Septic Abdomen Research Articles

Role Of Laprostomy In Septic Abdomen Cases

Abstract: Background: The fundamental principles of management of severe peritonitis include general supportive management, antibiotic therapy, and prompt surgical intervention. Surgical intervention includes source control, peritoneal toileting, and Prevention of recurrent infection. The definitive closure of the abdominal wall, i.e., a closure of the fascial layer and skin may not be favourable in the treatment of numerous surgical conditions, e. g., peritonitis, trauma, or mesenteric ischemia. In these cases, the abdominal wall is temporarily closed. And a Laprostomy is created to facilitate re-exploration or to prevent abdominal compartment syndrome. Objectives: To study the role of laprostomy in septic abdomen cases and to evaluate the importance of laprostomy in septic abdomen cases in rural hospital setup.Methods: Patients admitted with severe peritonitis where managed with prompt surgical intervention, 25 cases abdomen wall has been closed primarily and other group 25cases had undergone laprostomy, patients has been monitored post operatively and assessed by APACHE II. Results: Laprostomy patients had greater postoperative recovery and decrease in septicaemia when compared to primary closure. Conclusion: Laprostomy facilitates re-intervention, Prevents and treats persistent / recurrent infections, Avoids increased intra-abdominal pressure. Lastly, the risk of abdominal compartment syndrome is virtually eliminated. Background: The fundamental principles of management of severe peritonitis include general supportive management, antibiotic therapy, and prompt surgical intervention. Surgical intervention includes source control, peritoneal toileting, and Prevention of recurrent infection. The definitive closure of the abdominal wall, i.e., a closure of the fascial layer and skin may not be favourable in the treatment of numerous surgical conditions, e. g., peritonitis, trauma, or mesenteric ischemia. In these cases, the abdominal wall is temporarily closed. And a Laprostomy is created to facilitate re-exploration or to prevent abdominal compartment syndrome. Objectives: To study the role of laprostomy in septic abdomen cases and to evaluate the importance of laprostomy in septic abdomen cases in rural hospital setup.Methods: Patients admitted with severe peritonitis where managed with prompt surgical intervention, 25 cases abdomen wall has been closed primarily and other group 25cases had undergone laprostomy, patients has been monitored post operatively and assessed by APACHE II. Results: Laprostomy patients had greater postoperative recovery and decrease in septicaemia when compared to primary closure. Conclusion: Laprostomy facilitates re-intervention, Prevents and treats persistent / recurrent infections, Avoids increased intra-abdominal pressure. Lastly, the risk of abdominal compartment syndrome is virtually eliminated. INTRODUCTION The fundamental principles of management of severe peritonitis include general supportive management, antibiotic therapy, and prompt surgical intervention. Surgical intervention includes source control, peritoneal toileting, and Prevention of recurrent infection. The definitive closure of the abdominal wall, i.e., a closure of the fascial layer and skin may not be favourable in the treatment of numerous surgical conditions, e. g., peritonitis, trauma, or mesenteric ischemia. In these cases, the abdominal wall is temporarily closed. And a Laprostomy is created to facilitate reexploration or to prevent abdominal compartment syndrome. It is defined as the sudden increase in the intra-abdominal pressure to more than 25cm of water resulting in alteration in the respiratory mechanism, hemodynamic parameters, and renal as well as cerebral perfusion. Severe intra-abdominal sepsis requires Laprostomy and at least ventilator and cardiovascular support. The “open” abdomen has gained popularity in the management of severe intraabdominal sepsis. Drawbacks include evisceration, need for ventilator support, and recurrent abdominal sepsis. We have applied a more aggressive and effective technique consisting of abdominal “closure” with a sheetmade of medical grade soft and transparent PVC sheet (urobag). Temporary abdominal closure using this method is an inexpensivesimple method, permitting evaluation of underlying viscera and recognition of infection and prevention of abdominal compartment syndrome. METHODS Fifty patients (30males,20females,mean age 52.8years – range24 to 80 years) with secondary peritonitis were surgically treated.25 patients were managed with primary closure of the abdomen and the other 25 patients were managed with closed laprostomy with a soft sheet made of medical grade transparent PVC sheet(urobag), sterilised by ETO gas. Post operatively patients were assessed by APACHE II.The outcomes and effectiveness were analysed retrospectively between primary closure and laprostomy patients. The role of laprostomy-need for relook, peritoneal toileting and its merits, demerits were assessed in rural hospital setup. Period of study: one year. Role Of Laprostomy In Septic Abdomen Cases 2 of 6 Approval obtained from Ethical committee. Inclusion criteria: all age group, all secondary peritonitis cases. Exclusion criteria: primary peritonitis, severe co-morbid conditions.

Use of porcine dermal collagen graft and topical negative pressure on infected open abdominal wounds.

This article reports on two cases in which porcine dermal collagen grafts were used successfully alongside topical negative pressure therapy in order to close open abdominal wounds in which severe infection was present.

Systemic Peritoneal Cavity Lavage: a New Strategy for Treatment of the Open Septic Abdomen

Introduction: Management of the open abdomen is a challenge, certainly when fistulisation is present. This paper presents a new treatment modality for this specific situation.Methods: Abdominal sepsis increases the net flow across the peritoneum to 300–500 ml/h. This flow was used to clean and flush the abdomen. Meropenem was administered, as antibiotic concentration in the peritoneal cavity is known to reach therapeutic levels after 8 hours. The abdominal fluid was captured using the abdominal VAC system and additional drains. The total amount of drained fluid was compensated intravenously. Thus, the concept was named “Systemic Peritoneal Cavity Lavage” (SPCL).Results: Four patients with an open abdomen and severe abdominal sepsis were treated with SPCL and got out of their septic state within two weeks despite fistulisation and ongoing bowel leakage in three patients. A partial enterectomy with removal of the fistulas could be performed six weeks later.Conclusion: SPCL is a promising method to treat patients with severe abdominal sepsis. In combination with the fistula isolation technique it permits delayed treatment of fistulas in a hostile abdomen where immediate removal of the septic focus is impossible.

Proximal loop jejunostomy is a useful adjunct in the management of multiple intestinal suture lines in the septic abdomen

Bowel repair in the septic abdomen can be problematic. This study investigated the use of a proximal loop jejunostomy to protect injured or fistulated bowel that had been returned to the abdomen after repair and/or anastomosis. Ten patients who underwent laparotomy for intra-abdominal sepsis and/or fistulation, followed by distal enteric repair and/or anastomosis and construction of a proximal defunctioning loop jejunostomy, were studied retrospectively. Seven patients had 21 intestinal suture lines returned to the peritoneal cavity in the presence of intra-abdominal sepsis (14 anastomoses, two enterotomy closures and five serotomy repairs). Two patients had a difficult relaparotomy for pelvic abscess (two distal anastomoses, one enterotomy closure and three serotomy repairs). The final patient had pelvic sepsis and radiation enteritis; the distal anastomosis was defunctioned by a loop jejunostomy. The median distance from the duodenojejunal flexure to the loop stoma was 80 (range 30-170) cm. All jejunostomies were closed via a local approach, a median of 11 (range 9-18) months after formation. There was no significant postoperative morbidity and no postoperative death. At a median follow-up of 7 (range 0.5-56) months eight patients had no requirement for nutritional support. Use of a loop jejunostomy to protect suture lines in the septic abdomen justifies consideration of this procedure in selected patients.

Einsatzmöglichkeiten der Vakuumtherapie zur Therapie des septischen Abdomens

Progress in intensive care medicine contributed substantially in lowering the mortality rate of patients suffering from diffuse secondary peritonitis. In the medical care of patients presenting a septic abdomen the persisting septic focus is one of the greatest problems. This is associated with other problems like temporary closure of the abdomen, complications due to re-laparotomies, healing of the abdominal wall after soft tissue infection, loss of abdominal wall musculature, or persisting enteral fistulas. The vacuum therapy is used with increasing frequency for the treatment of septic complications in different areas of the body. The excellent drainage characteristics of the vacuum therapy appear to be a therapeutic option for the control of surgically untreatable septic processes in the abdominal cavity. More and more experience is gathered with the successful treatment of enterocutaneous fistulas, small intestine and pancreatic fistulas as well as anastomotic leakage after rectal surgery. There exist hardly any evidence-based recommendations for the application of vacuum therapy for treatment of the septic abdomen. But the good results of temporary closure of open abdomen of trauma patients by the vacuum therapy arises hope that the results can be transferred to the treatment modalities of persisting peritonitis. Additionally, these patients could profit from the drainage characteristics of the vacuum therapy.

Intra-operative peritoneal lavage – who does it and why?

Intra-operative peritoneal lavage (IOPL) is widely practised but its benefits are unclear. The frequency and pattern of its use amongst general surgeons is investigated. A postal questionnaire was sent to 153 general surgical consultants and registrars enquiring about their use of IOPL. The surgeon was asked the volume and type of lavage fluid used, under various circumstances. 118 (77%) questionnaires were returned. 115 (97%) surgeons used IOPL. The majority of surgeons (61%) lavaged until the fluid was clear, 20% used more than 1 l and 17% used between 500-1000 ml. In the case of the dirty abdomen (i.e. gross pus or faecal peritonitis), 47% used saline as the lavage fluid, 38% aqueous betadine, 9% water and 3% antibiotic lavage. Similar results were found in the case of a contaminated abdomen (i.e. a breached hollow viscus). 34% of surgeons used IOPL during clean cases. 36% used water lavage during intra-abdominal cancer surgery; 21% lavaged with saline and 17% with betadine. More registrars (47%) than consultants (29%) lavaged with water during cancer surgery. Consultants, however, used more aqueous betadine. The frequency of use and choice of lavage fluid varies widely. The successful management of the septic abdomen rests on at least 3 tenants - systemic antibiotics, control of the source of infection and aspiration of gross contaminants. There is little good evidence in the literature to support IOPL in the management of the septic abdomen. The use of IOPL during cancer surgery is supported by in vitro evidence. The current use of IOPL, as shown by this study, appears not to be evidence based.

Evaluation of prosthetic mesh closure in semiopen-abdomen patients.

To avoid the adverse consequences of abdominal compartment syndrome and to reduce the high mortality the celiotomy wound in patients with abdominal sepsis was closed without tension using prosthetic mesh. This produces a semiopen situation that permits staged reinterventions together with the functional reconstitution of the continuity of the abdominal wall. Twenty-five patients with intra-abdominal sepsis of various causes were evaluated retrospectively to assess the results of semiopen management of the septic abdomen and reoperations on demand in severe peritonitis. All of the patients were in a state of neglected peritonitis, and had at least one failing organ system. The Mannheim Peritonitis Index (MPI) scoring system was used for stratification of abdominal sepsis. The mean MPI score of 25 patients was 24, ranging 10 to 33. Eight (32%) patients were reexplored (MPI=21). There were overall 9 (36%) complications in patients with mean MPI score of 23. Six (24%) mesh-related complications (infection and enterocutaneous fistulas) developed (MPI=19). The mean MPI score of patients without complications was 24. Four (16%) patients died with index MPI score of 26 due to fulminant hepatitis, myocardial infarction, and multiple organ failure. The admission period averaged 63 days. In 25 critically ill patients with abdominal sepsis the mortality was lower than expected, relative to heterogeneous data from the literature; also, major complications occurred less frequently although the mean MPI score was high. The authors conclude that this approach is a reliable contribution to the complex treatment of these patients.

Intestinal Fistulas and the Open Management of the Septic Abdomen

<i>To the Editor</i>.—In the June 1989 issue of theArchives, Mastboom et al¹described what they call "noniatrogenic" small-bowel perforations of "unknown or uncertain" cause, which developed in 14 patients treated by open treatment who underwent 3 to 17 laparotomies, and claim that the "occurrence of intestinal perforation during open treatment has not been described so far." In fact, the article by Mastboom et al deals with a well-known and documented entity. Intestinal fistulas commonly develop in the frequently laparotomized abdomen due to the repeated mobilization and separation of bowel involved in the obliterative process. Commonly, the end result of repeated explorations is an abdominal-wall defect with multiple intestinal fistulas in its base. SitgesSerra et al²pointed out the poor prognosis of this entity, which in their experience carried a mortality rate of 60%. Levy et al³reported 120 cases of "exposed" intestinal fistulas opening into

SEQUENTIAL LAPAROTOMY AND ZIPPER CLOSURE IN THE MANAGEMENT OF GROSS PERIPANCREATIC SEPSIS

Four cases of gross peripancreatic sepsis have been managed with repeated laparotomies and packing of the lesser sac. A zipper was used for abdominal closure in three patients and the abdomen was left open in one. Sequential laparotomy enabled repeated debridement of non-viable pancreatic and peripancreatic tissue and prevented intra-abdominal septic accumulations. An additional benefit of this technique was the frequent detection and correction of clinically unsuspected complications of the septic abdomen.

Open Management for Severe Septic Abdomen

Open Management for Severe Septic Abdomen

Open management of the septic abdomen: therapeutic and prognostic considerations based on APACHE II.

We analyzed the results of open treatment in 30 patients with abdominal sepsis (11 patients after trauma [group 1], five patients with pancreatic abscess [group 2], and 14 patients with acute GI pathology [group 3]) uncontrolled by conventional methods as evidenced by continuing fever with leukocytosis and worsening organ functions. APACHE scores at the time of initial laparotomy and at the time of open management, respectively, were: group 1, 19.8 and 16.6; group 2, 8.4 and 12.4; and group 3, 14.2 and 15.0. Twenty-seven patients had multiple system failure. Sixteen (53%) of the 30 patients survived, 73% in group 1, 60% in group 2, and 36% in group 3. Survival correlated well with age less than 50 yr and the absence of multiple organ failure. The technique was easily performed and many of the pitfalls previously reported were not observed. In patients requiring fascial prosthesis, the absorbable polyglycol acid (Dexon) mesh was found to be superior to the nonabsorbable polypropylene. We conclude that the open technique is feasible, effective, and worthy of consideration in patients with extensive wound necrosis and uncontrolled abdominal sepsis.

The Open Abdomen: The Marlex Mesh and Zipper Technique: A Method of Managing Intraperitoneal Infection

In conclusion, a zipper technique has been outlined that allows effective continuing drainage of the septic abdomen, permits early diagnosis of organ damage, is rapid and cost effective, minimizes ventilator dependency and gastrointestinal complications, is well tolerated by the patients, and has produced a modest 65 per cent survival rate in the first 34 critically ill patients in whom it was used. Selection of patients is critical. It is a technique that must not be undertaken lightly but that appears to have life-saving potential.

Open Management of the Septic Abdomen

The mortality rate of severe intra-abdominal infections is still very high. The open management of the abdomen is a method of treatment which has gained popularity over the past few years. Its advantages include a better drainage of the peritoneal cavity, a greater protection of the parietes, an improved perfusion of the abdominal viscera and a decrease in postoperative pulmonary complications. It is indicated in patients with severe intra-abdominal sepsis, especially when multiple re-explorations of the abdomen are likely. A variety of techniques, including the use of Marlex mesh have been devised to contend with possible complications: spontaneous fistulas, exogenous bacterial contamination, evisceration and massive fluid losses. The open method of management has not made the treatment of septic abdomen much easier; it requires intensive care support and repeated assessment of the peritoneal cavity. The closure of the abdomen is a problem which must be addressed when the sepsis has subsided. The value of this technique is still difficult to assess in the absence of controlled randomized trials.

The septic abdomen: open management with Marlex mesh with a zipper.

The "open" abdomen has gained popularity in the management of severe intraabdominal sepsis. Drawbacks include evisceration, need for ventilator support, and recurrent abdominal sepsis. We have applied a more aggressive and effective technique consisting of abdominal "closure" with a Marlex mesh sheet containing a zipper. Manual exploration and lavage is performed daily through the zipper in the surgical intensive care unit. Ten patients with severe abdominal sepsis were treated for the following: fecal peritonitis (three patients), radiation enteritis with fistula (one patient), diverticular abscess and dehiscence (one patient), diffuse postoperative abdominal sepsis (two patients), and necrotizing pancreatitis (three patients). Thirteen meshes were inserted, four at first operation and nine at the second to sixth operations. Eight patients survived (80%). Only three patients required respirators; two died. Two patients underwent drainage of three defined abscesses in the surgical intensive care unit. Three patients underwent five major operations through the zipper. Intestinal stomas were present adjacent to the mesh in six patients and were not a management problem. No fistulas resulted from this technique. The Marlex/zipper was removed when all septic signs abated and adhesions were allowed to form (average of 10 to 12 days). Daily aggressive manual lavage of the abdomen through a Marlex mesh/zipper is rapid, simple, and well tolerated. It has permitted effective management of severe septic peritonitis and easier wound care. This technique merits further controlled trials to ascertain its ultimate benefit in survival.