Early Elevation of Intra-Abdominal Pressure After Laparotomy for Secondary Peritonitis: A Predictor of Relaparotomy?

BACKGROUND: Patients with secondary peritonitis often require relaparotomy; however, there is no consensus about the criteria for selecting patients who would benefit from early relaparotomy. Our goal was to evaluate whether elevated intra-abdominal pressure (IAP) during the early postoperative period could predict the need for relaparotomy. METHODS: A total of 102 consecutive adult patients with acute intra-abdominal conditions were admitted for laparotomy. Seventy-eight patients, who were diagnosed with secondary peritonitis at index surgery, underwent serial measurements of IAP. The primary outcomes measured in the study were incidence of postoperative peritonitis and mortality. RESULTS: Thirty-two of 78 patients with secondary peritonitis (41%) developed elevated IAP postoperatively. Sixteen (20.5%) of 78 patients developed postoperative peritonitis. Twelve of these 16 patients (75%) with postoperative peritonitis had significantly elevated IAP (P = 0.002) during the immediate postoperative period. Regression analysis revealed elevated IAP (P = 0.055) to be third most predictive of postoperative peritonitis in patients who underwent laparotomy for secondary peritonitis, after septic shock at admission (P = 0.012) and POSSUM score (P = 0.018). CONCLUSION: Our study shows that development of elevated IAP during the early postoperative period can increase the risk of postoperative peritonitis. IAP measured during the immediate postoperative period can be used as a predictor of early relaparotomy.     

Outcomes of early relaparotomy in pediatric patients at Tikur Anbessa teaching hospital,Addis Ababa,Ethiopia: a five-year retrospective review

Background

Early relaparotomy is defined as relaparotomy within the first 30 days following surgery. The aim of this study is to explore the indications, outcomes and factors associated with relaparotomy in our pediatric population.

Methods

We performed a retrospective study of pediatric surgical patients (<?13 yrs.) who underwent relaparotomy at Tikur Anbessa Teaching Hospital between September 1, 2011 and August 31, 2016. All children who had relaparotomy within the first 30 days of the initial surgery were included. We collected patient data including demographics, operative indication, and postoperative outcomes. Data analysis was performed using SPSS Version 23. Chi-square and Fisher’s exact tests were used to report outcomes stratified by patient characteristics. Multivariable logistic regression was used to identify patient variables associated with relaparotomy and other outcomes.

Results

In our patient population, relaparotomy rate was 17.2%. Patient age ranged from 2 days to 12 years with mean age of 37.5 months. Male to female ratio was 1.2:1. Thirty-one (58.5%) relaparotomies were performed between the 5th and 8th postoperative days. The two most common indications for relaparotomy were postoperative intra-abdominal collection and anastomotic leak, accounting for 18 (34.0%) and 17 (32.1%) respectively. Mortality rate following relaparotomy was 26.4%. The most common cause of mortality was sepsis with multi-system organ failure (90.6%). Neonatal age was found to be the independent risk factors for death following relaparotomy, (AOR?=?27.59, 95% CI [2.0–379.9]).

Conclusion

Prevalence of relaparotomy in pediatric patients is high (17.2%) in our patient population. Neonatal age was associated with increased mortality following relaparotomy.

     

Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy

HYPOTHESIS: Pancreaticogastrostomy (PG) is associated with a lower relaparotomy rate following pancreaticoduodenectomy (PD) than pancreaticojejunostomy (PJ). DESIGN: Retrospective clinical trial. SETTING: Department of digestive surgery and transplantation. PATIENTS: Between 1987 and 2001, 250 consecutive patients underwent PD in our institution. Among them, 83 patients underwent PJ and 167, PG. MAIN OUTCOME MEASURES: Preoperative clinicopathological features, intraoperative parameters, in-hospital mortality, postoperative morbidity, pancreatic fistula (PF), relaparotomy rates, and length of hospital stay were analyzed and compared between 2 reconstructive methods, PJ and PG, after PD. RESULTS: The morbidity rate, including PF, was lower in the PG group (38.3%) than in the PJ group (53.0%; P =.02). The mortality rate did not differ between the PG group (2.9%) and PJ group (2.4%). Conversely, the incidence of PF and the mean +/- SD length of hospital stay were significantly lower in the PG group (2.3% and 17.2 +/- 7.7 days) than in the PJ group (20.4% and 23.3 +/- 11.7 days; P<.001 for both variables). Moreover, the overall relaparotomy rate was significantly lower in the PG group (4.7%) than in the PJ group (18.0%; P =.001). Nine (52.9%) of 17 patients with PF in the PJ group underwent relaparotomy. These 9 patients underwent subsequent completion pancreatectomy (n = 7) or removal of peripancreatic necrotized tissue (n = 2) with a postoperative mortality rate of 22.2%. However, no patient required relaparotomy for PF in the PG group because medical therapy succeeded in all 4 patients with PF. Moreover, no mortality related to PF occurred in the PG group. CONCLUSION: The PG procedure is a safe method of reconstruction after PD, with a significantly lower rate of PF and relaparotomy.     

Postoperative intraabdominal bleedings

Based on complex diagnosis and treatment of 58 patients with postoperative intraabdominal bleedings (PIB), clinical classification and adequate surgical policy are proposed. It is demonstrated that in PIB of degree II-III urgent relaparotomy is indicated. In PIB of degree I dynamic follow-up of drainages, hemodynamic and hematological indices are possible.     

Relaparotomy following complications of feeding jejunostomy in esophageal surgery

BACKGROUND: After recognition of the importance of early postoperative enteral feeding, placement of a feeding jejunostomy as an adjunct to gastrointestinal surgery has become widely accepted. However, little attention has been paid to surgical complications and their consequences. Feeding jejunostomy as an adjunct to esophageal resection and reconstruction can lead to serious surgical complications. METHODS: Between 1978 and 2000, 1,387 patients underwent esophageal resection and reconstruction. Of these, 1,166 patients received a needle catheter feeding jejunostomy at the end of the operation. All postoperative complications were prospectively evaluated in a database including surgical complications related to the feeding jejunostomy. RESULTS: Overall, surgical complications occurred in 36%. There were 13 (1.1%) feeding jejunostomy related complications leading to relaparotomy. Of these, intraperitoneal leakage was the most common complication (n=5). Other jejunostomy-related complications included dislodgement (n=4), herniation (n=3) and torsion (n=1). Five patients (0.4%) died despite relaparotomy. CONCLUSIONS: Feeding jejunostomy as an adjunct to esophageal resection and reconstruction can lead to serious surgical complications. Preventive measures have not resulted in a decrease in complication rate. Complications of leakage necessitating relaparotomy are associated with a high mortality rate. Therefore, other means of enteral access should be considered.     

Factors Affecting Mortality in Generalized Postoperative Peritonitis: Multivariate Analysis in 96 Patients

Abstract Mortality of generalized postoperative peritonitis remains high at 22% to 55%. The aim of the present study was to identify prognostic factors by means of univariate and multivariate analysis in a consecutive series of 96 patients. Mortality was 30%. Inability to clear the abdominal infection or to control the septic source, older age, and unconsciousness were significant factors related to mortality in the multivariate analysis. Failure to control the peritoneal infection (15%) was always fatal and correlated with failed septic source control, high Acute Physiology and Chronic Health Evaluation (APACHE) II score, and male gender. Failure to control the septic source (8%) also was always fatal and correlated with high APACHE II score and therapeutic delay. In patients with immediate source control, residual peritonitis occurred in 9% after purulent or biliary peritonitis and in 41% after fecal peritonitis (p = 0.002). In patients without immediate control of the septic source, delayed control was still achieved in 100% after a planned relaparotomy (PR) strategy versus 43% after an on-demand relaparotomy (ODR) strategy (p = 0.018). In the same patients, mortality was 0% in the PR group versus 64% in the ODR group (p = 0.007). Early relaparotomy is related to improved septic source control. After relaparotomy for generalized postoperative peritonitis, a PR strategy is indicated whenever source control is uncertain. It also might decrease mortality in fecal peritonitis. An ODR approach is adequate for purulent and biliary peritonitis with safe septic source control.     

Relaparotomy after operations on the rectum and colon

During 15 years 1663 intraabdominal operations on the rectum and colon were performed, relaparotomy resulting from the complications was fulfilled in 134 patients (8%). The main indication for relaparotomy was peritonitis (57 patients). Its sources were: incompetence of the colonic anastomosis suture, technical errors during the first operation, opening of the abscess into the abdominal cavity. Five types of the course of postoperative peritonitis were established: primary, atypical, artificial, perforative and necrotic types.     

Relaparotomy in patients with perforated gastric and duodenal ulcers]

The article discusses the results of analysis of the causes of relaparotomy in 54 (3.1%) patients with perforating gastroduodenal ulcer in the period between 1966 and 1985, as well as the peculiarities of the course of complications, establishment of the diagnosis, and the methods and outcomes of surgical treatment. Postoperative mortality was 24.07%. The outcomes of relaparotomy were determined by early diagnosis of the complication, the time of the repeated operation, and the radical character of the first operative intervention. Mortality was less in relaparotomy undertaken in time (10.0%) than in late operations (41.7%). Mortality was highest among patients with postoperative peritonitis (46.7%). Postoperative peritonitis and intestinal obstruction were the most frequent conditions for which relaparotomy was carried out. Such factors as late hospitalization of the patients and generalization of peritonitis, the patients' age, doctors' errors, lateness and type of the first operative intervention played the principal role in the development of complication.     

Diagnosis and treatment of postoperative intraabdominal complications

Postoperative complications after 8168 reoperations were seen in 143 (1.8%) patients. Clinical symptoms, laboratory tests, results of x-ray and ultrasound examinations were taken into account in diagnosis of the complications. Differential diagnosis of postoperative peritonitis, stable paralytic intestinal obstruction, early adhesive obstruction and intraabdominal bleeding based only on clinical data is difficult in many cases. Ultrasonic examination and laparoscopy permitted to reduce number of unjustified relaparotomies. In the majority of cases relaparotomy was considered as a method of choice in treatment of these complications. Mini-invasive surgeries may be performed only in mild complications. Lethality in the treatment of postoperative complications after relaparotomy was 39.4%, after laparoscopic surgeries--8.8%, after US-assisted drainage--0. General lethality was 29.4%.     

Ultrasound examination for diagnosis of postoperative peritonitis

78 patients with peritonitis after various operations on the organs of abdominal cavity were followed up. Ultrasound examinations (n = 86) were carried out in 59 patients. In 28 of them US has revealed abscesses of the abdominal cavity. Comparative analysis showed coincidence of the diagnosis of peritonitis by clinical and roentgenological data with the results of relaparotomy in 10 (58.8%) of 17 examined patients. The same coincidence of the diagnosis of peritonitis by clinical, roentgenological and sonographic data on one side and of the results of relaparotomy on the other was found in 48 (81.4%) of 59 patients with peritonitis. It is stated, that US examination considerably increases the effectiveness of the diagnosis of postoperative peritonitis and incapsulated cavities.     

Indications for relaparotomy in acute postoperative intestinal obstruction]

For the period of 1977-1987, operations on the abdominal organs were performed in 13,306 patients. Of them, 115 (0.86%) developed 1 to 21 days after the operation acute ileus requiring the performance of emergency relaparotomy. Lethality in this complication was 33.9%. A retrospective analysis of 103 case records and observations on 12 patients who underwent at the early postoperative period emergency laparotomy for acute ileus were performed. The data were entered on a formalized card. The material was processed by means of a computer. The integral criteria for diagnosis of acute postoperative ileus which permitted to predict with an accuracy of 99% the complication serving an indication for relaparotomy were developed.     

Relaparotomy for postoperative mechanical intestinal obstruction in abdominal injuries]

The article analyzes an experience with the treatment of 41 patients with traumas of the abdomen who were subjected to relaparotomy for acute mechanical intestinal obstruction. A comparative estimation of early diagnostic symptoms allowing determination of indications for relaparotomy in postoperative acute mechanical intestinal obstruction was made. Medical errors responsible for relaparotomies and causes of death after it are analyzed.     

Postoperative eventration in abdominal injuries

In a work, the experience with treatment of 29 sufferers with abdominal traumas, who underwent relaparotomy for postoperative eventration, is analysed. Sudden soaking of a dressing by serous or serosanguineous fluid, abdominal pain, tachycardia, rising of a body temperature are the most informative symptoms permitting to establish the indications for relaparotomy in postoperative eventration.     

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%).     

Laparoscopic procedures at diagnosis and treatment of early postoperative intraabdominal complications in urgent surgery

Results of diagnosis and treatment of 318 patients with early postoperative intraabdominal complications (EPIAC) after urgent abdominal operations are analyzed. All the patients were divided into two groups depending on method of repeated operation. First group consisted of 212 patients who have undergone traditional relaparotomy, at 106 patients of second group the treatment was started with diagnostic laparoscopy. At 21 (6.5%) patients of 1st group the relaparotomy was diagnostic. At 58 (55%) patients of 2nd group the laparoscopic procedures was the final method of treatment, at 13 (12%) cases the EPIAC were excluded, conversion to open surgery was performed at 35 (33%) cases. Laparoscopy permitted to reduce lethality in 2.5 times and hospital stay in 2 times.     

Intra-abdominal hemorrhages in the early postoperative period and their diagnosis]

In the period from 1977 to 1987, after 13,306 operations carried out on the abdominal organs in the clinic, intra-abdominal hemorrhages occurred in 34 (0.25%) patients which had to de managed by emergency relaparotomy. From analysis of case records (28 taken from the archives and 6 of patients who were under observation) of the relationship between the large number (195) of signs represented by a block of clinico-laboratory and radiological data, an integral diagnostic criterion of intra-abdominal hemorrhages was obtained. The diagnostic significance of the criterion was 98.6%. Its practical application comes to recognition of intra-abdominal hemorrhage by identifying the symptoms and syndromes found in the patient with this early postoperative complication with the symptoms and syndromes composing the integral criterion. A revealed integral diagnostic criterion is a concrete indication for undertaking emergency relaparotomy.     

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目的 探讨腹部创伤再手术的原因和预防。方法 回顾分析14年间43例腹部创伤早期再手术病人的资料。结果 再手术病例占同期1126例创伤剖腹术病人的3.8%。钝性伤31例，穿透性伤12例。再手术原因主要为首次手术漏诊（13例）、处置失误（12例）、并发症（15例）、阴性再手术（3例）。43例病人共行再手术50例次，其中2例经受4次手术。病死率为11.6%(5/43），主要死因为再手术后消耗性凝血病或（和）严重感染并发症诱发多器官功能障碍综合征（MODS）。结论 剖腹术时坚持全面探查，正确掌握手术操作技术和重视腹部创伤的充分引流，是减少再手术的关键。     

Relaparotomy: clinical, strategic and organizational aspects

The results of relaparotomy (RL) performance in 118 patients were analyzed. Mortality was 16.1%. In 50.8% of patients RL was done with delay. There were proposed for timely diagnosis of postoperative complications to use the "alarm" symptoms group and during RL performance--to follow definite technical methods and rules. The RL performance necessity in 62.7% patients was caused by surgical technique failures and nonrational method of the first operation choice.     

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.