Septic Abdomen Research Articles

An Australian Shepherd with possible Behçet-like disease characterized by cutaneous and intestinal vasculitis leading to septic abdomen.

An Australian Shepherd with possible Behçet-like disease characterized by cutaneous and intestinal vasculitis leading to septic abdomen.

Impact of negative pressure wound therapy on enteroatmospheric fistulation in the septic open abdomen.

The effect of negative pressure wound therapy (NPWT) on the pathogenesis and outcome of enteroatmospheric fistulation (EAF) in the septic open abdomen (OA) is unclear. This study compares the development and outcome of EAF following NPWT with that occurring in the absence of NPWT. Consecutive patients admitted with EAF following abdominal sepsis at a National Reference Centre for intestinal failure between 01 January 2005 and 31 December 2015 were included in this study. Patients were divided into two groups based on those that had been treated with NPWT and those that had not (non-NPWT) and characteristics of their fistulas compared. Clinical outcomes concerning nutritional autonomy at 4 years and time to fistula development, size of abdominal wall defect and complete fistula closure were compared between groups. A total of 160 patients were admitted with EAF following a septic abdomen (31-NPWT and 129-non-NPWT). Median (range) time taken to fistulation after OA was longer with NPWT (18 [5-113] vs. 8 [2-60] days, p = 0.004); these patients developed a greater number of fistulas (3 [2-21] vs. 2 [1-10], p=0.01), involving a greater length of small bowel (42.5 [15-100] cm vs. 30 [3.5-170] cm, p=0.04) than those who did not receive NPWT. Following reconstructive surgery, nutritional autonomy was similar in both groups (77% vs. 72%) and a comparable number of patients were also fistula-free (100% vs. 97%). Negative pressure wound therapy appears to be associated with more complex and delayed intestinal fistulation, involving a greater length of small intestine in the septic OA. This did not, however, appear to adversely affect the overall outcome of intestinal and abdominal wall reconstruction in this study.

Open abdomen: is a dedicated emergency surgery team needed? A single center retrospective study on 141 consecutive patients.

Open Abdomen (OA) is widely used when facing a catastrophic abdomen. Still, no indication is validated by a strong and high quality of evidence. The study reports the 5year experience of a dedicated emergency general surgery (EGS) team. Retrospective observational cohort study. Patients undergoing OA management from 2/01/2015 to 19/07/2020 for trauma, non-traumatic emergencies or rescue surgery. One hundred and forty-one patients. Age 66.9 ± 15.1. Male 58.2%.9.3% OA for trauma, 64.5% for non-traumatic emergencies and 26.2% for rescue surgery. 40.4% performed by the EGS team 52.4% indication for surgery was a severe intra-abdominal infection. TAC device: commercial negative pressure wound therapy (NPWT) (83%), Sandwich VAC (12%), commercial NPWT with polypropylene mesh (5%) for pregressive fascial traction. Enteroatmospheric fistula (EAF) in 3 patients. OA duration 5.3 days (1-25). A 1.8 revision surgeries (0-12) required for definitive closure; ICU stay 9.9 days (0-78). 30-day mortality 23.5%. Overall and 1-year mortality were 47.5% and 43.3%. Overall survival 9.9months. An increased one-year mortality rate was found in the >65 group (P=0.01). We reported a wide use of OA in septic abdomen (90% of cases). We had a low rate of EAF, short ICU stay and OA duration. These results are related to the fact that patients were treated by a dedicated EGS team, suggesting that OA management should be cared for as much as possible by trained and experienced surgeons. Prospective studies with more accurate patient selection are needed to prove our conclusions.

Open Abdomen and Fluid Instillation in the Septic Abdomen: Results from the IROA Study

BackgroundOpen abdomen (OA) is a surgical option that can be used in patients with severe peritonitis. Few evidences exist to recommend the use of intraperitoneal fluid instillation associated with OA in managing septic abdomen.Materials and methodsA prospective analysis of adult patients enrolled in the International Register of Open Abdomen (trial registration: NCT02382770) was performed.ResultsA total of 387 patients were enrolled in two groups: 84 with peritoneal fluid instillation (FI) and 303 without (NFI). The groups were homogeneous for baseline characteristics. Overall complications were 92.9% in FI and 86.3% in NFI (p = 0.106). Complications during OA were 72.6% in FI and 59.9% in NFI (p = 0.034). Complications after definitive closure were 70.8% in FI and 61.1% in NFI (p = 0.133). Entero-atmospheric fistula was 13.1% in FI and 12% in NFI (p = 0.828). Fascial closure was 78.6% in FI and 63.7% in NFI (p = 0.02). Analysis of FI in negative pressure wound therapy (NPWT) showed: Overall morbidity in NPWT was 94% and in non-NPWT 91.2% (p = 0.622) and morbidity during OA was 68% and 79.4% (p = 0.25), respectively. Definitive fascial closure in NPWT was 87.8% and 96.8% in non-NPWT (p = 0.173). Overall mortality was 40% in NPWT and 29.4% in non-NPWT (p = 0.32) and morality during OA period was 18% and 8.8% (p = 0.238), respectively.ConclusionWe found intraperitoneal fluid instillation during open abdomen in peritonitic patients to increase the complication rate during the open abdomen period, with no impact on mortality, entero-atmospheric fistula rate and opening time. Fascial closure rate is increased by instillation. Fluid instillation is feasible even when associated with nonnegative pressure temporary abdominal closure techniques.

Application of Negative Pressure Wound Therapy with Instillation and Dwell Time of the Open Abdomen: Initial Experience.

Recent therapeutic advances in the management of severe abdominal sepsis (SAS) have improved patient mortality and morbidity. However, SAS and its impact on multiple organ failure remain a serious, life-threatening condition with a high mortality rate. The open abdomen (OA) technique has become an effective alternative to repeat laparotomy. The use of OA negative pressure wound therapy (OA NPWT) has been a significant advancement in the management of the open abdomen. Similarly, negative pressure wound therapy (NPWT) with instillation and dwell time (NPWT-i) has been used in patients with multiple comorbidities, with an American Society of Anesthesiology Classification ≥ 2, severe traumatic wounds, diabetic foot infections, and wounds complicated by invasive infection or extensive biofilm. Controlled instillation of saline during NPWT-i may further enhance healing by facilitating automatic and contained volumetric wound irrigation and cleansing and diluting local levels of inflammatory cytokines, improving the local as well as the systemic response to infection. Although the soft tissue and intra-abdominal compartments differ anatomically, they share very similar biologic responses to infections. Therefore, from a biologic and physiologic aspect, intraperitoneal instillation therapy may play a role as an adjunctive treatment of abdominal compartment inflammation from trauma or infection. The addition of saline solution instillation to OA NPWT (OAI) in a programmed, controlled manner may offer the clinician an effective adjunctive therapy for the treatment of the complex septic abdomen. The technical aspects of instillation into the OA and a pooled multicenter case study cohort utilizing OAI with saline solution, bacitracin, or hypochlorous acid in the management of the septic abdomen is presented.

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital.

Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis. Sixteen patients underwent surgery: six patients for septic abdomen, four patients for pancreatic necrosis and two patients due to abdominal compartment syndrome. Four patients had a combination of surgical procedures for pancreatic necrosis and for abdominal compartment syndrome. Overall mortality was 9.1%. Severe acute pancreatitis represents a complex pathology that requires a multidisciplinary approach. Establishing best practice treatments and evidence-based guidelines for severe acute pancreatitis may improve outcomes in low-volume hospitals.

Intestinal surgery in small animals: historical foundations, current thinking, and future horizons.

Intestinal wounds require precise closure after intestinal biopsy, enterotomy, or enterectomy in small animals. Preexisting factors such as intra-abdominal sepsis and hypoalbuminemia as well as poor surgical technique increase the risk of intestinal dehiscence, with considerable negative impact on patient morbidity and mortality. Live dog studies have demonstrated the dangers of mucosal eversion especially in the septic abdomen. Approximating patterns preserve luminal diameter, heal optimally, and have equal bursting strength compared with inverting patterns after 24 hours. Simple interrupted and simple continuous suture patterns and disposable skin staples are established alternatives for manual wound closure. Knotless quilled suture currently used in laparoscopic gastropexy techniques shows bursting strength equal to monofilament sutures in dog cadaveric intestine. Dehiscence rates with hand sewn vs titanium automated stapling anastomosis are similar in uncomplicated cases; however, auto stapling devices may be the preferred method of anastomosis when preexisting abdominal sepsis is present and when patient size allows it. Regardless of the technique, current standard of care involves leak testing and omental wrapping, followed by early postoperative feeding. The past decade has ushered in an exciting new era of laparoscopic assisted techniques that have the potential to reduce postoperative pain and patient morbidity. An understanding of these applications will establish the future of minimally invasive small animal intestinal surgery for veterinary specialists. In summary, surgeons have a variety of methods at their disposal for optimal clinical outcome in small animal intestinal surgery.

Blurring the boundary between open abdomen treatment and ventral hernia repair.

Therapeutic approaches for septic open abdomen treatment remain a major challenge with many uncertainties. The most convincing method is vacuum-assisted wound closure with mesh-mediated fascia traction with a protective plastic sheet placed on the viscera. As this plastic sheet and the mesh must be removed before final fascial closure, such a technique only allows temporary abdominal closure. This retrospective study analyzes the results of a modification of this technique allowing final abdominal closure using an anti-adhesive permeable polyvinylidene fluoride (PVDF) mesh. The outcome of all consecutive patients with septic open abdomen treatment at one academic surgical department from January 2013 to June 2015 was retrospectively analyzed. Retrospectively, 57 severely ill consecutive patients with septic open abdomen treatment with a 30-day mortality of 26% and a 2-year mortality of 51% were included in the study. In 26 patients, no mesh was implanted; in 31 patients, mesh implantation was done at median third-look laparotomy, median 5days postoperative. Re-laparotomies after mesh implantation (median n = 2) revealed anastomotic leakage in 16% but no new bowel fistula. In 40% of those patients who had mesh implantation, fascia closure was not achieved and the mesh was left in place in a bridging position avoiding planned ventral hernia. The application of an anti-adhesive PVDF mesh for fascia traction in vacuum-assisted wound closure of septic open abdomen is novel, versatile, and seems to be safe. It offers the highly relevant possibility for provisional and final abdominal closure.

An evaluation of the effect of ertapenem in rats with sepsis created by cecal ligation and puncture.

Intra-abdominal adhesions are still a major problem which is expected to be reduced by the provision of bacterial decontamination. Various antibiotics have been used to prevent the formation of adhesion in the septic abdomen. This study aims to investigate the efficacy of ertapenem in sepsis of rats induced by cecal ligation and puncture. Twenty-eight Wistar rats were divided into four groups randomly. In all groups, bacterial peritonitis was created by cecal ligation and puncture method. Group 1 was considered as sham group. Groups 2, 3 and 4 were given, respectively, saline, a single dose of ertapenem and a dose of ertapenem intraperitoneally every day. Intra-abdominal adhesions were assessed seven days after surgery by histopathological examination. Microbiological examination was performed through the ascites obtained. TNF-α was measured from blood taken from rats. Adhesion score decreased significantly by the application of ertapenem (p<0.001) and fibrosis scores were found to be significantly lower (p=0.005). Among all groups, the relationship between the decrease in the number of colonies and antibiotics application was not statistically significant (p=0.109). No statistically significant difference was found between the group given a single dose of ertapenem and the group given multiple ertapenem (p=1). Peritoneal lavage with ertapenem appears to be effective in preventing the adhesion in the septic abdomen. As no difference was detected at the end of a single dose and multiple-dose administration of antibiotics in the adhesion scores, a single dose after surgery seems to be enough. The findings suggest that the results should be evaluated in a clinical trial.

Negative Pressure Therapy with Intraperitoneal Saline Instillation in the Open Septic Abdomen

Negative Pressure Therapy with Intraperitoneal Saline Instillation in the Open Septic Abdomen

Retrospective evaluation of concurrent intra-abdominal injuries in dogs with traumatic pelvic fractures: 83 cases (2008-2013).

To report the occurrence of intra-abdominal injury (IA) in dogs with pelvic fractures due to blunt trauma, to evaluate for association between characterization of pelvic fractures and the presence of IA, and to evaluate for association between IA and other specific clinical conditions. Retrospective case series (2008-2013). University teaching hospital. Eighty-three client-owned dogs with pelvic fractures due to blunt trauma. None. Pelvic injuries included pubic fractures (90.4%), ischial fractures (80.7%), sacroiliac luxations (57.8%), iliac fractures (43.4%), acetabular fractures (30.1%), and sacral fractures (13.3%). Thirty-one dogs (37%) had IA, which included hemoabdomen (27 dogs), uroabdomen (3), and septic abdomen (3); 2 dogs had 2 types of IA. Dogs with sacral fractures were significantly more likely to have IA than dogs without sacral fractures (P = 0.0162). Characterization of pelvic fractures included the direction of compression, presence of a weight-bearing bone fracture, and degree of pelvic narrowing, none of which had an association with IA (P > 0.05). Dogs were more likely to have IA if they had cardiac dysrhythmia (P = 0.0002) or hematuria (P = 0.0001), and were more likely to have a hemoabdomen if they had cardiac dysrhythmia (P = 0.0005). Dogs with hematochezia were more likely to have a septic abdomen (P = 0.0123). Dogs were more likely to receive a transfusion if they had AI (P = 0.033) or hemoabdomen specifically (P = 0.0033). Overall survival to discharge was 89%, which was significantly greater than survival in dogs with pelvic injury that also had septic abdomen (33%; P = 0.0299). IA is common in dogs with pelvic fractures, especially those with sacral fractures. Pelvic fracture characterization had no bearing on the presence of IA.

Incidence and risk factors of abdominal surgical site infection in a Nigerian Tertiary Health care centre

This study aims to determine the incidence of and identify the risk factors responsible for surgical site infection (SSI) following laparotomies in adult patients in a Nigerian tertiary care facility. This is a prospective study carried out between January and December 2012. Wound assessment was done using standardized criteria stipulated by the Centres for Disease Control and Prevention. There were 291 patients during the study period, out of which 223 met the inclusion criteria: 157 (70.4%) males and 66 (29.6%) females. Surgical site infection was diagnosed in 85 patients giving an incidence rate of 38.1%. Identified risk factors for SSI include anaemia, contaminated and dirty wounds, retroviral disease status, physiological status (ASA scores IV and V), prolonged surgery time, cadre of surgeon, emergency surgeries and use of drains. The high incidence of SSI observed in this study was found more in patients that presented with septic abdomen and those that had large bowel procedures. Paying close attention to identified risk factors will reduce the burden of SSI.

Incidence and risk factors of abdominal surgical site infection in a Nigerian Tertiary Health care centre

This study aims to determine the incidence of and identify the risk factors responsible for surgical site infection (SSI) following laparotomies in adult patients in a Nigerian tertiary care facility. This is a prospective study carried out between January and December 2012. Wound assessment was done using standardized criteria stipulated by the Centres for Disease Control and Prevention. There were 291 patients during the study period, out of which 223 met the inclusion criteria: 157 (70.4%) males and 66 (29.6%) females. Surgical site infection was diagnosed in 85 patients giving an incidence rate of 38.1%. Identified risk factors for SSI include anaemia, contaminated and dirty wounds, retroviral disease status, physiological status (ASA scores IV and V), prolonged surgery time, cadre of surgeon, emergency surgeries and use of drains. The high incidence of SSI observed in this study was found more in patients that presented with septic abdomen and those that had large bowel procedures. Paying close attention to identified risk factors will reduce the burden of SSI.

Emergency management of the septic abdomen: part 2

The septic abdomen is an acute emergency where bacterial contamination of the peritoneum can cause profound systemic signs requiring immediate intervention. Techniques for diagnosing septic peritonitis, and appropriate stabilisation prior to surgery were discussed in the first part of this two-part series (Companion animal (2014) 19(5): 263–8). This second article concentrates on the surgical and postoperative aspects of managing this condition. It is easy to forget about postoperative management while performing any emergency surgery, but both aspects are of equally high importance, and good postoperative management strategies can make a significant difference to the survival of these patients.

Emergency management of the septic abdomen: part 1

The septic abdomen is a veritable acute emergency where bacterial contamination of the peritoneum can cause profound systemic signs requiring immediate intervention. Assessing the underlying cause and degree of systemic compromise is imperative in the early stages of managing this condition and goes a long way to creating a treatment plan. This article, the first in a two-part series, discusses how to rapidly stabilise these patients while simultaneously performing focused diagnostic investigations on which decisions for surgical intervention can be made. Surgical and postoperative aspects of the septic abdomen will be discussed in part two.

Damage control surgery/laparostomy in nontrauma emergency abdominal surgery: A new concept of care

Introduction: The established success of damage control surgery (DCS) in trauma of torso motivates surgeon to apply similar concept in managing complicated intra-abdominal sepsis. The main objective of this study is to audit our new practice of such in nontrauma emergency abdominal surgery. Materials and Methods: We retrospectively reviewed all emergency abdominal surgeries (nontrauma) done from February 2013 to February 2014. All patients who had damage control procedures done for complicated intra-abdominal sepsis were analyzed. Results: A total of 60 patients were operated within that period. Six patients (10%) had undergone DCS with or without laparostomy. All were male with mean age of 48.5-year-old (26-61-years-old). Most were in ASA 3 (83%, 5 patients) with only one in ASA 4. Primary indications were ischemic bowel with mesenteric vein thrombosis (3 patients, 50%), abdominal compartment syndrome (ACS), bleeding post near total splenectomy for splenic abscess and gangrenous proctitis with purulent peritonitis. Nearly, all patients (5 patients, 83.3%) were severely acidotic with pH <7.2 intra-operatively, which triggered the DCS. Nevertheless, only 3 patients (50%) benefited from laparostomy and all of them achieved complete fascial closure within 2.6 days (mean). Their mean total Intensive Care Unit (ICU) stay was 15 days (9-32 days). Overall predicted mean Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity mortality rate was 51%. However, the observed (actual) mortality rate was only 33% (2 patients). Conclusion: The result of the practice of DCS in the septic abdomen is very encouraging. It appears able to reduce the mortality by 35%. A comparative analysis with larger series is therefore warranted to further confirm the findings.

VAWCM-Instillation Improves Delayed Primary Fascial Closure of Open Septic Abdomen.

Background. Failure to achieve delayed primary fascial closure (DPFC) is one of the main complications of open abdomen (OA), certainly when abdominal sepsis is present. This retrospective cohort study aims to evaluate the effect of combined therapy of vacuum-assisted mesh-mediated fascial traction and topical instillation (VAWCM-instillation) on DPFC in the open septic abdomen. Methods. The patients with abdominal sepsis who underwent OA using VAWCM were included and divided into the instillation and noninstillation (control) groups. The DPFC rate and other outcomes were compared between the two groups. Results. Between 2007 and 2013, 73 patients with open septic abdomen were treated with VAWCM-instillation and 61 cases with VAWCM-only. The DPFC rate in the instillation group was significantly increased (63% versus 41%, P = 0.011). The mortality with OA was similar (24.6% versus 23%, P = 0.817) between the two groups. However, time to DPFC (P = 0.003) and length of stay in hospital (P = 0.022) of the survivals were significantly decreased in the instillation group. In addition, VAWCM-instillation (OR 1.453, 95% CI 1.222–4.927, P = 0.011) was an independent influencing factor related to successful DPFC. Conclusions. VAWCM-instillation could improve the DPFC rate but could not decrease the mortality in the patients with open septic abdomen.

Effect of Antibiotic Lavage in Adhesion Prevention in Bacterial Peritonitis.

Intra-abdominal adhesions remain a major clinical problem. Previously, rifamycin lavage was used to prevent adhesion formation in the septic abdomen. The aim of our study was to test the effectiveness of intraperitoneal application of alternate antibiotics in an abdominal sepsis model. Sixty Wistar-albino rats were randomly divided into 6 equal groups. Bacterial peritonitis was induced using caecal ligation and puncture model in all groups. Group 1 was an untreated control. The peritoneum was lavaged with isotonic saline in Group 2, with imipenem in Group 3, with ceftriaxone in Group 4, with cefazolin in group 5 and with metronidazole in group 6. Four weeks after the surgery, intra-abdominal adhesions were graded, tensile strength of the adhesions was measured and histopathological examinations were performed. Imipenem, ceftriaxone and cefazolin significantly reduced adhesion formation (p<0.001) with significantly reduced fibrosis scores (p=0.013). Adhesion formation was greatest in the metronidazole treatment group. The breaking force of adhesions was significantly reduced in Groups 4 and 5 (p<0.001). Although, the inflammation scores were similar between groups (p=0.058), grade 3 inflammation scores were only seen in control, saline and metronidazole-treatment groups. According to these data, cephalosporins may be effective in preventing adhesion formation in septic abdomens. These antibiotics need to be evaluated in a clinical trial.

The Value of Vacuum-Assisted Closure in Septic Patients Treated with Laparostomy

The ideal method of temporary abdominal closure (TAC) should allow rapid closure, easy maintenance, and wound repair with minimal tissue damage. The aim of this retrospective study is to compare open abdomen outcomes between patients managed with vacuum-assisted closure (VAC), and patients managed with other methods of TAC, when septic abdomen is present. Two groups of patients with septic open abdomen: 27 treated with VAC versus 31 treated with other techniques of TAC. We studied open abdomen duration, number of dressing changes, re-exploration rate, successful abdominal closure rate, overall mortality, and development of enteroatmospheric fistulas. The VAC device demonstrated its superiority concerning open abdomen duration (P < 0.001), number of dressing changes (P < 0.001), re-exploration rate (P < 0.002), successful abdominal closure rate (P < 0.0001), and development of enteroatmospheric fistulas (P < 0.00001). Compared with other methods of TAC, our experience with the VAC device demonstrated its advantages concerning clinical feasibility. The high rates of direct fascia closure with an acceptable rate of ventral hernias are further benefits of this technique.

Damage control surgery: it's evolution over the last 20 years

In less than twenty years, what began as a concept for the treatment of exsanguinating truncal trauma patients has become the primary treatment model for numerous emergent, life threatening surgical conditions incapable of tolerating traditional methods. Its core concepts are relative straightforward and simple in nature: first, proper identification of the patient who is in need of following this paradigm; second, truncation of the initial surgical procedure to the minimal necessary operation; third, aggressive, focused resuscitation in the intensive care unit; fourth, definitive care only once the patient is optimized to tolerate the procedure. These simple underlying principles can be molded to a variety of emergencies, from its original application in combined major vascular and visceral trauma to the septic abdomen and orthopedics. A host of new resuscitation strategies and technologies have been developed over the past two decades, from permissive hypotension and damage control resuscitation to advanced ventilators and hemostatic agents, which have allowed for a more focused resuscitation, allowing some of the morbidity of this model to be reduced. The combination of the simple, malleable paradigm along with better understanding of resuscitation has proven to be a potent blend. As such, what was once an almost lethal injury (combined vascular and visceral injury) has become a survivable one.