The treatment of appendicular peritonitis in children]

The experience of treatment of 513 children with an acute destructive appendicitis, complicated by peritonitis, was presented. The guided laparostomy conduction in patient in terminal state had promoted the frequency lowering of the postoperative complications occurrence and of the patients deaths. In 11 patients, whose state was estimated as extremely severe, laparostomy with double bottom according to classical method was performed. Of them 8 had recovered, 3 died, in 7 patients the complications occurred: the intestinal loops eventration--in 2 and postoperative infiltrate--in 5. The prolonged novocainic block of the terminal ileum mesentery and ileocecal valve with transcutaneous retroperitoneal introduction of catheter to mesentery according to Seldinger was applied for the treatment.     

Programmed cleansing of abdominal cavity in postoperative generalized suppurative peritonitis]

Programmed cleansing of the abdominal cavity was performed in 54 patients in the management of postoperative generalized purulent peritonitis. Indications for stage inspection of the abdomen in different variants are discussed. The results were best in the group of patients (42 cases) treated by programmed relaparotomy and poor in patients (10 cases) in whom laparostomy had to be established. Total mortality in the analysed group was 46.3%. Polyorganic insufficiency was the main cause of death.     

预防性腹腔造口术临床应用研究

目的：探讨预防性腹腔造口术对防治复杂性腹部外科手术后并发症的作用。方法：对60例腹部外科手术患者随机分为2组,使用预防性腹腔造口术组（治疗组）30例,与使用常规手术组（对照组）30例进行对比,观察术后腹腔并发症的诊断和处理时间及临床结果。结果：治疗组并发症的诊断和处理时间分别为0.83h和0.68h,明显优于对照组的20.67h和20.34h;治疗组治愈率76.67%,明显高于对照组治愈率46.67%;治疗组死亡率为3.33%,明显低于对照组的16.67%。结论：采用预防性腹腔造口,能够及时发现术后并发症,加速其诊断及处理,并且有有良好的可操作性。     

Laparostomy in treatment of diffuse peritonitis

Two methods for laparostomy were used in peritonitis: programmed sanitation and variant of N.S. Makokha method (68.8 and 31.2% of patients respectively). 215 patients with diffuse peritonitis have been under control for the period from 1989 to 1997, beginning with the method of Makokha for laparostomy and then converting to programmed sanitation. Lethality rate in 1989-1992 made up 67.6%, in 1993-1997--35.4%. Among the patients, in whom for performing elective sanitation "ventrophiles" were fixed during the initial operation, lethality made up 25.7% and if it was done during the second and later procedures, lethality made up 45.7%.     

Surgical aspects of the treatment of generalized peritonitis

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

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

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

A new approach to treatment of the intraabdominal hypertension syndrome in patients with diffuse peritonitis

Results of treatment of 49 patients with diffuse purulent peritonitis were analyzed. The patients were divided into two statistically similar groups. The control group of patients consisted of 27 patients treated using traditional methods. Patients of the main group (22) were treated by the same method, but the defect of the abdominal wall was closed using wide-meshed reticular polypropylene endoprosthesis with total size of the meshes not less than 70% of the general square surface. During every programmed sanation the prosthesis was cut longitudinally along the whole length and sutured so that the level of intraabdominal pressure was not more that 15 mm Hg. In the nearest postoperative period the main group patients had endotoxicosis 1.3 less, and the motor-evacuatory function of the intestine was 2.2 times higher which resulted in 1.3 times less postoperative lethality. In the long-term postoperative period excellent results of treatment became 13.3% more often, good results were 12.7% as compared with the control group.     

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.     

Initial Experience of Laparostomy with Immediate Vacuum Therapy in Patients with Severe Peritonitis

INTRODUCTION

To report our initial experience of laparostomy and immediate intra-abdominal vacuum therapy in patients with severe peritonitis due to intra-abdominal catastrophes.

PATIENTS AND METHODS

Twenty-seven patients underwent emergency laparotomy and laparostomy formation with the application of immediate intra-abdominal TRAC–VAC® therapy (male:female ratio, 1:1.2; median age, 73 years; range, 34–84 years). Predicted mortality was assessed using the P-POSSUM score and compared with clinically observed outcomes.

RESULTS

Ten patients (37%) with a mean predicted P-POSSUM mortality of 72%, died of sepsis and multi-organ failure. Seventeen patients (mean P-POSSUM 48% expected mortality) survived to discharge. One patient with pancreatitis died from small bowel obstruction 1-year post discharge, two patients developed a small bowel fistula. One patient had an allergic reaction to the VAC dressing. Our patients, treated with laparostomy and TRAC VAC therapy, had a significantly improved observed survival when compared to P-POSSUM expected survival (P = 0.004).

CONCLUSIONS

Laparostomy with immediate intraperitoneal VAC therapy is a robust and effective system to manage patients with intra-abdominal catastrophes. There were significantly improved outcomes compared to the mortality predicted by P-POSSUM scores. Damage control surgery with laparostomy formation and intra-abdominal VAC therapy should be considered in patients with severe peritonitis.     

Disorders of acid-alkaline status and electrolyte composition in appendicitis-related peritonitis in a child

In children with diffuse appendicular peritonitis the disorders of acidic-alkaline state (AAS) and the electrolytes composition (EC) of venous blood were studied. Before the operation in patients with extended peritonitis metabolic and respiratory alkalosis dominated, with general one--metabolic acidosis. In diffuse local peritonitis the conduction of ethiotropic antibacterial therapy and intravenous infusion of 2.5% thiotriazolin solution was effective; in extended peritonitis without concurrent pathology the application of potassium chloride was the method of choice. After the laparostomy conduction with programmed sanation the prolonged therapy using 2.5% thiotriazolin solution in maximal concentration was administered, in patients with general peritonitis and closed abdominal cavity the sittings of hyperbaric oxygenation were applied. Application of proposed differential complex correction of the AAS and EC disorders in conjunction with surgical methods of treatment had permitted to avoid mortality as a complication of appendicular peritonitis in last decade.     

The effects of repeat laparoscopic surgery on the treatment of complications resulting from laparoscopic surgery

Laparoscopic surgery is frequently applied in the operative management of appendicitis and symptomatic cholelithiasis because it is a minimally invasive procedure. There are, however, some complications of laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA) that result in the need for reoperation. In the current study, we examine the effects of repeat laparoscopic surgery on the treatment of complications arising from LC/LA. From April 2005 to March 2011, we examined a cohort of patients who had received LC or LA and experienced complications that required reoperations. We focused on patients with postoperative hemorrhages, postoperative peritonitis, early postoperative small bowel obstructions (EPSBO), and biliary complications (after LC) who were treated through a repeat laparoscopic approach. The general demographics of the patients, their postoperative complications, procedures for selecting the appropriate reoperation method, and repeat laparoscopic findings are described in detail. During the 6-year period examined, 1608 patients received LC and 1486 patients received LA at the hospitals participating in this study. In patients with complications requiring reoperation, the repeat laparoscopic approach was performed successfully (without the need for further laparotomy) in 50 per cent of the patients with postoperative hemorrhage (2 of 4), 50 per cent of the patients with postoperative peritonitis (2 of 4), 75 per cent of the EPSBO patients (3 of 5), and 50 per cent the of patients with biliary complications (1 of 2). The repeat laparoscopic approach is an appropriate method for the management of complications arising from laparoscopic surgery. In patients with postoperative hemorrhage, laparoscopic hemostasis and hematoma evacuations can be performed while maintaining stable hemodynamics. In addition, laparoscopic approaches are also feasible for selective post-LC ductal injuries, EPSBO, and unconfirmed diagnoses of peritonitis after laparoscopic surgery.     

Surgical procedures on aorto-iliac segment from mini-approach in chronic lower limb ischemia

First experience of reconstructive surgeries on aorto-iliac segment from mini-approach at 62 patients (1st group) is analyzed. Control (2nd) group consisted of 80 patients operated with traditional techniques. Both groups were similar by main parameters; patients of 1st groups had more concomitant diseases. Mini-invasive methods did not lead to increase of overall surgery and aorta clamping time. Postoperative period was easier at patients of 1st group. Postoperative complications were seen at 5 (8%) patients of 1st group, 1 (1.6%) patient died; at 2nd group the postoperative complications were diagnosed at 8 (10%) patients, 2 (2.5%) patients died. The postoperative hospital stay was 8.47+/-0.9 days at patients of 1st group compared with 15.7+/-1 days at patients of 2nd group.     

Characteristics of surgical tactics in children with acute appendicitis

There were 849 children with various forms of acute appendicitis under observation in 1988. Generalized and circumscribed peritonitis was found in 44.2% of cases. The new clinical approach-based introduction of a previously elaborated surgical tactics showed it to be rational. The changing conditions led to a wider use of diagnostic laparoscopy, rejection of the "lavage" system in the postoperative period, and introduction of the method of laparostomy which is simpler and more effective.     

Laparostomy in the treatment of severe peritonitis: a review of 60 cases

The aim of this study was to evaluate the use of laparostomy in the management of patients with severe abdominal infections. From June 1992 to December 2000 sixty patients with severe peritonitis were treated with laparostomy and studied retrospectively. Thirty-eight had post-operative peritonitis. Twelve patients had necrotic pancreatitis. Five patients had peritonitis due to ischemic colitis. Two patients had hemoperitoneum following multiple abdominal operations, and three patientshad severe wound dehiscence. The APACHE II score was used to determine the severity of patients' condition. The median age was 46 years, the mean APACHE II score was 19.7, and the observed mortality was 38.3%. The incidence of spontaneous fistulation of the exposed loop of intestine was 13.3%. In 11 patients abdominal wall closure was accomplished by primary intention. Incisional hernias were inevitable in the rest of patient and were repaired 1 years after surgery. Laparostomy is a good way to manage patients with severe peritonitis but it should be performed before irreversible septic shock and subsequent multi organ failure develop.     

Algorithm for the management of large abdominal wall defects due to laparostomy wounds following intra-abdominal catastrophe

Background

Abdominal reconstruction of large defects is a challenge, and there is an additional morbidity and mortality when it is associated with emergency laparotomy or laparostomy. This study describes the surgical management of abdominal defects and describes an algorithm for complex abdominal reconstruction. We assessed complications such as fistula formation and the development of incisional hernias following formalised introduction of laparostomy for the management of these emergency patients.

Methods

A retrospective case review of 89 patients who underwent emergency laparotomy with laparostomy formation between January 2007 and March 2009 in our hospital was carried out.

Results

During the 27-month study period, 89 patients (33 females, median age 60, range 12–86) underwent emergency laparotomy and formation of laparostomy. Thirty-one patients (35 %) died. Failure of laparostomy closure was inversely related to death (p?=?0.001). Thirty of 58 patients who survived (52 %) had their laparostomy closed prior to discharge from intensive care (mean 4 days, range 1–7). Of the 28 patients who did not have their laparostomy closed prior to discharge from intensive care, 13 subsequently underwent abdominal reconstruction using Vicryl® mesh and primary closure as there was minimal tension to close the abdomen. The remaining 15 patients had tension at the wound edge and so underwent a two-stage abdominal reconstruction by initial skin grafting followed by active abdominal wall reconstruction using a modified component separation technique. No dermal substitutes were required.

Conclusions

The aim of a tension-free closure was achieved using a one- or two-stage abdominal reconstruction algorithm. A lateral release of fascia avoids the need for artificial dermal substitutes and can be used in the presence of a stoma. Multidisciplinary team decision making improves primary fascial closure rate and minimises the risk of enterocutaneous fistulae and incisional hernia formation. Level of Evidence: Level IV, therapeutic study     

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.     

Current trends in surgical treatment of peritonitis

Results of treatment using laparoscopic operations, traditional laparotomy with passive abdominal drainage and laparostomy at 1835 patients with peritonitis are analyzed. It is demonstrated that choice of surgical policy depends on ethiology, generalization of peritonitis, abdominal microphlora, degree of endogenous intoxication and organs failure, prognosis of disease. Lethality after laparoscopic operations was 1.8%, after traditional laparotomy--3.4%, after laparostomy--47.7%. Lethality at local peritonitis was 1.3%, at generalized--13.8%, at postoperative--22%. General lethality was 7.4%. Experimental studies on 55 mongrel dogs demonstrated the advantage of mechanical suture at peritonitis that prevents insufficiency of anastomoses.     

New approaches to the surgical treatment of diffuse peritonitis]

OBJECTIVE: We intend to analyze if additional treatment concepts are necessary in any case as a part of the standard therapy next to the well established principle of source control in the treatment of secondary peritonitis. DESIGN: A treatment concept with early intervention, source control and extensive intraoperative lavage (20-301) should be evaluated as a standard procedure in a prospective survey. Additional treatment concepts will be applied only for special reason (on demand). RESULTS: From 11/1993 to 9/1997 241 patients with diffuse peritonitis were treated with the concept mentioned above. Additional treatment concepts as continuous postoperative lavage (n = 20) and staged lavage (n = 4) were applied as primary treatment in 24 patients only (10%), mainly for impossibility of source control and evisceration. Source control at the initial operation was possible in 216 patients (90%). Due to secondary evisceration 3 patients had to undergo laparostomy for staged lavage later. Severity of peritonitis was determined according to the Mannheim Peritonitis Index (median 26, range 15-43). The primary causes of peritonitis were perforation, leakage and abscess after operation (n = 56), followed by diverticular (n = 42) and gastric or duodenal perforation (n = 39). The hospital mortality rate was 14% in the whole group, and the postoperative morbidity rate was 39%. CONCLUSIONS: Due to progress in intensive care and antibiotic treatment only a few patients (ca. 10%) need additional therapies such as postoperative or staged lavage. Surgical source control in combination with intraoperative lavage is sufficient in most of the patients with diffuse peritonitis.     

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.     

Postoperative morbidity, functional results and quality of life of patients following orthotopic neobladder reconstruction

AIM: To evaluate postoperative morbidity, functional results and health-related quality of life of patients with an orthotopic neobladder. METHODS: A total of 37 patients with orthotopic neobladder (modified Studer method: 35 cases; Hautmann method: one case; sigmoid neobladder: one case) were included in the present study. Postoperative morbidity and neobladder function were analyzed. To determine quality of life, the Sickness Impact Profile questionnaire was used. The quality of life of patients who underwent orthotopic neobladder was compared with that of patients who underwent ileal conduit. RESULTS: In 37 consecutive patients with neobladder reconstruction, early complications included 10 cases of pyelonephritis (27.0%) and one of stenosis of ureterointestinal anastomosis (2.7%). Two patients died of ARDS and sepsis following peritonitis and pneumonia in the perioperative period. Late complications included pyelonephritis in three patients (8.6%). In 32 cases, except for an early postoperative case and those that died, complete daytime and night-time continence was achieved in 31 patients (96.9%) and 16 patients (50.0%), respectively. Concerning health-related quality of life, the mean sum scores per category of the Sickness Impact Profile were calculated for 32 patients with orthotopic neobladder and 30 patients with ileal conduit. There were no significant differences in overall satisfaction, however, the scores for patients with orthotopic neobladder reconstruction were significantly higher than those for patients with ileal conduit in the three categories of emotions, feelings and sensation, social interaction and recreation. CONCLUSION: Orthotopic neobladder reconstruction exhibited good functional results with acceptable complications. Patients who underwent neobladder reconstruction were satisfied with their voiding. Assessment of quality of life using the Sickness Impact Profile questionnaire demonstrated that orthotopic neobladder improved their quality of life better than ileal conduit, especially with regard to mental, physical and social functioning in daily life.