Mode of surgery completion in peritonitis

1310 patients with various forms of peritonitis were operated during 1989-1998. The tactics of the treatment was determined depending on bacterial contamination of the abdominal cavity. In abscesses of the abdominal cavity with massive bacterial contamination (6-7 CFU/g) drainage procedure was used. Mortality rate made up 4.8%. In local extended and diffuse peritonitis with a slight bacterial contamination of the abdominal cavity (3-5 CFU/g) and in absence of fibrinous deposition fixed on peritoneum, the drainage of the abdominal cavity was not used, and laparoscopy was performed in postoperative period for the control of the course of infectious process. Mortality rate was 0.6%. In extended peritonitis with massive bacterial contamination (6-8 CFU/g) the method of repeated explorations and sanitations of the abdominal cavity was used, mortality rate being 17.8%. The overall lethality made up 7.8%. Postoperative wound infection occurred in 6.7%, intraabdominal infection as abscesses or progressing peritonitis--in 2.1% of cases.     

Surgical tactics in anaerobic non-clostridial peritonitis

Under observation there were 128 patients with neclostridial peritonitis (NP) which made up 19.3% of the total number of patients with peritonitis. In spreaded NP when the source of NP was successfully eliminated and fibrinous layers on the peritoneum the laparotomy wound was tightly sutured up to the aponeurosis (included), primary delayed sutures were put on the skin. When it was impossible to completely remove all the fibrin from the peritoneum, the wound was sutured through all the layers, the sutures were tied in bows followed by numerous revisions of the abdominal cavity. Laparotomy was performed in postoperative NP with phlegmons of the abdominal cavity. The use of the tactics described allowed lethality to be reduced from 39.4% to 13.7%.     

Postoperative complications in patients with peritonitis

One thousand three hundred and ten patients with peritonitis have undergone surgery: local limited peritonitis was in 230 patients, local unlimited--in 342, general--in 738 patients. After surgery suppuration of the wound was seen in 92 (7.1%) patients, phlegmons of the abdominal wall--in 16 (1.3%), progressive peritonitis--in 40 (3.1%), abscesses of abdominal cavity--in 13 (1.0%), eventration--in 19 (1.5%), adhesive intestinal obstruction--in 17 (1.3%). Laparoscopy was used for diagnosis of intraabdominal complications in 47 patients. This allowed to avoid unjustified laparotomies in 20 patients. Application of laparoscopy is limited by degree of bacterial contamination of peritoneal exudates. Early adhesive intestinal obstruction in 7 patients was treated with endoscopic procedure. Sonography is effective in diagnosis of intraabdominal complications, detection of site of safe puncture before postoperative laparoscopy and drainage of abscesses.     

Role of prolonged intraarterial catheter therapy in general peritonitis

The analyses of treatment results in 82 patients with general purulent peritonitis are presented. In these patients long-term intraarterial catheter therapy (IACT) was included in the complex of postoperative treatment after elimination of infection source. Postoperative peritonitis was in 66 patients, 52 patients of them underwent reoperations for persisting general peritonitis. Use of IACT promoted arrest of abdominal inflammatory process and polyorganic insufficiency due to high concentration of antibiotics in the affection focus, improvement of regional circulation, reduced number of postoperative complications and a sharp fall of lethality of 8.5%.     

Surgical aspects of the treatment of generalized peritonitis

Advantages and disadvantages of different methods of surgery termination at generalized peritonitis are discussed. Drainage of abdominal cavity can not guarantee adequate sanation. Disadvantages of peritoneal lavage exceed the clinical value of this method. Active influence on infectious process during postoperative period can be realized with laparostomy, programmed revisions and sanations of abdominal cavity. These methods lead to recovery of more 80% patients with generalized peritonitis. Laparoscopic sanation is effective when bacterial contamination of peritoneal exudation doesn't exceed 10(5) mb/g.     

New approaches to the treatment of postoperative peritonitis

A retrospective comparative analysis of results of surgical treatment of 245 patients with postoperative peritonitis was made. In 114 patients (control group) furacin was used for sanitation of the abdominal cavity, and in 131 patients (main group) sanitation of the abdominal cavity was performed with water-soluble antibacterial ointments. It was established that the proposed ointment sanitation of the abdominal cavity in combination with active surgical methods based on using programmed relaparotomy resulted in 24.1% lower lethality as compared with the traditional method of sanitation. The authors assert that under conditions of marked polyorganic insufficiency the method of programmed relaparotomy with the ointment sanitation of the abdominal cavity is not very effective while using this method before the development of systemic complications is the decisive factor of the favorable prognosis.     

Diagnosis and treatment of pancreatic peritonitis]

Results of diagnosis and treatment of 71 patients with general pancreatogenic peritonitis (7.3% of all patients with general peritonitis) are analyzed. The main diagnostic methods were ultrasound (100% cases), computed tomography (29.5%), laparoscopy (60%). Based on clinical, instrumental, bacteriologic and morphologic examinations primary and secondary pancreatogenic peritonitis are distinguished. Optimal policy of treatment depended on peritonitis forms. In primary (enzyme peritonitis) minimally invasive methods of treatment were used: laparoscopic drainage of abdominal cavity and bursa omentalis, therapeutic blockades etc. in secondary (bacterial) peritonitis wide laparotomy with sanations of abdominal cavity and minor bursa omentalis were used. Consecutive necrectomies and sequestrectomies were preferred (70.2%). Advantages of hemofiltration over other methods of efferent therapy are demonstrated. The above methods of treatment permitted to decrease postoperative lethality in secondary purulent pancreatogenic peritonitis from 68 to 44%.     

Abdominal compartment syndrome in urgent surgery

Results of measurement and monitoring of intraabdominal pressure at 288 patients treated for different abdominal diseases and trauma were analyzed. In early postoperative period the increase intraabdominal pressure to 10-15 mm Hg (I degree) was revealed at 161 (56.0%) patients, from 16 to 25 mm Hg (II degree)--at 95 (33.0%), from 25 to 35 mm Hg (III degree)--at 23 (8.0%), more 35 mm Hg (IV degree)--at 8 (2.7%) patients. When intraabdominal pressure decreased on 4-5 mm per day the prognosis was positive at 257 (89.2%) operated patients. Critical type regarded as compartment syndrome (III-IV degree) was diagnosed at 31 (10.8%) patients. Relaparotomy was performed at 23 (8.0%) patients with III degree hypertension, the lethal outcome was at 6 (26.1%) cases. Relaparotomy at 8 (2.7%) patients with IV degree hypertension was late, and all the outcomes at these patients were lethal. General lethality at compartment syndrome was 45.2%. It is concluded that monitoring of intraabdominal hypertension should be mandatory diagnostic method, and critical parameters of abdominal hypertension--absolute indication to repeated laparotomy and decompression of abdominal cavity.     

Prognosis of outcomes and choice of surgical strategies in general purulent peritonitis

A comparative analysis of the results of surgical treatment of 233 patients with general peritonitis of different etiology was carried out. It is demonstrated that Manheim's index of peritonitis (MIP) may be used not only for prognosis of outcome, but also as one of main criteria for programmed revisions and sanations of the abdominal cavity, and appliance of laparostomy. Combination of MIP with clinical and laboratory evaluation of endotoxicosis severity permits one to define objectively indications for early preventive methods of enteral and extraorganic detoxication. Differential approach to choice of treatment policy reduced postoperative lethality in general peritonitis from 24.4 to 15.8%.     

Modern approaches to the problem of temporary closure of the abdominal cavity

The literature data are adduced concerning the problem of the abdominal cavity temporary closure after performance of operative intervention in the enhanced intraabdominal pressure conditions, in particular in patients with diffuse peritonitis, extended abdominal wall defect, abdominal trauma and intestinal ischemia. Retrospective analysis of the treatment results was conducted in 35 patients with peritonitis and abdominal trauma, in whom the laparostomy method was applied in the clinic. The operations for the abdominal wall restoration or the operative wound edges approximation were performed under the intraabdominal pressure control. Application of the method of the abdominal cavity temporary closure in the treatment of severe forms of peritonitis have promoted the complications rate lowering, the treatment duration reduction and the patients quality of life improvement.     

The application of immobilized forms of sodium hypochlorite in complex treatment of diffuse purulent peritonitis

Complex examination and the following treatment of 380 patients with diffuse purulent peritonitis were analyzed. The patients were divided into 2 groups. The first group included 245 patients to whom the sanitization of the abdominal cavity used traditional antiseptics. The main group included 135 patients to whom the immobilized form of sodium hypochlorite in the carboxymethyl cellulose was introduced instead of aqueous solution. An original method of sanitization of the abdominal cavity allows 1.2-1.5 times decreased degree of endotoxicosis, 2-2.5 times improved the motor-evacuatory function of the intestine in different forms of treatment of peritonitis. In the main group of patients the number of postoperative complications was 10% less, lethality was 8.2% less.     

Characteristics of the course of peritonitis in relation to the degree of perforation of the gastrointestinal tract

An examination and treatment of 80 patients with general forms of peritonitis has shown that the course of the disease is greatly dependent on the character of the bacterial dissemination of the abdominal cavity. A microbiological examination has shown that in all the levels of perforation of the gastro-intestinal tract there are associations of various microorganisms. The most severe course of peritonitis is observed when caused by infection by colonic contents with prevailing anaerobic ++non-clostridial microflora in the exudate. The method of repeated revisions of the abdominal cavity should be used for these forms of peritonitis.     

Relaparotomy in abdominal injuries

Relaparotomies in the postoperative period were performed in 56 out of 529 patients (10,6%) operated upon for injuries of organs of the abdominal cavity. Twenty-two of them died. In most cases relaparotomies were caused by peritonitis, intraabdominal bleedings and abscesses.     

Diagnosis and treatment of the toxic syndrome in diffuse peritonitis

Based on an analysis of clinico-laboratory manifestations of intoxication in 202 patients with widespread forms of peritonitis the authors give a classification of severity of the intoxication syndrome. The role of proteases and middle size peptides in pathogenesis of endogenous intoxication in peritonitis is shown. The irrigation of the abdominal cavity with Kontrical is recommended in the postoperative period for decreasing the intoxication. Hemosorption was also used in patients with the growing syndrome of endogenous III degree intoxication. The methods used lowered lethality from 29.9% to 17.8%.     

Early relaparotomy

An analysis of 14565 operations on organs of the abdominal cavity has shown that main causes of early relaparotomies were peritonites (47,4%), intestinal obstruction (33,3%), eventration of the abdominal organs (16,0%) and hemoperitoneum (3,3%). The highest lethality was after postoperative peritonitis (54,1%). For the recent 10 years the total lethality has become 31,6% lower due to better diagnosis and early relaparotomies.     

Postoperative biliary peritonitis

An analysis of results of surgical treatment of 91 patients with postoperative biliary peritonitis has shown that frequency of postoperative biliary peritonitis depended on the volume and character of operative interventions, as well as on technical errors made at the preoperative period and during operation. The presence of latent hepatic insufficiency made for the development of polyorganic insufficiency, had negative influence on the course of the disease and might be one of the causes of high postoperative lethality (up to 23.1%) in this category of patients.     

Treatment of peritonitis of appendicular etiology

The authors had 475 patients with appendicular peritonitis under observation. All of them underwent emergency operation and were given antibacterial therapy with metronidazole and agents of the aminoglycoside series. Among 223 patients, the operation on whom was completed by traditional drainage of the abdominal cavity and complete closure of the operative wound, 148 patients developed postoperative complications. Five patients died. In 252 patients, primarily delayed sutures were applied to the wound and drainage of the abdominal cavity was limited. The abdominal cavity was inspected repeatedly in 24 patients with generalized peritonitis and clinical signs of anaerobic nonclostridial infection. Postoperative complications occurred in 87 patients and were limited to suppuration of the wound. One patient died.     

Means of reducing mortality in peritonitis of appendicular origin

An experience with the treatment of 836 patients with appendicular peritonitis has shown that early diagnosis of the disease and exact determination of the degree of peritonitis could improve results of their treatment. The operative measures should be fulfilled under general anesthesia. The access should ensure good treatment of the abdominal cavity and drainage of the small intestine in paralytic obstruction. Special care is necessary in the postoperative period for timely recognition of intraabdominal abscesses.     

Multivisceral resections at disseminated abdominal tumors

Overall 131 multivisceral resections at disseminated abdominal malignant tumors have been performed. The main arguments to extended operations were local dissemination of tumor (35.1%), synchronous hepatic metastases (49.6%), combination of local dissemination with synchronous metastases (6.1%), isolated synchronous tumors (6.1%), and multiple metastases with polyorganic localization (3%). The rate of postoperative complications and lethality at the patients undergone multivisceral operations were 34.3 and 6.8% respectively. There were no significant differences in postoperative complications rate and lethality between adjusted multivisceral and standard operations groups.     

Planned reoperation for generalized intraabdominal infection

Intraabdominal infection remains a common cause of death in surgical patients. Progress in this area with improved survival rates is difficult to demonstrate despite the use of antibiotics, nutritional support, and aggressive maintenance of function of failed organs. This report documents our experience with planned reoperation to cleanse the abdominal cavity in 77 patients with generalized intraabdominal infection. In 34 of the patients, reoperation to cleanse the abdominal cavity was performed every 24 to 48 hours after the first operation until the abdominal cavity was judged to be clean. Forty-three patients underwent a single operation for intraabdominal contamination and were treated expectantly, only undergoing reoperation for signs of recurrent infection. In all patients, the hole in the intestinal tract was controlled primarily by stoma formation at the initial operation to treat intraabdominal infection. Patients with appendiceal disease were excluded. The severity of illness in the two patient groups was compared by a modified acute physiologic score. Planned reoperation was not associated with improvement in survival when compared with patients managed expectantly. Patients managed by planned reoperation had significantly more laparotomies than patients managed expectantly without improving survival. The results of this study disclosed that empiric reoperation to clean the abdominal cavity in patients with generalized intraabdominal infection produced no improvement in survival when compared with observation and reoperation when indicated.