Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review

Aim This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis. Method We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included. Results Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy. Conclusion There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic diverticulitis. The published papers do, however, show promising results, with high efficacy, low mortality, low morbidity and a minimal need for a colostomy.     

The impact of systemic fungal infection in patients with perforated oesophagus

INTRODUCTION

Perforated oesophagus is a surgical emergency with significant morbidity and mortality. Systemic fungal infection represents a poor response to the magnitude of the insult, which adds significantly to the risk of morbidity and mortality in these patients. We reviewed our experience with this group of patients over a six-year period in a tertiary referral centre.

METHODS

A retrospective clinical review was conducted of patients who were admitted following a ruptured oesophagus over a period of six years (January 2002 – January 2008).

RESULTS

We had 27 admissions (18 men and 9 women) following an isolated perforated oesophagus to our unit. The median patient age was 65 years (range: 22–87 years). The majority (n=24,89%) presented with spontaneous perforations (Boerhaave’s syndrome) and three (11%) were iatrogenic. Fungal organisms, predominantly Candida albicans, were positively cultured in pleural or blood samples in 16 (59%) of the 27 patients. Fourteen patients grew yeasts within the first seven days while two showed a delayed growth after ten days. Overall mortality was 5 out of 27 patients (19%). There was no mortality among the group that did not grow yeasts in their blood/pleural fluid while mortality was 31% (5/16) in the group with systemic fungal infection (p<0.001). A positive fungal culture was also associated with increase ventilation time, intensive care unit stay and inpatient hospital stay but not an increased rate of complications.

CONCLUSIONS

Systemic fungal infection in patients with a ruptured oesophagus affects a significant proportion of these patients and carries a poor prognosis despite advanced critical care interventions. It may represent a general marker of poor host response to a major insult but can add to mortality and morbidity. It is worth considering adding antifungal therapy empirically at an early stage to antimicrobials in patients with an established diagnosis of a perforated oesophagus.     

Mortality in Perforated Peptic Ulcer Patients After Selective Management of Stratified Poor Risk Cases

Introduction Perforated peptic ulcer disease continues to inflict high morbidity and mortality. Although patients can be stratified according to their surgical risk, optimal management has yet to be described. In this study we demonstrate a treatment option that improves the mortality among critically ill, poor risk patients with perforated peptic ulcer disease. Methods In our study, two series were retrospectively reviewed: group A patients (n = 522) were treated in a single surgical unit at the Dhaka Medical College Hospital, Dhaka, Bangladesh during the 1980s. Among them, 124 patients were stratified as poor risk based on age, delayed presentation, peritoneal contamination, and coexisting medical problems. These criteria were the basis for selecting a group of poor risk patients (n = 84) for minimal surgical intervention (percutaneous peritoneal drainage) out of a larger group of patients, group B (n = 785) treated at Khulna Medical College Hospital during the 1990s. Results In group A, 479 patients underwent conventional operative management with an operative mortality of 8.97%. Among the 43 deaths, 24 patients were >60 years of age (55.8%), 12 patients had delayed presentation (27.9%), and 7 patients were in shock or had multiple coexisting medical problems (16.2%). In group B, 626 underwent conventional operative management, with 26 deaths at a mortality rate of 4.15%. Altogether, 84 patients were stratified as poor risk and were managed with minimal surgical intervention (percutaneous peritoneal drainage) followed by conservative treatment. Three of these patients died with an operative mortality of 3.5%. Conclusions Minimal surgical intervention (percutaneous peritoneal drainage) can significantly lower the mortality rate among a selected group of critically ill, poor risk patients with perforated peptic ulcer disease.     

Risk factors of mortality in perforated peptic ulcer.

OBJECTIVE: To assess the risk factors that influence mortality from perforated peptic ulcer. DESIGN: Retrospective study. SETTING: General hospital, Taiwan. SUBJECTS: 179 patients who had their perforated peptic ulcers operated on and who had minimum follow-up of one year. MAIN OUTCOME MEASURES: Mortality. RESULTS: The overall mortality was 15% (26/179). Of the 26 patients who died, the cause of death was uncontrolled systemic infection in 21 (81%), hypovolaemic shock in 2, and fatal arrhythmia and heart failure in 1 each. 15 of the patients who died of sepsis did not have fulminant abdominal sepsis. Most deaths occurred early after operation, (range 1-96 days). Old age, preoperative shock, and type of operation seemed to be related to these deaths on univariate analysis, but multivariate analysis showed that coexisting medical illness, delayed treatment, and low albumin concentration were independent risk factors for mortality. CONCLUSIONS: To improve the result of treatment of perforated peptic ulcer, the diagnosis and treatment should not be delayed, the associated medical illnesses should be treated, and nutritional support should be given.     

Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis

Aim Currently in the UK the standard surgical practice for the management of perforated sigmoid diverticulitis is a Hartmann’s procedure. There have been a number of recent publications on the use of laparoscopic peritoneal lavage for perforated sigmoid diverticulitis, as an alternative to the emergency Hartmann’s procedure, with its associated morbidity and mortality. We aim to review the current literature on this topic. Method A search was made on the electronic database MEDLINE from PubMed, EMBASE and the Cochrane library. The keywords ‘diverticulitis’, ‘perforated’ and ‘laparoscopy’ were searched for in the titles and abstracts without language restrictions. Further studies were identified from searches on Google Scholar, as well as manual searches through reference lists of the relevant studies found. All included studies were quality assessed. Results Twelve relevant studies were included. A total of 301 patients were reported, with a mean age of 57 years. All were non‐randomized studies. The majority of patients were of Hinchey classification III. All were treated with intravenous antibiotics followed by laparoscopic lavage and insertion of intra‐abdominal/pelvic drains. The mean conversion rate was 4.9% and mean length of hospital stay was 9.3 days. The mean complication rate was 18.9% and the overall mortality rate was 0.25%. Subsequent elective resections with primary anastamosis were performed in 51% of patients and the majority were completed laparoscopically. Conclusion Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis appears to be a potentially effective and more conservative alternative to a Hartmann’s procedure. Randomized control trials are needed to better evaluate its role.     

A prospective study of operative risk factors in perforated duodenal ulcers.

Operative risk factors for patients with perforated duodenal ulcers were examined prospectively in 213 operated patients. Nine hospital deaths (4.2%) resulted from respiratory failure, sepsis, and bleeding. Forty-five complications developed in 27 patients (12.7%). Concurrent medical illness, preoperative shock, and longstanding perforations (more than 48 hours) were significant features that increased mortality. Old age, gross peritoneal soiling, and the length of the ulcer history did not affect mortality in the absence of risk factors. No death attributable to either sepsis or abscess formation occurred when surgery was performed within two days of perforation. Bacterial contamination may not signify clinical peritonitis during this period. We conclude that simple closure of perforated ulcers is a more prudent choice when any risk factor is present, but that definitive surgery in good-risk patients merits further evaluations.     

Selective surgical management of perforated duodenal ulcer

In an effort to clarify the preoperative indications and factors predisposing to an increased operative morbidity for "definitive" ulcer procedures, the medical records of 114 patients with perforated duodenal ulcers were reviewed. One hundred nine patients underwent operation, with 55 patients treated with ulcer closure (Group 1) and 54 underwent a "definitive" operation (Group 2). Thirty-two complications developed in 27 patients (25%), with major infectious complications occurring in 9 per cent and 7.5 percent in the simple ulcer closure and definitive surgery groups, respectively. This study demonstrates that preoperative shock, operation delayed greater than 48 hours, and patient age greater than 60 years were significant factors increasing morbidity. The importance of peritoneal soilage and positive cultures are unreliable in predicting subsequent clinical infection and do not contraindicate definitive surgical management.     

Bacteria and septic complications in patients with perforated duodenal ulcers

To evaluate the clinical significance of bacterial contamination in perforated duodenal ulcers, we prospectively studied septic complications in 184 consecutive patients. All patients received parenteral antibiotics (over 90 percent preoperatively) for at least 7 days. Thirteen infections developed in eight patients (4.3 percent). Peritoneal cultures, performed in 143 unselected patients, were positive in 33.6 percent of cases. Bacterial growth occurred more often and in heavier amounts in patients who underwent exploration late (after 48 hours) and those who had gross peritoneal soilage. Candida and gram-negative organisms predominated, but there was no correlation with pathogens that produced abscesses or wound infections. Old age and late exploration significantly increased the risk of infection. Neither peritoneal soiling nor a positive culture was likely to be clinically important when exploration was performed within 2 days of perforation. We treat perforated ulcers as clean-contaminated cases, and recommend that three doses of prophylactic antibiotics be begun preoperatively in all patients.     

Persistence of Candida despite seemingly adequate systemic and intraperitoneal amphotericin B treatment in a patient on CAPD

A case of Candida peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD) is presented. Despite 2 weeks of intravenous and 4 weeks of intraperitoneal amphotericin B, good clinical response, and repeatedly negative fungal cultures from the peritoneal dialysate, her Tenckhoff catheter upon removal grew the same Candida species. This case emphasizes the point that Candida may persist on the catheter despite seemingly adequate antifungal treatment and good clinical and microbiologic response.     

Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation

BACKGROUND/PURPOSE: To better define the indications for peritoneal drainage (PD) in premature babies with intestinal perforation, the authors reviewed their experience with this procedure in a tertiary neonatal intensive care setting. METHODS: The charts of all neonates who underwent PD as initial treatment for intestinal perforation between 1996 and 1999 were reviewed. Those patients with pneumatosis intestinalis on abdominal radiograph had perforated necrotizing enterocolitis (NEC) diagnosed; whereas, those infants with no pneumatosis had isolated intestinal perforation diagnosed. The clinical characteristics and outcomes of these 2 groups were compared. RESULTS: Twenty-one premature neonates had primary PD between 1996 and 1999, 10 for isolated intestinal perforation and 11 for perforated NEC. Patients with isolated intestinal perforation had lower birth weights (708 v 949 g; P < .05), were less likely to have started feedings (30% v 91%, P < .05), and the perforation developed at an earlier age (10.6 v 28.0 d, P < .05) compared with the patients who had perforated NEC. Only 2 of 10 infants with isolated perforation required subsequent laparotomy (at 10 weeks for stricture and 12 weeks for a persistent fistula). For these patients, the long-term survival rate was 90%. In contrast, 8 of 11 infants with perforated NEC required laparotomy, and although the 30-day survival rate was 64%, the long-term survival rate was only 27%. CONCLUSIONS: Peritoneal drainage provides successful and definitive treatment for most premature babies with isolated intestinal perforation. For neonates with perforation caused by NEC, peritoneal drainage may provide temporary stabilization, but most of these infants require subsequent laparotomy, and few survive.     

Disseminated candidiasis developing during prophylaxis with fluconazole in a small-intestine transplant recipient

A 31-year-old man underwent immunosuppressive treatment and was treated with 150 mg per day of prophylactic oral fluconazole after receiving a small-intestine transplant. The patient had acute rejection by the end of the first week after the transplant. Endoscopic examination showed white plaques. In blood and urine cultures, growth of Candida albicans was detected. Biopsy specimens showed high levels of conidia and hyphae in all regions. Intravenous treatment with caspofungin was started for the patient. Candidal findings had regressed on follow-up endoscopy. However, the patient died 3 months after transplant because of the effects of immunosuppression on his bone marrow and the development of disseminated intravascular coagulation. Candida species are the most common cause of invasive fungal infections that develop after solid-organ transplant. Following transplant, candidemia may develop during systemic antifungal treatment with a high level of mortality.     

Candida species. Insignificant contaminant or pathogenic species

The pathogenicity of Candida species cultured from peritoneal fluid or from an intra-abdominal abscess is unknown. A review of cultures at NCMH from 1978 to 1983 showed that Candida species were cultured from the peritoneal fluid of 39 patients and from intra-abdominal abscesses in 24 patients. The average age was 49 (range 6 months to 102 years); there were 38 men and 25 women. None of the 39 patients with Candida species grown from the peritoneal fluid was treated with Amphotericin B and only 1 (2.6%) subsequently developed an abscess. This patient was treated by surgical drainage without Amphotericin B and recovered. Twenty-four patients had Candida cultured from an intra-abdominal abscess. Of these, 21 (87.5%) also grew other bacterial organisms. Twenty of these 24 patients were treated with surgical drainage and antibacterial antibiotics without Amphotericin B. Six (30%) died, but only one death was felt to be directly related to the Candida infection. The remaining four were treated with surgical drainage, appropriate antibacterial antibiotics, and Amphotericin B. Two of these four (50%) died; one of the two deaths was related to Candida infection. Candida species grown from the peritoneum were not related to later Candida infection. Treatment of patients with contamination of the peritoneum by Candida with Amphotericin B appears unnecessary and because of Amphotericin renal toxicity, may be potentially harmful. Patients with polymicrobial intra-abdominal abscesses that contain Candida species should be treated with surgical drainage and appropriate antibacterial antibiotics. The value of adding Amphotericin B therapy in patients with polymicrobial abscess containing Candida was not demonstrated in this study, and its role is unclear.     

Perforated diverticulitis: a surgical dilemma.

Thirty-eight patients, 18 males and 20 females (mean age 61 years) have been operated on for perforated diverticulitis, over the past 14 years. We assigned the patients into stage A (n = 12) when the inflammation was confined to the mesosigmoid folds, stage B (n = 16) when an intraabdominal abscess was walled off and stage C (n = 10) when a generalized peritonitis had developed. Resection of the perforated sigmoid was carried out in 24 patients either as Hartmann's procedure (n = 18) or with primary anastomosis (n = 6). The mortality rate in this setting was 0.0% and 16.6% respectively. In 14 patients, no resection was carried out in 24 patients either drainage and colostomy (n = 10) or only drainage (n = 4) with corresponding mortality rate 30% and 25%. Mortality rate in relation to the stage was: Stage A 16.16%, Stage B 12.5% and Stage C 10%. The higher mortality rate in stage A and B was due to the fact that less radical operations were carried out. Four of our five deaths in all stages occurred in patients in whom the perforated sigmoid was not resected. In conclusion resection of the perforated sigmoid with or without primary anastomosis regardless of the stage of the disease is recommended.     

深部真菌的感染特点及耐药分析

目的：了解深部真茵感染的临床分布特点及耐药情况,以指导临床合理应用抗真菌药物。方法收集我院临床患者深部的标本（痰液、尿液、粪便、血液、脑脊液、生殖道分泌物、创口分泌物）共426份,接种到沙保弱培养基和显色培养基鉴定菌株。将分纯的菌种接种梅里埃公司生产的ATB Fungus 2真菌药敏板条,用ATB Expression鉴定仪读取最小抑菌浓度（MIC）,得出临床常见真菌对抗真菌药物的药敏结果。结果发生深部真菌感染167例,感染真菌标本以痰液检出率最高为63.5%,其次为尿液占15.6%。167株真菌中,假丝酵母菌属感染有160株,其中以白假丝酵母菌为主（67.1%,112/167）。科室分布中,干诊科感染率最高,为41.9%;其次为呼吸科,占26.3%。＞60岁老年患者有123例,占73.6%。假丝酵母菌属对伏立康唑和伊曲康唑的耐药率较高,分别为75.05%和51.10%,对5-氟胞嘧啶和两性霉素B耐药率较低,分别为2.20%和2.90%。结论老年患者容易患深部真菌感染,感染部位主要为呼吸道,假丝酵母菌属为主要病原菌,其中以白假丝酵母菌感染率最高;两性霉素B、氯康唑和5-氟胞嘧啶耐药率最低,氟立康唑和伊曲康唑的耐药率最高。     

Significance of intraoperative peritoneal culture of fungus in perforated peptic ulcer

BACKGROUND: The incidence of postoperative fungal infection is increasing and the gastrointestinal tract is the major source, but antifungal therapy in perforated peptic ulcer (PPU) is still controversial. The aim of this study was to determine the significance of intraoperative peritoneal fluid culture of fungus and establish the indications for treatment. METHODS: Between July 1997 and September 2001, all patients admitted with a PPU were studied. Clinical data and peritoneal fluid for culture were collected. Risk factors for a positive peritoneal fluid culture of fungus and outcome were evaluated, and related to the development of surgical site infection, duration of hospital stay and mortality rate. RESULTS: One hundred and forty-five patients with a PPU were included; 63 (43.4 per cent) had positive peritoneal fluid fungal culture. Age, preoperative organ failure, delay in operation, high Mannheim Peritonitis Index (MPI) and Acute Physiology And Chronic Health Evaluation (APACHE) II scores, and preoperative antibiotic therapy were risk factors for a positive fungal culture. Sex and an MPI score of 20 or more remained significant in multivariate analysis (P < 0.001). Patients with a positive fungal culture had a higher incidence of surgical site infection, a longer hospital stay and a significantly higher mortality rate, especially when this was combined with a high MPI score. CONCLUSION: Positive peritoneal fungal culture was common and was a significant risk factor for adverse outcome in patients with a PPU. A high MPI score could be used as an indicator for prophylactic antifungal therapy.     

The role of definitive surgery in the management of perforated duodenal ulcer disease.

From 1970 to 1973, 147 patients were treated at Wayne State University Affiliated Hospitals for perforated duodenal ulcer disease. One hundred thirteen were observed for at least 18 months and findings showed that (1) mortality was dependent on the condition of the patient rather than on the choice of operation, (2) current indications (previous ulcer history, degree of peritoneal contamination, and time interval between performation and surgery) were not reliable in choosing the initial operation or in predicting the need for subsequent surgery, and (3) morbidity was high following simple closure. Therefore, we recommend vagotomy and pyloroplasty as the procedure of choice for a perforated duodenal ulcer, unless the patient is in septic shock at admission.     

Fatal esophageal perforation caused by invasive candidiasis

Instrumental lesions, spontaneous rupture, and trauma cause most esophageal perforations. Transmural fungal infection is extremely rare, although Candida may be detected in as many as 25% of normal esophagus. In this report we present a case of fatal esophageal perforation due to transmural Candida infection in a 76-year-old woman. The patient died from septic shock and multiorgan failure, despite esophageal resection and systemic antifungal therapy. Pathogenetic aspects and treatment strategies are discussed.     

Emergency management of perforated peptic ulcers in the elderly patient

The results of selective operative treatment for perforated peptic ulcers in 93 elderly patients 60 years of age or older have been found to be similar to those in a large group of patients of all ages with selective operative treatment for perforated peptic ulcers (1,127 patients). Elderly patients with previous symptoms of acid-peptic disease who do not have serious associated diseases that increase the risk of operation or generalized peritonitis or localized abscesses in the peritoneal cavity can undergo definitive ulcer procedures for perforated peptic ulcers with satisfactory morbidity and low mortality rates. Simple closure or omental patch closure is performed when such contraindications to a definitive operation are present and can be expected to have a greater mortality for this reason. Gastrectomy for a perforated gastric ulcer and truncal vagotomy and hemigastrectomy for a perforated duodenal ulcer offer the best long-term results for elderly patients who are fit to undergo definitive operation.     

Candida infections in surgical patients.

Serious Candida infections were seen in 55 surgical patients from January 1977 through December 1980. Most of the patients had compromising underlying conditions and many were elderly. Broad-spectrum antibiotics and total parenteral nutrition (TPN) appeared to predispose patients to Candida infections. Mortality rate from Candida was 38%. A high percentage of patients with positive blood or bile cultures died as a result of Candida infection. Therapy with intravenous amphotericin B was highly effective if given in adequate dosage. No patient receiving more than 200 mg of amphotericin B died, but the mortality rate was 56% in those receiving lower doses.     

Association of fungal infection and increased mortality in liver transplant recipients

BACKGROUND: Invasive fungal infection is associated with increased morbidity and mortality following orthotopic liver transplantation (OLTx). Understanding the risk factors associated with fungal infection may facilitate identification of high-risk patients and guide appropriate initiation of antifungal therapy. OBJECTIVES: The aim of this study was to determine the incidence of fungal infections, identify the most common fungal pathogens, and determine the risk factors associated with fungal infections and mortality in OLTx recipients. METHODS: Medical records from 96 consecutive OLTx in 90 American veterans (88 males, 2 females; mean age 48 years, range 32 to 67) performed from January 1994 to December 1997 were retrospectively reviewed for fungal infection in the first 120 days after transplantation. Infection was defined by positive cultures from either blood, urine (<105 CFU/mL), cerebrospinal or peritoneal fluid, and/or deep tissue specimens. Superficial fungal infection and asymptomatic colonization were excluded from study. All patients received cyclosporine, azathioprine, and prednisone as maintenance immunosuppressive therapy. Fungal prophylaxis consisted of oral clotrimazole (10 mg) troches, five times per day during the study period. RESULTS: Thirty-five patients (38%) had documented infection with one or more fungal pathogens, including Candida albicans (25 of 35; 71%), C torulopsis (7 of 35; 20%), C tropicalis (2 of 35; 6%), non-C albicans (2 of 35; 6%), Aspergillus fumigatus (4 of 35; 11%), and Cryptococcus neoformans (1 of 35; 3%). The crude survival for cases with or without fungal infection was 68% and 87%, respectively (P <0.0001). The median intensive care unit stay and overall duration of hospitalization were significantly longer for patients with fungal infection (P <0.01). The mean time interval from transplantation to the development of fungal infection was 15 days (range 4 to 77) with a mean survival time from fungal infection to death of 21 days (range 3 to 64). Fungal infections occurred significantly more often in patients with renal insufficiency (serum creatinine >2.5 mg/dL), biliary/vascular complications, and retransplantation. CONCLUSIONS: Fungal infections were associated with increased morbidity and mortality following OLTx, with Candida albicans being the most common pathogen. Treatment strategies involving antifungal prophylaxis for high-risk patients and earlier initiation of antifungal therapy in cases of presumed infection are warranted.