Total parenteral nutrition: a four-year audit

A four-year audit was carried out on 278 patients who received 289 courses of total parenteral nutrition (TPN) over 5213 patient days in a Saudi Arabian hospital. One hundred and forty-seven patients were discharged healthy, two of these after home TPN. The overall mortality was 36 per cent. ICU patients had the highest mortality (53 per cent). Among the survivors, 74.8 per cent showed an improvement in nutritional status. The incidences of metabolic complications and catheter sepsis were 2.9 per cent and 3.6 per cent, respectively. As a direct result of the audit, changes have been made in protocols and staffing patterns, and an attempt is being made to address the major problem of better selection of patients.     

Penetrating duodenal injuries. Analysis of 100 consecutive cases.

One hundred consecutive patients with penetrating duodenal injuries were reviewed retrospectively to analyze the results of various methods of treatment. The severity of the abdominal injury was quantified by the Penetrating Abdominal Trauma Index (PATI). The overall mortality was 25%. Sixteen per cent of the deaths were related to extensive associated organ injury, eight per cent to sepsis, and one per cent to concurrent head trauma. Duodenal fistulas occurred in four per cent and were associated with mortality in two per cent. The complications of duodenal fistula, abdominal sepsis, and mortality from sepsis were significantly higher in those patients treated by repair and decompressive enterostomy with or without a serosal patch than in those with repair or resection. The severity of duodenal and associated organ injuries, as well as the clinical status, were similar in both groups. It is concluded that the majority of duodenal injuries from penetrating trauma may be treated effectively by primary repair, and that the use of decompressive enterostomy or serosal patch appears to contribute to an increased morbidity rate.     

Comparison of cefamandole and carbenicillin in preventing sepsis following penetrating abdominal trauma

One hundred and five patients with penetrating abdominal injuries were treated with single-antibiotic regimens. Forty-seven patients were treated with intravenous (IV) cefamandole and for comparison 58 patients were treated with IV carbenicillin previously shown to be effective against postoperative infections associated with abdominal trauma. The overall incidence of deep infection on a single antibiotic therapy was 8.6 per cent, including two patients on cefamandole alone (4.3%) and seven (12.1%) on carbenicillin alone. One in each antibiotic group died of sepsis with a total mortality of 1.9 per cent. The authors concluded that cefamandole when used alone was found to be safe and more effective than carbenicillin alone in preventing sepsis in patients with abdominal trauma.     

An 11-year experience of enterocutaneous fistula

BACKGROUND: Enterocutaneous fistula has traditionally been associated with substantial morbidity and mortality, related to fluid, electrolyte and metabolic disturbance, sepsis and malnutrition. METHODS: A retrospective review of enterocutaneous fistula in 277 consecutive patients treated over an 11-year period in a major tertiary referral centre was undertaken to evaluate current management practice and outcome. RESULTS: Most fistulas occurred secondary to abdominal surgery, and a high proportion (52.7 per cent) occurred in association with inflammatory bowel disease. A low rate of spontaneous healing was observed (19.9 per cent). The healing rate after definitive fistula surgery was 82.0 per cent, although more than one attempt was required to achieve surgical closure in some patients. Definitive fistula resection resulted in a mortality rate of 3.0 per cent. In addition, one patient died after laparotomy for intra-abdominal sepsis and an additional 24 patients died from complications of fistulation, giving an overall fistula-related mortality rate of 10.8 per cent. CONCLUSION: Early recognition and control of sepsis, management of fluid and electrolyte imbalances, meticulous wound care and nutritional support appear to reduce the mortality rate, and allow spontaneous fistula closure in some patients. Definitive surgical management is performed only after restitution of normal physiology, usually after at least 6 months.     

Temporary closure of open abdominal wounds by the modified sandwich-vacuum pack technique

BACKGROUND: A 5-year experience with the modified sandwich-vacuum pack technique, using an opened 3-litre urological irrigation bag and continuous high-pressure suction, for temporary abdominal wall closure is presented. METHODS: The records of all patients who underwent temporary abdominal wall closure using this method from January 1996 to December 2000 were examined. RESULTS: The modified sandwich-vacuum pack was used 139 times in 55 patients. Forty patients sustained penetrating trauma while 15 patients sustained blunt trauma. The mean Injury Severity Score was 19 (range 9-34). Intra-abdominal sepsis (51 per cent) was the commonest indication, followed by visceral oedema (18 per cent), abdominal compartment syndrome (16 per cent), intra-abdominal packing (11 per cent) and abdominal wall defects (4 per cent). The overall mortality rate was 45 per cent. Three patients (5 per cent) developed enterocutaneous fistula. Of the 30 survivors, 16 patients underwent primary fascial closure. CONCLUSION: The modified sandwich-vacuum pack technique of temporary abdominal wall closure is easy and rapid, cost effective and provides an effective means of containing abdominal wall contents.     

Effects of antibiotics on prevention of infection in contaminated abdominal operations.

A prospective study was undertaken on 102 patients with massice intraperitoneal contamination from traumatic or spontaneous perforation of intestinal or pancreaticobiliary tract to determine the effects of combined systemic and intraperitoneal antibiotic administration on the prevention of the postoperative sepsis, intra-abdominal abscess formation and wound infection. Large doses of gentamicin and clindamycin were given parenterally before, during, and after the operation for five days. In addition, the peritoneal cavity and the abdominal incision were irrigated intraoperatively with antibiotic solution containing the same antibiotics. The drugs were given so as to provide a potent level of antibiotics during the operation and in the immediate postoperative period. The postoperative wound infection rate was 4 per cent, intra-abdominal abscess 2.9 per cent, sepsis 1 per cent, resulting in a total infectious complication rate of 7.9 per cent. This is a marked reduction in the incidence of infectious complications and compares favorably with the results from either parenteral or intraperitoneal therapy alone. Furthermore, no complications were encountered due to this method of therapy. These results do not indicate that antimicrobial drugs be given prophylactically to all surgical patients, but they strongly suggest the advantages of combined systemic and intraperitoneal antibiotics in the management of patients with massive intraperitoneal contamination.     

Open abdomen management of intra-abdominal sepsis

Despite surgical advances, antimicrobial therapy, and intensive care, the morbidity and mortality of intra-abdominal sepsis remains high. The primary purpose of this study was to determine whether open abdomen management of intra-abdominal sepsis reduces intensive care unit (ICU) and hospital mortality. The records of 81 consecutive patients with open abdomen management for intra-abdominal sepsis admitted to the surgical ICU from January 1998 to April 2002 were retrospectively reviewed. Outcomes were compared to a historical control group with primary abdominal closure, also admitted to the surgical ICU with intra-abdominal sepsis and matched for sex, age, source of sepsis, and APACHE III score. ICU mortality for the open abdomen group was 25 per cent versus 17 per cent for the control group. Hospital mortality was 33 per cent and 25 per cent for the open abdomen patients and historical controls, respectively. Both ICU and hospital length of stay were significantly longer for the open abdomen group. An overall fistula rate of 14.8 per cent was demonstrated in the open abdomen patients. A significant difference in overall ICU and hospital mortality was not demonstrated between patients treated with open abdomen management and historical controls. A prospective randomized study accounting for extent of sepsis may define a role for open abdomen management in selected subgroups of patients.     

Immediate resection in emergency large bowel surgery: a 7 year audit

In a consecutive series of 153 emergency admissions with large bowel disease during a 7 year period, 49 per cent were for colonic obstruction, 46 per cent for peritonitis and 5 per cent for miscellaneous conditions. Urgent operation was performed on 104 (68 per cent) patients. Of those operated upon, 82 (79 per cent) had a primary resection with a mortality rate of 12.2 per cent, intraperitoneal sepsis rate of 2.4 per cent and wound sepsis rate of 7.3 per cent. The median postoperative hospital stay was 21 days. An immediate anastomosis was performed in 46 (56 per cent) patients with a mortality rate of 8.7 per cent, anastomotic leak rate of 2.2 per cent, and wound sepsis rate of 8.7 per cent. The median postoperative hospital stay was 19 days. The mortality in patients presenting with large bowel emergencies is related to age and advanced malignant disease. Immediate resection is applicable in over 80 per cent of patients requiring urgent operation and morbidity can be low and treatment economical. Immediate anastomosis after proximal colonic resection is safe and the use of intra-operative colonic irrigation permits a primary anastomosis in selected patients after emergency resection of the distal colon.     

Continuous single-layer gastrointestinal anastomosis: a prospective audit

Single-layer bowel anastomoses have conventionally been constructed using an interrupted suture technique. A single-layer continuous technique has been avoided on the grounds that it may predispose to ischaemia of the bowel ends. We have routinely used a single-layer continuous suture technique with an absorbable suture material (polyglycolic acid) to construct all recent intraperitoneal bowel anastomoses, and we present a 3-year audit of this technique. A total of 131 patients were studied of whom 66 had undergone upper gastrointestinal resections and 65 had had colonic resections. Twenty-two patients had emergency operations. Anastomotic failure was noted in 4.5 and 6.2 per cent of patients in each group respectively. The incidence of minor wound infection was 1.5 and 7.7 per cent respectively. The overall mortality rate was 8.4 per cent. This study suggests that a single-layer continuous suture technique gives acceptably reliable results when used in gastrointestinal anastomosis.     

The open peritoneal cavity: etiology correlates with the likelihood of fascial closure

The use of laparostomy in damage control surgery and uncontrolled intra-abdominal infection has been well described. We examined 71 patients who required laparostomy to see if trends in management and outcome could be identified based on the underlying disease state. The underlying etiology included gastrointestinal sepsis (n = 25), pancreatitis (n = 21), or trauma (n = 25). Pancreatitis patients required more operations per patient (P < 0.05). The likelihood and type of closure (fascial, mesh, or none) was related to the underlying etiology: trauma patients were more likely to have fascial closure (P < 0.02), patients with GI sepsis were more likely to require mesh closure, and pancreatitis patients were more likely to have no formal closure (P < 0.02). Only 29 per cent of patients achieved definitive fascial closure. Mortality in trauma patients was 20 per cent, 36 per cent for GI sepsis, and 43 per cent in patients with pancreatitis. Complications of laparostomy included enterocutaneous fistula (16.9%) and abscess formation (7%). Though the use of laparostomy has become more prevalent, it is still associated with significant hospital stay, morbidity, and mortality. In our study, the number of operations and likelihood of abdominal closure appears to correlate with the etiology of the underlying disease requiring use of laparostomy.     

Gastrointestinal fistulas associated with large abdominal wall defects: experience with 43 patients

Experience with 43 patients with gastrointestinal fistulas associated with a large abdominal wall defect is presented. The overall mortality rate was 60 per cent; 37 per cent in patients who underwent the primary procedure in the home unit and 74 per cent in those from elsewhere. An average of five operations per patient was performed. The abdominal wall defect developed spontaneously as a consequence of postoperative peritonitis in 24 patients (mortality rate, 71 per cent) and was created intentionally as a part of the 'open management' in 19 cases (mortality rate, 47 per cent). Errors in management were identified in 63 per cent of the patients and this adversely influenced the outcome. Patients with this condition should be referred early to tertiary care facilities where diversion of the intestinal leak away from the defect, prompt control of the associated intra-abdominal infection and adequate handling of the defect itself can be performed.     

Short-course antibiotic prophylaxis in penetrating abdominal injuries: ceftriaxone versus cefoxitin

This was a prospective, randomized study of 123 patients with penetrating abdominal injuries. The patients received ceftriaxone or cefoxitin for 24 h (in the presence of colonic injury, 48 h). The overall incidence of abdominal sepsis was 7.3 per cent (ceftriaxone 5 per cent, cefoxitin 9.5 per cent, P greater than 0.05). Colonic injury was the most important risk factor for the development of septic complications. Other factors, such as the weapon used, a prehospital time longer than 4 h, shock on admission, multiple organ injuries, and small bowel perforation, did not influence the incidence of sepsis.     

Abdominal pain: a surgical audit of 1190 emergency admissions

In an audit of 1190 emergency admissions with abdominal pain (1166 patients) in a general surgical unit, the diagnosis was non-specific abdominal pain (NSAP) in 415 (35 per cent), acute appendicitis in 200 (17 per cent) and intestinal obstruction in 176 (15 per cent). The largest number of admissions occurred in the age groups 10-29 years (31 per cent) and 60-79 years (29 per cent). Surgical operations were performed in 551 patients (47 per cent) and there was a 16 per cent incidence of unnecessary appendicectomy (22 per cent in the age group 20-29 years). Fifty-one deaths resulted in a 30-day hospital mortality rate of 4.4 per cent and a perioperative mortality rate of 8 per cent. The mortality rate increased significantly in patients aged greater than or equal to 60 years, and patients aged 80-89 years had a perioperative mortality rate of 20 per cent. The causes of perioperative death included laparotomy for inoperable disease (28 per cent), ruptured abdominal aortic aneurysm (23 per cent), perforated peptic ulcer (16 per cent) and colonic resections (14 per cent). The perioperative mortality rates for ruptured aneurysm and perforated ulcer were 71 and 23 per cent respectively. The duration of inpatient stay increased significantly with the age of the patients, including those with NSAP. The results of the study indicate a need to review the methods of management of ruptured aortic aneurysm and perforated peptic ulcer, the methods of diagnosis of appendicitis, particularly in young females, and the factors that determine the duration of stay of patients suffering from NSAP.     

Risk-adjusted surgical audit with the POSSUM scoring system in a developing country. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity

BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is an objective and appropriate scoring system for risk-adjusted comparative general surgical audit. This score was devised in the UK and has been used widely, but application of POSSUM to centres outside the UK has been limited, especially in developing countries. This prospective study validated its application in a surgical practice with a different population and level of resources. METHODS: All general surgical patients who were operated on under regional or general anaesthesia as inpatients over a 4-month period at Sarawak General Hospital in 1999 were entered into the study. All data (12 physiological and six operative factors) were analysed for mortality only with the POSSUM equation and the modified Portsmouth POSSUM (P-POSSUM) equation. Comparisons were made between predicted and observed mortality rates according to four groups of risk: 0-4, 5-14, 15-49 and 50 per cent or more using the 'linear' method of analysis. RESULTS: There were 605 patients who satisfied the criteria for the study. Some 56.7 per cent of patients were in the lowest risk group. The POSSUM predictor equation significantly overestimated the mortality in this group, by a factor of 9.3. The overall observed mortality rate was 6.1 per cent and, again, the POSSUM predictor equation overestimated it at 10.5 per cent (P < 0.01). In contrast, the observed and predicted mortality rates for all risk groups, including the predicted overall mortality rate of 4.8 per cent, were comparable when the P-POSSUM predictor equation was used. CONCLUSION: The POSSUM scoring system with the modified P-POSSUM predictor equation for mortality was applicable in Malaysia, a developing country, for risk-adjusted surgical audit. This scoring system may serve as a useful comparative audit tool for surgical practice in many geographical locations.     

Protocol for bedside laparotomy in trauma and emergency general surgery: a low return to the operating room

Bedside laparotomy (BSL) was introduced as a heroic procedure in trauma patients too unstable for safe transport to the operating room (OR). We hypothesize a BSL protocol would maintain patient safety while reducing OR use. Patients were prospectively entered into a BSL protocol from July 2002 to June 2003 and retrospectively reviewed. Protocol indications for BSL were abdominal compartment syndrome, decompensation due to hemorrhage, washout/closure, and sepsis in a patient too unstable for safe transport to the OR. Primary outcomes were mortality, emergent return to OR, and primary fascial closure (PFC). Trauma operating room charges and OR time were analyzed. One hundred thirty-three BSL were performed on 60 patients with an overall mortality of 23.3 per cent (14/60). There was an average of 2.2 BSL per patient (range 1-8). Indications for BSL were 1) explore/washout (n = 100, 75.2%), 2) decompression (n = 14, 10.5%), 3) infection/abscess (n = 12, 9.0%), 4) hemorrhage (n = 7, 5.3%). Five of 133 BSL (5.8%) were emergently returned to the OR because of perforation or compromised bowel. Trauma OR charges were dollar 5,300 per cases with 2.12 hours per cases. The protocol standardized the conduct of BSL procedure to allow for a low return to OR rate of 5.8 per cent and had an overall in-hospital mortality rate of 23.3 per cent. Primary fascial closure of the abdomen had a significantly reduced hospital stay. BSL allowed trauma OR charges of dollar 5,300 per cases with 2.12 hours per cases savings.     

Relationship between bile colonization, high-risk factors and postoperative sepsis in patients undergoing biliary tract operations while receiving a prophylactic antibiotic. West of Scotland Surgical Infection Study Group

A prospective audit of 644 patients undergoing biliary tract operations has been conducted to assess the incidence of bile colonization and its association with the incidence of postoperative sepsis when all patients received the same prophylactic antibiotic. The accuracy of the determination of high-risk factors has been assessed as has the correlation between bile colonization and patients assessed as 'high risk'. Organisms were cultured from the bile of 121 (19 per cent) patients and among these the incidence of wound or intra-abdominal sepsis was 22 per cent whereas among patients with sterile bile the incidence was only 2 per cent (P less than 0.0001). Although the incidence of bile colonization within the high-risk group (32 per cent) was more than twice that in the low-risk group (14 per cent), more than half (54 per cent) of the patients with positive bile cultures were in the low-risk group. It is concluded that, despite prophylactic antibiotics, bile colonization remains the major factor associated with postoperative sepsis, but that this cannot be predicted accurately by preoperative assessment of high-risk factors. Furthermore, we believe that a policy of selective administration of prophylactic antibiotics solely to high-risk patients cannot be justified.     

The importance of early internal fixation in multiply injured patients to prevent late death due to sepsis

Three hundred and seventy-one multiply injured patients with 1063 fractures, who were admitted to our service over an 8-year period (1978-1985), were studied retrospectively. The impact of early osteosynthesis on the overall, and especially of the late, mortality due to sepsis was analysed. The patients were divided into two groups depending on whether they were treated with osteosynthesis (group I) or underwent conservative fracture treatment (group II). The late mortality (more than 7 days after injury) due to sepsis fell to 1.8 per cent in patients treated with osteosynthesis compared with 13.5 per cent (P less than 0.001) in patients treated conservatively. The best results were obtained when the osteosynthesis was performed within 24 hours after injury; less than 1 per cent died from late sepsis. We feel that fractures in multiply injured patients should be treated with early osteosynthesis in order to reduce the late mortality from sepsis.     

Acute pancreatitis after aortic surgery

Acute pancreatitis (AP) after aortic surgery has rarely been reported. A retrospective review of all abdominal and thoracoabdominal aortic operations complicated with AP from January 1982 to March 1992 was performed to study the presentation and outcome of this infrequently recognized complication. Thirteen cases of AP were found among 1965 abdominal aortic operations (0.7% incidence). The distribution of the original aortic operations was as follows: eight elective abdominal aortic aneurysm repairs, two aortoiliac grafts for aortoiliac occlusive disease, and three aortorenal bypasses. Two cases of pancreatitis complicated 170 thoracoabdominal aortic operations (1.2% incidence). Ten patients had mild pancreatitis, nine were discharged without any pancreatic complications after receiving supportive treatment. Five patients with severe AP died of multisystem organ failure despite aggressive surgical treatment; 4 had infected necrosis. The overall mortality was 40 per cent; severe AP resulted in a 100 per cent mortality. The diagnosis of severe AP was usually made in the second postoperative week, significantly later (P < 0.01) than for patients with mild disease. Typically, patients with mild AP presented with hyperamylasemia at a median of 5 postoperative days, and severe AP was found at reoperation or autopsy after a period of unexplained sepsis. Five patients with mild AP were found to have biliary tract stones, with one requiring endoscopic stone extraction. In conclusion, pancreatitis is an uncommon, although perhaps underreported complication. Underreporting may be due to a lack of hyperamylasemia when severe pancreatitis is diagnosed. The severe form is diagnosed late in patients with postoperative sepsis, associated with infected necrosis, and lethal. The complication may be reduced by incidental cholecystectomy for cholelithiasis.     

Cirrhosis and trauma: a deadly duo

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and X2 were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantly greater in the trauma patients with cirrhosis. Fifty-five per cent of deaths in the cirrhosis group was due to sepsis, and, as the Child's class increases, so does the mortality (Child's A, 15%; B, 37%; and C, 63%). In 64 per cent of cirrhotics without an emergent abdominal operation, mortality was 21 per cent. In the 36 per cent of cirrhotics who had emergent abdominal operation, mortality was 55 per cent. Hepatic cirrhosis in trauma patients, regardless of severity of injury or the need for an abdominal intervention, is a poor prognostic indicator. The necessity of an abdominal operative intervention further amplifies this effect. Trauma and cirrhosis is, in fact, a deadly duo.     

Metronidazole and Augmentin in the prevention of sepsis after appendicectomy

Two hundred and fifty patients were admitted to a prospective randomized trial to compare the efficacy of Augmentin with metronidazole in the prevention of sepsis after appendicectomy. Pre-operatively they received either 500 mg metronidazole or 1.2g Augmentin intravenously. Those patients with gangrenous or perforated appendices received eight additional doses of the trial drug at 8 hourly intervals. Overall there were 13 wound infections in the Augmentin group (11 per cent) and 21 in the metronidazole group (18 per cent). The 90 per cent confidence limits for the overall 7 per cent difference in infection rates were +/- 8.5 per cent. There were high rates of wound infection in the gangrenous group (Augmentin 8 per cent versus metronidazole 19 per cent) and especially in the perforated group (Augmentin 33 per cent versus metronidazole 63 per cent). There was no statistically significant difference between the infection rates with the two antibiotics but our study suggests that Augmentin, which is active against both aerobes and anaerobes, may be more effective than metronidazole in reducing wound sepsis after appendicectomy.