Clinical Features and Outcome of Postoperative Peritonitis Following Bariatric Surgery

Background

We assessed the clinical features and outcome of morbidly obese patients admitted to the intensive care unit (ICU) for management of postoperative peritonitis (POP) following bariatric surgery (BS).

Methods

In a prospective, observational, surgical ICU cohort, we compared the clinical features, empiric antibiotic therapy, and prognosis of BS patients with those developing POP after conventional surgery (cPOP).

Results

Overall, 49 BS patients were compared to 134 cPOP patients. BS patients were younger (45?±?10 versus 63?±?16 years; p?<?0.0001), had lower rates of fatal underlying disease (39 vs 64 %; p?=?0.002), and the same SOFA score at the time of reoperation (8?±?4 vs 8?±?3; p?=?0.8) as the cPOP patients. BS patients had higher proportions of Gram-positive cocci (48 vs 35 %; p?=?0.007) and lower proportions of Gram-negative bacilli (33 vs 44 %; p?=?0.03), anaerobes (4 vs 10 %; p?=?0.04), and multidrug-resistant strains (20 vs 40 %; p?=?0.01). Despite higher rates of adequate empiric antibiotic therapy (82 vs 64 %; p?=?0.024) and high de-escalation rates (67 % in BS cases and 51 % in cPOP cases; p?=?0.06), BS patients had similar reoperation rates (53 vs 44 %; p?=?0.278) and similar mortality rates (24 vs 32 %; p?=?0.32) to cPOP patients. In multivariate analysis, none of the risk factors for death were related to BS.

Conclusions

The severity of POP in BS patients resulted in high mortality rates, similar to the results observed in cPOP. Usual empiric antibiotic therapy protocols should be applied to target multidrug-resistant microorganisms, but de-escalation can be performed in most cases.     

Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli. Study of an outbreak in an intensive care unit

STUDY OBJECTIVE: To study the efficacy of intestinal decontamination by oral nonabsorbable antibiotic agents to control a nosocomial outbreak of intestinal colonization and infection with multiresistant Enterobacteriaceae, and to examine its effects on endemic nosocomial infection rates. DESIGN: A 10-week prospective incidence study (group 1), and then an 8-week randomized, open trial of intestinal decontamination (groups 2 and 3). SETTING: A medical intensive care unit of a tertiary care university hospital. PATIENTS: Consecutive patients with unit stay of over 2 days and a severity score at admission of more than 2; 124 patients were included in group 1, 50 in group 2 (control), and 36 in group 3 (intestinal decontamination). INTERVENTIONS: Neomycin, polymyxin E, and nalidixic acid were given to group 3 patients throughout their stay in the unit. MEASUREMENTS AND MAIN RESULTS: Intestinal colonization with multiresistant strains occurred in 19.6% of patients in group 1, at a mean of 16 days after admission, and preceded detection in clinical samples by a mean of 11 days. During the decontamination trial, intestinal colonization rates decreased to 10% (group 2), and 3% (group 3) (P = 0.12 and P less than 0.01, compared with group 1, respectively). Corresponding infection rates were 9% (group 1), 3% (group 2), and 0 (group 3). No new cases were detected in the following 4 months. The intestinal colonization rate with gram-positive cocci was higher in group 3 than group 2 (P less than 0.001). The overall rate of nosocomial infections was at 28% (group 1), 33% (group 2), and 32% (group 3). CONCLUSIONS: Intestinal decontamination can help to control an outbreak of intestinal colonization and infection with multiresistant gram-negative bacilli in the intensive care unit, but should not be recommended for routine prevention of endemic nosocomial infections.     

Renovascular hypertension with renal failure: value of renal revascularization

The purpose of this work was to determine the effects of renal revascularization on blood pressure and renal function in 9 patients with arterial stenosis involving both kidneys (7) or a solitary kidney (2). There were five women and four men with a mean (SD) age for 64.5 +/- 7 years. The duration of hypertension ranged from 2 to 28 years (mean = 12 +/- 8). Blood pressure ranged from 210/100 to 260/150 mmHg, despite the use of three or more antihypertensive agents in 7 cases. The serum creatinine level, on presentation, ranged from 160 to 265 mumol/l (mean = 198 +/- 30 mumol/l). Intravenous pyelograms were not suggestive of renovascular disease in 4 of 7 cases. Digital angiography or arteriography demonstrated severe stenosis of the artery of the solitary kidney in 2 patients, severe bilateral atherosclerotic disease in 7 patients, three of them had complete occlusion of a main renal artery. During hospitalization, therapy with captopril (5 patients) or minoxidil (1 patient) lowered blood pressure in 3 cases, but induced a marked increase in serum creatinine level in 4 cases. In two patients, medically treated, severe and rapidly progressive impairment of renal function was observed. The seven remaining patients underwent surgical revascularization (two after unfructuous percutaneous transluminal angioplasty). One died 45 days later. Blood pressure control with diastolic blood pressure of 100 mmHg or less was achieved in the other six, although each patient continued to require antihypertensive medication (bitherapy: 2, monotherapy: 4).(ABSTRACT TRUNCATED AT 250 WORDS)     

Role of radioisotopic investigations in breast cancer diagnosis and follow-up

Breast cancer represents the disease with the highest incidence in the female population. In the last years there was observed, in western countries, an increase of morbidity by breast tumors and in the same time, a decrease of mortality in direct relation with an earlier diagnosis. Until the spread at distance, breast cancer it's a loco-regional disease that can be curable by surgical treatment and adjuvant therapy, like chemotherapy or radiotherapy. The principal goal is to diagnose it before distal metastases appear, most frequently bone metastasis. Certain role has nuclear medicine in the diagnosis and prognosis of breast cancer because it's more sensitive and gives functional imaging. The aim of this study is to answer the question: what technique, in what indication. The detection of sentinel lymph node has now a clear place in the algorithm, the scintimammography test is important, especially for prediction of tumor resistance to chemotherapy. The bone scintigraphy (which explores the entire body in one time)is generally used in the detection of bony metastases and FDG tomoscintigraphy for the evaluation of local and distal recurrences, or response to chemotherapy. The measure of the isotopic ejection fraction, actually considered the gold standard, is very useful and also very easy to perform, in patients who will receive chemotherapy.     

Detection of recurrent colorectal carcinoma by 18F-FDG: comparison of the clinical performances of FDG PET and FDG CDET

OBJECTIVES: To assess the clinical performance of fluorodeoxyglucose positron emission tomography (FDG PET) using either a coincidence (CDET) gamma camera or PET equipment with Nal crystals for the detection of recurrences of colorectal cancer. METHODS: From July 1997 to December 1999, 290 examinations were performed in 244 patients using a CDET gamma camera (2-dimensional system with 19 mm thick crystals). Additionally, from January 2000 to July 2002, 354 examinations were performed in 303 patients using PET (3-dimensional system with Nal crystals). RESULTS: Four hundred and seventy-three of the 644 examinations performed were evaluable on the basis of histological data (202 examinations) or more than 6 months of follow-up (273 examinations). The performances of the two systems were equivalent on a patient basis (sensitivity, specificity and accuracy of dedicated PET was 92%, 84% and 90%, respectively; and sensitivity, specificity and accuracy of CDET was 90%, 94% and 91%, respectively). On a site basis, a highly significant reduction in sensitivity was observed for lesions < or = 10 mm vs. > 10 mm with both PET and the CDET gamma camera, but no difference was observed between PET and CDET according to the size of the lesions. CONCLUSION: For detection of recurrent colorectal carcinoma, a 2-D coincidence gamma camera with 19 mm thick crystals and optimized acquisition and reconstruction parameters provides similar results in terms of accuracy, both per patient and per site, to those of an Nal PET camera.     

Superinfection of posttraumatic retroperitoneal hematoma secondary to ascending urinary tract infection

Retroperitoneal hematoma is a common feature after blunt abdominal trauma, but secondary infection of these hematomas is a rare complication and its mechanisms have not been fully elucidated. We report a case of infected retroperitoneal hematoma secondary to renal trauma related to ascending urinary tract infection.     

Epidural anesthesia for Cesarean section in a patient with von Hippel-Lindau syndrome

Von Hippel-Lindau (VHL) disease is an autosomal dominant disorder with variable penetrance. It is mainly characterized by haemangioblastomas of the retina and central nervous system. Because of physiological effects of uterine contractions, labour and spontaneous vaginal delivery increase the risk of disrupting central nervous system haemangiblastomas. We report the case of a 28-year-old woman with an history of VHL disease who had an epidural anaesthesia for labour and for Caesarean section performed because of failure to progress and of fetal distress. The overall maternal and neonatal outcomes were excellent.     

Microbiological and inflammatory effects of murine recombinant interleukin-10 in two models of polymicrobial peritonitis in rats

A protective effect of interleukin-10 (IL-10) against the development of lethal shock has been demonstrated in various animal models. In contrast, the immunosuppressant properties of this mediator have been minimally evaluated in low-mortality models of infections. The clinical, microbiological, and inflammatory effects of murine recombinant IL-10 (mrIL-10) therapy were evaluated in two models of peritonitis in rats, which differed in the degree of severity of peritoneal inflammation 3 days after inoculation of Escherichia coli and Bacteroides fragilis with or without Enterococcus faecalis. The severity of the disease remained unchanged compared to that in control animals. A dose-related decrease in the peritoneal phagocyte count was observed in the treated groups compared to the counts in control animals. The subsequent experiments were performed exclusively in the mixed gram-positive-gram negative model, which exhibits an intense and prolonged inflammatory response with similar criteria. The early effects of mrIL-10 (evaluated 6 h after inoculation), repeated injections of mrIL-10 (four doses injected from 0 to 9 h after bacterial challenge), and pretreatment (two doses injected 6 and 3 h before inoculation) were evaluated. The clinical and microbiological parameters remained unchanged in the treated animals. Decreases in the peritoneal phagocyte count and the peritoneal concentration of tumor necrosis factor were observed following repeated injections of mrIL-10. In summary, our data suggest that mrIL-10 does not worsen the manifestations of sepsis. However, these results need to be confirmed in clinical practice.