Essence and significance of DIC-syndrome in acute peritonitis

Section specimens of 20 patients who had died of peritonitis of different genesis and specimens of various organs from 10 rats which had of died experimental peritonitis were studied morphologically. It was revealed that 100% patients demonstrated intravascular blood coagulation, it was disseminated in 60% cases and localized--in 40%. In experimental peritonitis intravascular blood coagulation developed in 6 of 10 animals only, and it was disseminated in 3 rats only. It is demonstrated that microthrombi don't lead to focal necrosis due to their special localization in microcirculatory bed vessels.     

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.     

腹腔镜诊治急性腹膜炎528例分析

目的:探讨为急性腹膜炎患者行腹腔镜手术的可行性。方法:回顾分析为528例急性腹膜炎患者行腹腔镜手术的临床资料。结果:8例中转开腹2,例死亡2,例放弃治疗,25例发生炎性肠梗阻,经保守治疗缓解,其余患者腹腔镜手术均获成功。结论:腹腔镜手术诊治急性腹膜炎安全可行,尤其老年人、儿童及妇科急腹症患者具有独特优势。     

Differing outcomes of gram-positive and gram-negative peritonitis

Peritonitis remains the leading cause of patient dropout from continuous peritoneal dialysis (CPD) therapy. Few studies have compared patient morbidity, mortality, and outcome for patients undergoing CPD who develop gram-positive and gram-negative peritonitis. We retrospectively reviewed the charts of patients who developed either gram-positive or gram-negative peritonitis between January 1, 1993, and December 31, 1995. Three hundred seventy-five patients who developed 415 episodes of gram-positive and gram-negative peritonitis were maintained on CPD therapy during this time period. There was no difference in age, race, and sex between patients who developed gram-positive or gram-negative peritonitis. More patients with diabetes developed gram-negative peritonitis than gram-positive peritonitis (53% v 40%, respectively; P < 0.05). Coagulase-negative staphylococcal species accounted for 47% of all gram-positive episodes, whereas Klebsiella organisms, Escherichia coli, and Enterobacter organisms accounted for 63% of all gram-negative episodes. Significantly more patients who developed gram-positive peritonitis continued CPD therapy 2 weeks and 6 months after the onset of peritonitis than patients who developed gram-negative peritonitis (97% v 73%; P < 0.05 at 2 weeks and 81% v 58% at 6 months; P < 0.05, respectively). Nine percent of the patients who developed gram-positive peritonitis died within 6 months after the onset of peritonitis, whereas 21% of the patients who developed gram-negative peritonitis died (P < 0.05). Patients who developed gram-negative peritonitis were significantly more likely to require hospitalization than patients who developed gram-positive peritonitis (74% v 24%; P < 0.001). More patients with gram-negative peritonitis required peritoneal catheter removal than patients with gram-positive peritonitis (18% v 4%; P < 0.001). Thirty-two percent of the patients who developed gram-positive peritonitis re-developed an episode of peritonitis with the same organism compared with only 9% of the patients who developed gram-negative peritonitis. Furthermore, peritonitis recurrence with the same organism within 6 months after the initial episode was noted in 60% of the patients with peritonitis caused by Staphylococcus aureus compared with 24% of patients with peritonitis caused by other gram-positive organisms (P < 0.05). We conclude that the outcomes of gram-positive and gram-negative peritonitis are different. When rates of peritonitis are used to predict outcome, it appears that gram-positive and gram-negative peritonitis rates need to be examined separately.     

Ten years experience with using directed laparostomy in treatment of diffuse purulent peritonitis

During the recent ten years operations were made on 331 patients with diffuse purulent peritonitis, 214 of them had traditional management of the postoperative period, 117 were managed using directed laparostomy by the method developed in the clinic. Toxic phase of peritonitis was noted in 66.76%, with the terminal phase--33.24% of patients, in the group of patients with laparostomy their number being 10% more than in the group of comparison (with a traditional method of management at the postoperative period). In cases with using directed laparostomy with programmed sanitation of the abdominal cavity the number of postoperative complications was 29.9%, 21.36% of patients died. In the group of patients with traditional management of the postoperative period there were 68.2% of complications, 80 patients (37.4) required relapatotomy, 55.6% died.     

Treatment of perforated appendicular peritonitis

The article analyses the results of treatment of 104 patients with generalized appendicular peritonitis. Sixty-four patients were admitted for acute disease and 40 patients for chronic disease. Twenty-three patients had been previously subjected to appendectomy for destructive appendicitis at other clinics. Among 100 patients who were operated on 60 were treated by appendectomy: cecostomy was established in 5 and ileostomy in 3 patients with incompetence of the stump of the vermiform process; in nonviability of the wall of the small intestine (11 patients) the wall was resected and an anastomosis formed in 7 and enterostomy was performed in 4 cases. The method of "closed evisceration" was employed in 24 patients with neglected forms of peritonitis. Thirty-three hemosorption sessions were conducted in 30 patients in the terminal stage of peritonitis. Four patients died in the preoperative period and 12 died after the operation. Seventeen complications were encountered after the operation: intestinal fistulas 4, abscess of Douglas' space 2, suppuration of wounds 5, and pneumonia 6.     

Peculiarities of treatment of patients, suffering postoperative peritonitis, complicated by abdominal sepsis

In 2001-2011 yrs 241 patients, 18-80 years old, including 148 (61.4%) men and 93 (38.6%) women, were treated in the clinic f postoperative peritonitis. In 156 (64.7%) patients abdominal sepsis was diagnosed. In 74 (83%) patients a puncture-draining interventions were performed under ultrasonographic control for local postoperative peritonitis, and relaparotomy - in 15 (16.9%). In 18 (11.8%) patients, suffering extended peritonitis, miniinvasive technologies were applied. For extracorporal detoxication in 96 (40%) patients the intermitting veno-venous hemodiafiltration was conducted as well as plasmapheresis, peritoneal dialysis. As a result of polyorgan insufficiency development 34 (14.1%) patients died, of them after miniinvasive interventions - 5 (5.4%).     

Sanative postoperative laparoscopy using rapid bacteriological methods in comprehensive treatment of patients with diffuse peritonitis]

In treatment of patients with diffuse peritonitis the authors have been using postoperative sanative laparoscopy which proved to provide a means not only for rapid evaluating the dynamics of peritonitis course, but also for carrying out a series of therapeutic manipulations aimed at proper management of infections and inflammatory complications. Sanative laparoscopy was accompanied by taking samples of peritoneal exudate to study sensitivity of microflora to antibiotics and antiseptic substances, ensuring rational antibacterial treatment of peritonitis. This therapeutic method was used in 38 patients who underwent 60 examinations. Sanative laparoscopy was of a planned character in 30 patients, and in 8 cases it was carried out for emergency indications. All the studies were performed within 12-23 hours. A single examination was carried on in 11 subjects, the rest of the patients demanding from 2 to 3 examinations. No complications related to sanative laparoscopy were observed. Positive outcome was noted in the majority of the patients, re-laparoscopy being indicated but for 3 patients. Two patients died due to causes not related to the pathology involved.     

Recent peritonitis associates with mortality among patients treated with peritoneal dialysis

Peritonitis is a major complication of peritoneal dialysis, but the relationship between peritonitis and mortality among these patients is not well understood. In this case-crossover study, we included the 1316 patients who received peritoneal dialysis in Australia and New Zealand from May 2004 through December 2009 and either died on peritoneal dialysis or within 30 days of transfer to hemodialysis. Each patient served as his or her own control. The mean age was 70 years, and the mean time receiving peritoneal dialysis was 3 years. In total, there were 1446 reported episodes of peritonitis with 27% of patients having ≥ 2 episodes. Compared with the rest of the year, there were significantly increased odds of peritonitis during the 120 days before death, although the magnitude of this association was much greater during the 30 days before death. Compared with a 30-day window 6 months before death, the odds for peritonitis was six-fold higher during the 30 days immediately before death (odds ratio, 6.2; 95% confidence interval, 4.4-8.7). In conclusion, peritonitis significantly associates with mortality in peritoneal dialysis patients. The increased odds extend up to 120 days after an episode of peritonitis but the magnitude is greater during the initial 30 days.     

Use of low-frequency ultrasound with special gas agents in acute generalized peritonitis

Optimal parameters of peritoneal cavity treatment by low-frequency ultrasound with alternative use of carbon dioxide and oxygen were selected in experimental animals. Sanitation of peritoneal cavity in fecal peritonitis led to a significant desintoxication effect. The results of treatment of acute generalized peritonitis by this method in 28 patients were good. On day 2 or 3 after surgery all the patients underwent extracorporeal detoxication with hemosorbent AUSRITC-1 with good result. In severe toxemia and water-electrolyte disturbances plasmapheresis was applied. 4 patients of 28 died, lethality was 14.2%.     

Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis. Three recoveries in 5 cases without catheter removal

We attempted to treat 5 patients on CAPD with fungal peritonitis without removing the catheter. In 1 case, amphotericin B caused a severe chemical peritonitis. The other 4 patients received amphotericin B intravenously and miconazole or flucytosine intraperitoneally. Recovery was obtained in 3 cases without removing the catheter and in 1 case the patient died.     

持续性非卧床腹膜透析与肾移植（附46例报告）

单独应用持续性非卧床腹膜透析（ＣＡＰＤ）后行肾移植４６例，死亡１０例，死因为术后粘连性肠梗阻２例，急性排斥反应４例，败血症、自发性肾破裂、肝脓疡各１例，慢性排斥２年后再次移植死亡１例．本组术后无腹膜炎发生．     

Treatment of generalized suppurative peritonitis]

In the period from 1980 to 1986 fifty-nine patients were treated for generalized purulent peritonitis of 72-hour duration. The traditional methods of therapy were applied--removal of the source of peritonitis and drainage of the abdominal cavity. The mortality was 62.7%. Since 1987, peritoneal lavage with enteral administration of oxygenized 5% glucose solution is used in the treatment of patients with generalized peritonitis in the stage of poly-organic insufficiency. Peritoneal-enteral lavage was applied in the management of 41 patients, 10 of them died. The mortality was 36.5%. The efficacy of the method was judged on basis of bacteriological study, electroenterography, and functional tests for the absorptive capacity of the small intestine. The results of stage peritoneal lavage and the findings of bacteriological study lead to the conclusion that it is extremely dangerous to postpone repeated cleansing of the abdominal cavity in such patients because progressive deterioration of the condition with a fatal outcome occurs in this case. Cleansing of the abdominal cavity must be accomplished during the first lavage or 24 hours later during relaparotomy and no hope should be entertained that inadequate cleansing will be compensated for during subsequent relaparotomies.     

Circulatory shock associated with purulent peritonitis

The relative roles of bacterial infection, fluid loss and myocardial failure were investigated in 24 patients in whom circulatory shock appeared as a complication of purulent peritonitis. The 13 acute survivors, including 6 hospital survivors, had strikingly lower initial plasma volumes and total blood volumes than the 11 patients who died. Differences in blood volume were not explained by differences in previous treatment or in duration of peritonitis. Acute survivors promptly improved after fluid repletion, whereas the patients who died failed to respond to the infusion of equivalent volumes of fluid. In contrast to acute survivors, the fatal cases demonstrated disproportionate increases in both right- and left-sided filling pressure, increases in pulmonary vascular resistance and decreased right and left ventricular work capability. These observations in patients complement experimental studies in which biventricular cardiac failure was implicated in the fatal progression of septic shock.     

Tuberculous peritonitis complicating long-term peritoneal dialysis. Report of 5 cases and review of the literature

The characteristics of 5 patients who developed tuberculous peritonitis while receiving long-term peritoneal dialysis (PD) are presented. There were 2 males and 3 females. 3 patients were on intermittent and 2 were on continuous ambulatory peritoneal dialysis when tuberculous peritonitis was first diagnosed. None of the patients had recently received immunosuppression therapy or were diabetics. The clinical presentations were similar to other forms of peritonitis complicating PD except for a more insidious onset. As extraperitoneal involvement and peritoneal lymphocytosis were rarely present, the diagnosis was mainly dependent on the direct demonstration of Mycobacterium tuberculosis with smear (1 patient) and culture (4 patients). In 1 patient with a pleuroperitoneal communication, the diagnosis was made by pleural biopsy and a positive response to antituberculous therapy. All patients responded to treatment with a combination of three antituberculous drugs which included streptomycin, isoniazid, rifampicin and pyrazinamide. Two patients were transferred to hemodialysis. In 3 patients, peritoneal dialysis was continued. Peritoneal clearance and ultrafiltration capacity were unchanged for up to 16 months after treatment in 2 patients who continued peritoneal dialysis but was reduced by 30 and 50%, respectively, in the remaining patient. Only 1 patient died, but her death was not directly related to tuberculous peritonitis. It was concluded that with a high index of suspicion and early institution of treatment, tuberculous peritonitis complicating PD can be successfully treated with low mortality and without compromising the dialysis capacity of the peritoneal membrane.     

Intraperitoneal rupture of amoebic liver abscess

A retrospective analysis of 23 cases of amoebic liver abscess with intraperitoneal rupture is presented. Group I consisted of 16 patients with clinical features of generalized peritonitis. Eight of these patients were treated surgically, and four died. Group II consisted of seven patients with features of localized peritonitis and all were treated conservatively. In all cases the diagnosis of liver abscess was established by liver scan or ultrasound examination; peritonitis was established either at operation or, in the conservatively managed group, by aspiration of pus from the peritoneal cavity. Amoebiasis was diagnosed by serology. Eight group I and all group II patients were managed conservatively by aspiration of the liver abscess, antibiotics and amoebicides. There were no deaths in this group. It is suggested that, if the diagnosis can be made early, conservative treatment offers the best chance of cure for patients of amoebic liver abscess with intraperitoneal rupture.     

Audit on complicated diverticular disease.

Seventy-three patients were seen between 1970 and 1983 with complicated diverticular disease. There were only six hospital deaths (8%). Two out of 7 patients with faecal peritonitis died, 2 of 27 patients with purulent peritonitis died and there was one death each associated with an inflammatory mass and a peridiverticular abscess. Five of the six hospital deaths were from cardiorespiratory disease and only one was from sepsis. Three of the early deaths were in patients who were receiving steroid therapy. There were three late deaths: one from uncontrolled sepsis, one an anaesthetic death from coronary occlusion during revision of a Hartmann operation and the third was an incidental myocardial infarction. A very conservative surgical policy was adopted, primary resection only being used for an inflammatory mass and selectively for fistula and local purulent disease. Despite our apparent low hospital mortality there was a high incidence of complication; wound sepsis 29%, fistula after colostomy closure 12% and anastomotic dehiscence after primary or secondary reconstruction 12%. These findings indicate the need for a prospective audit which is now in progress.     

Treatment of perforated gastroduodenal ulcers

139 patients with perforated ulcers of the stomach and the duodenum were operated. Diffuse peritonitis was encountered in 117 (84.3%) patients. Radical organ-saving operations were carried out in 111 (79.9%) patients. 6 patients (4.3%) died after operation. The authors suggest that usage of organ-saving operations in perforated pyloroduodenal ulcers complicated by peritonitis is quite justified and does not lead to increase in postoperative complications and mortality rate.     

THE MANAGEMENT OF PERFORATED DIVERTICULITIS WITH DIFFUSE PERITONITIS

In a ten-year period 53 patients presented with perforated colonic diverticular disease with diffuse peritonitis. Eight patients died - all with uncontrolled intraabdominal sepsis. Various surgical techniques were employed. None of the 12 patients having immediate resection of the affected bowel segment died. There was no mortality from subsequent operations in any form of staged treatment. Primary resection without anastomosis is supported as the treatment of choice for this condition.     

Use of the "Bogota bag" for temporary abdominal closure in patients with secondary peritonitis

Various methods may be used for temporary closure of the abdomen. Use of the "Bogota bag" (BB) technique for abdominal closure has been reported primarily in the management of injuries. This review describes our experience using the BB technique in cases of secondary peritonitis. Abdomenal closure using BB was reviewed retrospectively in 152 patients with secondary peritonitis. Of the 152 cases of BB use reviewed, 79 patients had complications of previous abdominal operations, 57 had secondary peritonitis, 14 had complications of abdominal trauma, and 2 were cases of mesenteric events. The BB remained in situ from 1 to 19 days. Changes occurred between 1 and 11 times per patient (mean, 2.8). In nine patients, early diagnosis of leaking of small bowel content under the bag was noted, and 36 patients (24%) died from sepsis. In 12 patients, the resolution of abdominal sepsis permitted secondary closure 10 days later. In 16 patients, mesh repair was performed after 4 weeks. Musculocutaneal flap repair was used in one case, and 13 patients had skin grafts. Eleven patients eventually underwent ventral hernia repair. Early temporary closure of the abdominal wall using BB in patients with abdominal sepsis and planned re-explorations is simple, safe, inexpensive, and effective. This temporary abdominal cover provides good exposure of abdominal content between re-explorations and may prevent fistula formation. The development and subsequent repair of large hernias constitute one of the difficult postoperative problems requiring future solution.