Abdominal negative-pressure therapy : A new method in countering abdominal compartment and peritonitis - prospective study and critical review of literature

Publisher Copyright: © 2012 Plaudis et al.Background: Application of abdominal negative-pressure therapy (NPT) is lifesaving when conservative measures fail to reduce sustained increase of the intra-abdominal pressure and it is impossible to achieve source control in a single operation due to severe peritonitis. The aim of this study is to share the initial experience with abdominal NPT in Latvia and provide a review of the relevant literature. Methods: In total, 22 patients were included. All patients were treated with KCI® ABThera™ NPT systems. Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission, daily sequential organ failure assessment score and Mannheim peritonitis index (MPI) were calculated for severity definition. The frequency of NPT system changes, daily amount of aspirated fluid effluent and the time of abdominal closure were assessed. The overall hospital and ICU stay, as well as the outcomes and the complication rate, were analysed. Results: A complicated intra-abdominal infection was treated in 18 patients. Abdominal compartment syndrome due to severe acute pancreatitis (SAP), secondary ileus and damage control in polytrauma were indications for NPT in four patients. The median age of the patients was 59 years (range, 28 to 81), median APACHE II score was 15 points (range, 9 to 32) and median MPI was 28 points (range, 21 to 40), indicating a prognostic mortality risk of 60%. Sepsis developed in all patients, and in 20 of them, it was severe. NPT systems were changed on a median of every 4 days, and abdominal closure was feasible on the seventh postoperative day without needing a repeated laparotomy. Two NPT systems were removed due to bleeding from the retroperitoneal space in patients with SAP. Intestinal fistulae developed in three patients that were successfully treated conservatively. Incisional hernia occurred in three patients. The overall ICU and hospital stay were 14 (range, 5 to 56) and 25 days (range, 10 to 87), respectively. Only one patient died, contributing to the overall mortality of 4.5%. Conclusions: Application of abdominal NPT could be a very promising technique for the control of sustained intra-abdominal hypertension and management of severe sepsis due to purulent peritonitis. Further trials are justified for a detailed evaluation of abdominal NPT indications.publishersversionPeer reviewe

Ultrasound-Assisted Focused Open Necrosectomy in the Treatment of Necrotizing Pancreatitis

Publisher Copyright: © 2015, JOP. J Pancreas (Online). All rights reserved.Introduction The surgical treatment of necrotizing pancreatitis includes percutaneous drainage of acute necrotic collections and sequestrectomy in the late phase of the disease. The aim of the study was to compare the conventional open necrosectomy (CON) approach with the alternative focused open necrosectomy (FON) approach in patients with infected necrosis and progression of sepsis. Methods Patients with acute necrotizing pancreatitis were included in the study prospectively from January 2004 to July 2014. All patients had been admitted with the first or a new episode of disease. Symptomatic large fluid collections were drained percutaneously. The step-up approach was used in patients with several distant localizations of infected necrosis. The methods were analysed by comparing the individual severity according to the ASA, APACHE II and SOFA scores, infection rate, postoperative complication rate and mortality. Results A total of 31 patients were included in the FON group and 39 in the CON group. The incidence of infection was similar in groups. More ASA III comorbid conditions, a higher APACHE II score, a more frequent need for renal replacement therapy was observed in the CON group. The postoperative complication rate was in the range of 32% to 44%; mortality reached 6.5% in the FON group and 12.8% in the CON group. Conclusions Comorbid conditions, organ failure, and infection are the main risk factors in patients with necrotizing pancreatitis. The step-up approach and perioperative ultrasonography navigation improves the clinical outcome and reduces the extent of invasive surgical intervention in patients unsuited to other minimally invasive procedures.publishersversionPeer reviewe

Focused open necrosectomy in necrotizing pancreatitis

AbstractBackgroundThe control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with a focused open necrosectomy (FON) in patients with infected necrosis.MethodA prospective pilot study conducted to compare a semi‐open/closed drainage laparotomy and FON with the assistance of peri‐operative ultrasound. The incidence of sepsis, dynamics of C‐reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed.ResultsFrom a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post‐operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139.DiscussionFON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis

Endoscopic hemostasis followed by preventive transarterial embolization in high-risk patients with bleeding peptic ulcer : 5-year experience

Publisher Copyright: © 2019 The Author(s).Background: Upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease is one of the leading causes of death in patients with non-variceal bleeding, resulting in up to 10% mortality rate, and the patient group at high risk of rebleeding (Forrest IA, IB, and IIA) often requires additional therapy after endoscopic hemostasis. Preventive transarterial embolization (P-TAE) after endoscopic hemostasis was introduced in our institution in 2014. The aim of the study is an assessment of the intermediate results of P-TAE following primary endoscopic hemostasis in patients with serious comorbid conditions and high risk of rebleeding. Methods: During the period from 2014 to 2018, a total of 399 patients referred to our institution with a bleeding peptic ulcer, classified as type Forrest IA, IB, or IIA with the Rockall score ≥ 5, after endoscopic hemostasis was prospectively included in two groups-P-TAE group and control group, where endoscopy alone (EA) was performed. The P-TAE patients underwent flow-reducing left gastric artery or gastroduodenal artery embolization according to the ulcer type. The rebleeding rate, complications, frequency of surgical interventions, transfused packed red blood cells (PRBC), amount of fresh frozen plasma (FFP), and mortality rate were analyzed. Results: From 738 patients with a bleeding peptic ulcer, 399 were at high risk for rebleeding after endoscopic hemostasis. From this cohort, 58 patients underwent P-TAE, and 341 were allocated to the EA. A significantly lower rebleeding rate was observed in the P-TAE group, 3.4% vs. 16.2% in the EA group; p = 0.005. The need for surgical intervention reached 10.3% vs. 20.6% in the P-TAE and EA groups accordingly; p = 0.065. Patients that underwent P-TAE required less FFP, 1.3 unit vs. 2.6 units in EA; p = 0.0001. The mortality rate was similar in groups with a tendency to decrease in the P-TAE group, 5.7% vs. 8.5% in EA; p = 0.417. Conclusion: P-TAE is a feasible and safe procedure, and it may reduce the rebleeding rate and the need for surgical intervention in patients with a bleeding peptic ulcer when the rebleeding risk remains high after primary endoscopic hemostasis.publishersversionPeer reviewe

Preventive transarterial embolization in upper nonvariceal gastrointestinal bleeding

Publisher Copyright: © 2017 The Author(s).Background: Transarterial embolization (TAE) is a therapeutic option for patients with a high risk of recurrent bleeding after endoscopic haemostasis. The aim of our prospective study was a preliminary assessment of the safety, efficacy, and clinical outcomes following preventive TAE in patients with non-variceal acute upper gastrointestinal bleeding (NVUGIB) with a high risk of recurrent bleeding after endoscopic haemostasis. Methods: Preventive visceral angiography and TAE were performed after endoscopic haemostasis on patients with NVUGIB who were at a high risk of recurrent bleeding (PE+ group). The comparison group consisted of similar patients who only underwent endoscopic haemostasis, without preventive TAE (PE- group). The technical success of preventive TAE, the completeness of haemostasis, the incidence of rebleeding and the need for surgical intervention and the main outcomes were compared between the groups. Results: The PE+ group consisted of 25 patients, and the PE- group of 50 patients, similar in age (median age 66 vs. 63 years), gender and comorbid conditions. The ulcer size at endoscopy was not significantly different (median of 152 mm vs. 127 mm). The most frequent were Forest II type ulcers, 44% in both groups. The distribution of the Forest grade was even. The median haemoglobin on admission was 8, 2 g/dl vs. 8,7 g/dl, p = 0,482, erythrocyte count was 2,7 × 1012/L vs. 2,9 × 1012/L, p = 0,727. The shock index and Rockall scores were similar, as well as and transfusion - on average, four units of packed red blood cells for the majority of patients in both groups, however, significantly more fresh frozen plasma was transfused in the PE- group, p = 0,013. The rebleeding rate was similar, while surgical treatment was needed notably more often in the PE- group, 8% vs. 35% accordingly, p = 0,012. The median ICU stay was 3 days, hospital stay - 6 days vs. 9 days, p = 0.079. The overall mortality reached 20%; in the PE+ group it was 4%, not reaching a statistically significant difference. Conclusion: Preventive TAE is a feasible, safe and effective minimally invasive type of haemostasis decreasing the risk of repeated bleeding and preparing the patient for the definitive surgical intervention when indicated.publishersversionPeer reviewe

Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion

Abstract Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The “surgeon champion” can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.https://deepblue.lib.umich.edu/bitstream/2027.42/145433/1/13017_2018_Article_198.pd

The management of intra-abdominal infections from a global perspective : 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.Peer reviewe

The Global Alliance for Infections in Surgery : defining a model for antimicrobial stewardship-results from an international cross-sectional survey

Background: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. Methods: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. Results: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p <0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). Conclusion: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.Peer reviewe

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs