a pBDG threshold of 45 pg/ml, the negative predictive value in assessing IAC was 82.3%. The median sBDG level with WT (n = 42) at day 1 was higher in IAC (5 [3.0–9.0] pg/ml) than in non-IAC patients (3 [3.0–3.0] pg/ml), P = 0.012. Similarly, median sBDG level with FA (n = 140) at day 1 was higher in IAC (104 [38.0–211.0] pg/ml) than in non-IAC patients (50 [23.0–141.0] pg/ml), P = 0.009. Combining a peritonitis score < 3, sBDG < 3.3 pg/ml (WT) and pBDG < 45 pg/ml (WT) yielded a negative predictive value of 100%.ConclusionIn critically ill patients with intra-abdominal infection requiring surgery, the IAC prevalence was 44%. Combining low sBDG and pBDG with a low peritonitis score effectively excluded IAC and could limit unnecessary antifungal agent exposure.Trial registration: The study was registered with ClinicalTrials.gov (ID number 03997929, first registered on June 24, 2019).Graphical abstract

Endotoxin removal therapy with Polymyxin B immobilized fiber column: a single center experience from EUPHAS2 registry

Although the precise clinical indication for initiation of PMX-HA is widely debated in the literature, a proper patient selection and timing of treatment delivery might play a critical role in the clinical course of a specific subphenotype of septic shock (endotoxic shock). In light of this view, since 2019, we have introduced in our clinical practice a diagnostic-therapeutic flowchart to select patients that can benefit the most from the treatment proposed. In addition, we reported in this study our experience of PMX-HA in a cohort of critically ill patients admitted to our intensive care unit (ICU). We analyzed a single centre, retrospective, observational web-based database (extracted from the EUPHAS2 registry) of critically ill patients admitted to the ICU between January 2016 and May 2021 who were affected by endotoxic shock. Patients were divided according to the diagnostic-therapeutic flowchart in two groups: Pre-Flowchart (Pre-F) and Post-Flowchart (Post-F). From January 2016 to May 2021, 61 patients were treated with PMX-HA out of 531 patients diagnosed with septic shock and of these, fifty patients (82%) developed AKI during their ICU stay. The most common source of infection was secondary peritonitis (36%), followed by community-acquired pneumonia (29%). Fifty-five (90%) out of 61 patients received a second PMX-HA treatment, with a statistically significant difference between the two groups (78% of the Pre-F vs. 100% of the Post-F group, p = 0.005). In both groups, between T0 and T120, the Endotoxin Activity Assay (EAA) decreased, while the SOFA score, mean arterial pressure (MAP), and Vasoactive Inotropic Score (VIS) improved with no statistically significant difference. Furthermore, when performing a propensity score matching analysis to compare mortality between the two groups, statistically significant lower ICU and 90-day mortalities were observed in the Post-F group [p = 0.016]. Although in this experienced centre data registry, PMX-HA was associated with organ function recovery, hemodynamic improvement, and current EAA level reduction in critically ill patients with endotoxic shock. Following propensity score-matched analysis, ICU mortality and 90-day mortalities were lower in the diagnostic-therapeutic flowchart group when considering two temporal groups based on strict patient selection criteria and timing to achieve PMX. Further Randomised Control Trials focused on centre selection, adequate training and a flowchart of action when assessing extracorporeal blood purification use should be performed.

System of choice of surgical approach and option to complete laparotomy in generalized peritonitis

In modern surgery, there are three options that are used to complete laparotomy after performing the main stage of the operation for peritonitis: 1. closed method, in which the wound of the anterior abdominal wall is tightly sutured after drainage of the abdominal cavity, 2. staged planned operations planned relaparotomy), 3. open abdomen technique — laparostomy. Meanwhile, the criteria for choosing one or another option for completing a laparotomy are contradictory (especially when selecting between planned relaparotomy and laparostomy), which is explained by the lack of clear indications and convincing evidence of the benefits of any of those. The aim of the study was the development of a system of objective criteria for choosing an operative approach and an option for completing the operation in patients with generalized peritonitis. The work is based on the analysis of the results of treatment of 686 patients with the final diagnosis of generalized peritonitis. Abdominal sepsis at admission was diagnosed in 44 patients (6.4 %). In 302 (44.0 %) patients, a full surgical intervention was performed with laparoscopy. Initially, median laparotomy was performed in 205 patients (29.9 %). The closed method of completing laparotomy was used in 345 patients (77, 22.3 % died), staged planned operations — in 28 patients (18, 64.3 % died), and the open abdomen technique was used in 11 patients (5, 45.5 % died). The overall mortality was 15.0 % (103 patients died). Results. A system that, to a large extent, allows making a decision on the approach and completion of the operation in patients with generalized peritonitis has been created. The system was called the Index of Approach and Completion of Surgery for Secondary Peritonitis. The development of integral systems for assessing the severity of patient condition and choosing treatment tactics helps in systematizing the results, evaluating treatment results, and conducting scientific research.

Antimicrobial therapy of severe “civilian” intra-abdominal infections: a modern approach to empiric antibiotic therapy

This publication discusses the problems of treatment of severe intra-abdominal infections, namely empirical antimicrobial therapy for secondary peritonitis in view of the current state of the issue as understood by the authors, as well as modern guidelines and orders of the Ministry of Health of Ukraine. The use of well-known, but new for Ukraine drug, such as piperacillin / tazobactam, carbapenems, reserve antibiotics, is explored. We do not consider candidal, primary and tertiary peritonitis here, we hope to pay attention to this in future publications.

S4107 An Unusual Case of Secondary Pneumococcal Peritonitis in the Presence of COVID-19 Infection

S4107 An Unusual Case of Secondary Pneumococcal Peritonitis in the Presence of COVID-19 Infection

Reappraisal of intra-abdominal candidiasis: insights from peritoneal fluid analysis

BackgroundThe understanding of high mortality associated with intra-abdominal candidiasis (IAC) remains limited. While Candida is considered a harmless colonizer in the digestive tract, its role as a true pathogen in IAC is still debated. Evidence regarding Candida virulence in the human peritoneal fluid are lacking. We hypothesized that during IAC, Candida albicans develops virulence factors to survive to new environmental conditions. The objective of this observational exploratory monocentric study is to investigate the influence of peritoneal fluid (PF) on the expression of C. albicans virulence using a multimodal approach.Materials and methodsA standardized inoculum of a C. albicans (3.106 UFC/mL) reference strain (SC5314) was introduced in vitro into various PF samples obtained from critically ill patients with intra-abdominal infection. Ascitic fluids (AFs) and Sabouraud medium (SBD) were used as control groups. Optical microscopy and conventional culture techniques were employed to assess the morphological changes and growth of C. albicans. Reverse transcriptase qPCR was utilized to quantify the expression levels of five virulence genes. The metabolic production of C. albicans was measured using the calScreener™ technology.ResultsA total of 26 PF samples from patients with secondary peritonitis were included in the study. Critically ill patients were mostly male (73%) with a median age of 58 years admitted for urgent surgery (78%). Peritonitis was mostly hospital-acquired (81%), including 13 post-operative peritonitis (50%). The infected PF samples predominantly exhibited polymicrobial composition. The findings revealed substantial variability in C. albicans growth and morphological changes in the PF compared to ascitic fluid. Virulence gene expression and metabolic production were dependent on the specific PF sample and the presence of bacterial coinfection.ConclusionsThis study provides evidence of C. albicans virulence expression in the peritoneal fluid. The observed variability in virulence expression suggests that it is influenced by the composition of PF and the presence of bacterial coinfection. These findings contribute to a better understanding of the complex dynamics of intra-abdominal candidiasis and advocate for personalized approach for IAC patients.Trial registrationhttps://clinicaltrials.gov/ (NCT05264571; February 22, 2022)Graphical

The values of indices of non-specific resistance and cytokine regulation for early diagnosis of secondary peritonitis

The aim of the work is to study the changes in indices of non-specific resistance and cytokine regulation, relevant for the early diagnosis of secondary peritonitis. During the period 2016-2022, in the Surgery Department of the Communal Non-Profit Enterprise “Regional Clinical Hospital, Ivano-Frankivsk Regional Council” there were treated 192 patients with postoperative peritonitis. Of them, in 69 (35.9%) patients the changes in indices of non-specific resistance and cytokine regulation were studied. These studies were performed in the laboratory of the Department of Biological and Medical Chemistry of the Ivano-Frankivsk National Medical University. The content of CD3+-lymphocytes in the blood of patients with secondary peritonitis on admission to the hospital was 35.49±3.39%, which is 1.8-fold less than in the comparison group (p&lt;0.002), with their subsequent drop up to 31.00±2.88% (p&lt;0.002) during the third day of the disease. When determining CD4+-lymphocytes during the first day of observation, their indices were 21.49±3.11%, by 56% less than in the comparison group (p&lt;0.002). During the third day of the disease, we observed a slight increase in this index – up to 23.90±3.26% (p&lt;0.01). The study of the level of CD8+-lymphocytes showed that, on admission to the hospital, their level in blood serum was 13.92±1.05%, which is 1.6-fold lower than in patients of the comparison group (p&lt;0.002). Their decrease was observed further, and during the third day this index was 8.08±2.28% (p&lt;0.002). The content of CD11a+-cells on hospitalization was 11.32±0.54%, which is more than 6-fold less than in the comparison group (p&lt;0.002). The content of CD162+-cells in the blood on hospitalization was 21.49±3.11%, which is 3.1-fold less than in the comparison group (p&lt;0.002). The content of CD16+-cells in the blood on hospitalization was 10.83±0.87% (p&lt;0.002). A significant increase in the content of IL in the blood serum at the initial stage of secondary peritonitis with subsequent pathological changes are contributing factors in the disorder of the body’s immune response. The content of IL-6 on admission was 759.72±28.06%, which is almost 3.4-fold higher than the indices in the comparison group (p&lt;0.002). After surgery, this index gradually decreased and during the seventh day was 438.63±19.84% (p&lt;0.002). The results obtained on such indices of non-specific resistance and cytokine regulation as CD3+, CD4+, CD8+, CD11a, CD162, CD95, CD16, HLA-DR+, IL-2, IL-4, IL-6 showed their significant differences between the subgroups studied (p&lt;0.002), indicating their high sensitivity for diagnosing and predicting the development of secondary peritonitis.

Primary anastomosis and suturing combined with vacuum-assisted abdominal closure in patients with secondary peritonitis due to perforation of the small intestine: a retrospective study

BackgroundIntestinal resection and a proximal stoma is the preferred surgical approach in patients with severe secondary peritonitis due to perforation of the small intestine. However, proximal stomas may result in significant nutritional problems and long-term parenteral nutrition. This study aimed to assess whether primary anastomosis or suturing of small intestine perforation is feasible and safe using the open abdomen principle with vacuum-assisted abdominal closure (VAC).MethodsBetween January 2005 and June 2018, we performed a retrospective chart review of 20 patients (> 18 years) with diffuse faecal peritonitis caused by small intestinal perforation and treated with primary anastomosis/suturing and subsequent open abdomen with VAC.ResultsThe median age was 65 years (range: 23–90 years). Twelve patients were female (60%). Simple suturing of the small intestinal perforation was performed in three cases and intestinal resection with primary anastomosis in 17 cases. Four patients (20%) died within 90-days postoperatively. Leakage occurred in five cases (25%), and three patients developed an enteroatmospheric fistula (15%). Thirteen of 16 patients (83%) who survived were discharged without a stoma. The rest had a permanent stoma.ConclusionsPrimary suturing or resection with anastomosis and open abdomen with VAC in small intestinal perforation with severe faecal peritonitis is associated with a high rate of leakage and enteroatmospheric fistula formation.Trial registrationThe study was approved by the Danish Patient Safety Authority (case number 3-3013-1555/1) and the Danish Data Protection Agency (file number 18/28,404). No funding was received.

Nutritional support in the complex therapy of clostridial infection after surgery

This article presents the tactics of nutritional support in a patient with pseudomembranous colitis after repeated consecutive operations on the abdominal organs, which led to significant violations of the nutritional status. Competent, individually selected correction of protein-energy deficiency in patients with pseudomembranous colitis allows achieving an effective treatment result, avoiding severe complications such as perforation, toxic dilatation, and bleeding. The peculiarity of this clinical case is that a patient with perforation of Meckels diverticulum and abdominal abscess developed a complication secondary widespread peritonitis, phlegmon, which required repeated surgical interventions. Surgical treatment and massive antibiotic therapy led to the development of Clostridium difficile infection: during the treatment the patient developed multiple loose stools and C. difficile toxins A and B were detected. Severe pseudomembranous colitis was accompanied by protein-energy deficiency (hypoproteinemia, hypoalbuminemia), severe dehydration, hypokalemia, hyponatremia, and moderately severe anemia of complex genesis. When selecting nutritional support for patients with clostridial infection, it is important to take into account severe systemic inflammation, which affects the absorption and absorption of the intestinal wall, which in turn determines the route of introduction of nutrient substrates. In this case we needed to choose the right method for correcting the patients nutritional status.

The Role of Serum and Peritoneal Biomarkers in Predicting Sepsis and Septic Multiorgan Failure in Patients With Secondary Peritonitis.

Purpose Secondary peritonitis is still one of the most important causes of severe sepsis in the world; therefore, it is of utmost importance to identify biomarkersthat could be employed for the purpose of selecting patients at high risk for developing life-threatening complications after emergency surgery. In view of this quest, our study seeks to reveal the possible role for serum and peritoneal concentrations of selected biomarkers, specifically presepsin, procalcitonin, monocyte chemoattractant protein-1 (MCP-1), high mobility group box 1 protein (HMGB-1) and interleukins (IL-6, -8, -10), in early prediction of sepsis and septic multiorgan failure for patients with secondary peritonitis. Methods We prospectively observed 32 selected patients with secondary peritonitis that underwent emergency surgery. Blood and peritoneal fluid samples were drawn at the time of surgery (T0), and after that, blood samples were taken at 24 (T1) and 48 (T2) hours postoperatively. Cytokines concentrations were determined using a sandwich enzyme-linked immunosorbent assay (ELISA), a non-competitive variant, both in peritoneal fluid and serum. For determining whole blood concentration of presepsin and procalcitonin, PATHFAST™ assays (Polymedco, Cortlandt, New York) were used, based on the principle of non-competitive chemiluminescent enzyme immune-assay (CLEIA). The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of University Emergency Hospital Bucharest (no. 40325/6 April 2023). Results We found significant elevations in the peritoneal concentrations of interleukins 6, 8, 10, HMGB-1, and MCP-1 in all patients with secondary peritonitis at the moment of surgery; however, no clear correlation could be made based on this data with patient evolution. With regards to blood concentrations of the aforementioned serum cytokines and presepsin, procalcitonin (as already established markers of sepsis), our results showed good predictive value of presepsin for developing sepsis and septic multiorgan failure from the first hoursin this patient category. All other biomarkers, despite having higher concentrations than baseline, in particular at 24-48 hours after surgery, had unpredictable dynamics that couldn't be correlated with the severity of the disease. Conclusion Cytokine production is the mainstay in developing sepsis and septic multiorgan failure in patients with secondary peritonitis; therefore, studying the dynamics of said cytokines seems of interest in finding tools to predict the development of sepsis or sepsis-related mortality. However, at the time, there seemed to be no clear correlation between the values of these cytokines and the development of complications.