Postoperative peritonitis after elective surgery

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Postoperative peritonitis after elective surgery

  1. 1. Postoperative peritonitis after elective surgery<br />Hakan Yanar, MD<br />IstanbulUniversity, IstanbulFaculty of Medicine,<br />General Surgery Service <br />Istanbul, Turkey<br />12 thEuropeanCongress of TraumaandEmergencySurgery<br /> April, 27-30, 2011, Milan<br />
  2. 2. Synonymous<br />Abdominalsepsis<br />İntraabdominalinfection<br />Peritonitis<br />
  3. 3. Post-operativeperitonitis<br />Morbidityandmortality↑↑<br />Multidisciplinaryapproach (surgeon, intensivist, interventionalradiology, infectiousdiseases…)<br />Earlydiagnosisandcorrectionunderlyingmicrovasculardisfunction ↑↑ survival<br />Term, concencus<br />
  4. 4. Mortality<br />Among patients with perforatedappendicitis1%, <br />Complicated intra-abdominal infections overall: 6%, <br />A non-appendiceal source of intra-abdominal infection:13%,<br />Intra-abdominal infections -severely ill patients: 17% to 32%.<br />Sartelli M, W J Em Surg, 2011<br />
  5. 5.
  6. 6.
  7. 7.
  8. 8. Intra-abdominal infections are generally the result of invasion and multiplication ofenteric bacteria in the wall of a hollow viscus or beyond<br />May be “complicated” or “uncomplicated” intra-abdominal infection<br />
  9. 9. Classification of Peritonitis<br />SurgClin N Am, 2009<br />
  10. 10. Secondaryperitonitis<br />Post-cholecystectomy<br />Traumaticliverinjury<br />
  11. 11. Pathogeneticprinciples (1)<br />
  12. 12. Pathogeneticprinciples (2)<br />
  13. 13.
  14. 14. Anatomyintra-abdominalinfections<br /><ul><li>Infections of parenchymatousorgans
  15. 15. Infections of thewalls of viscera (cholys, appy)
  16. 16. Infections of serousmembranesandspaces</li></li></ul><li>Rarecauses / Foreign bodies<br />Macroscopic:<br />Surgical drains<br />Suture<br />Laparotomy sponges<br />Hemostatic pads and powder<br />Surgical clips<br />Microscopic:<br />Barium sulfate<br />Clothing gibers, fecal material<br />Necrotic tissue<br />Talcum powder<br />
  17. 17. Missedpads<br />
  18. 18. Meckel’sdiverticulitis<br />
  19. 19. Hemostatic powderandpads <br />
  20. 20. Remmantapandisitis<br />
  21. 21. Inflammatuaryboweldiseases<br />
  22. 22. Bacteriology<br />The resident gastrointestinal flora are the cause of most intra-abdominal infections:<br />Level of Gastrointestinal Perforation:<br /><ul><li>In the terminalileum, bacterial counts may reach 108 organisms per gram of contents, and manyanaerobic organisms are present in addition to the aerobic organisms.
  23. 23. In the colon,1010to 1011microorganisms are present per gram of contents, and obligate anaerobicmicroorganisms predominate by as much as 100 to 1000 fold over the aerobic andfacultativeanaerobicmicroorganisms</li></ul>Virulence:<br /><ul><li>Impairs opsonization or phagocytosis & abscess formation. -------> B. fragilis (polysaccharide capsule).</li></li></ul><li>Microbial adherence to peritoneum:<br /><ul><li>Bacteria adherent to the peritoneum are resistant to removal by peritoneal lavage, in contrast to bacteria in peritoneal fluid.
  24. 24. 1st 4hrs ----> aerobic E. coli, etc
  25. 25. 8hrs. -------> B. fragilis</li></ul>Microbial synergy:<br /><ul><li>Aerobic gm(-)bacteria – lowers oxidation – reduction potential; endotoxin produced suppress local host defense
  26. 26. B. fragilis – capsular polysaccharide interferes complement activation and inhibit leukocyte function</li></li></ul><li>MicrobialSynergy in“MixedInfections”<br />
  27. 27. Causativebacteria<br />CommonBacteria:<br />E. coli<br />Enterococcusfaecalis<br />Klebsiellaspeices<br />Staphylococci<br />MRSA<br />P. aeruginosa<br />Proteusspeices<br />Bacteroidessp.<br />
  28. 28.
  29. 29. Morales, et al<br />Intraabdominal infection after trauma<br />Escherichia coli (n = 39 [43.3%])<br />Staphylococcus aureus (n = 17 [18.9%])<br />Klebsiellapneumoniae (n = 13 [14.4%])<br />Enterococcusfaecalis (n = 5 [5.6%])<br />
  30. 30. ClinicalSymptoms<br />Abdominalpain<br />Anorexia<br />Nausea, vomiting<br />Fever (38ºC↑)<br />Abdominaldistentionandtenderness<br />Hypoactive or faint bowel sounds<br />
  31. 31. Clinicalfinding<br /><ul><li> 71% with leak exhibited at least one of above features before POD #5
  32. 32. Typicallyoccurs 5-7 days, but may be muchwider</li></ul>Alves A et all, J AM CollSurg, 1999<br />
  33. 33. Suspitionof AL<br />Combination of signs observed before day 5<br />If 2 – leakage 18%<br />If 3 – leakage 67%<br />Reoperatedafterday 5 (5 of 23 patients) death 22% versus 0% reoperatedbefore day 5 (0 of 11 patients)<br />Alves A & all, J AM CollSurg, 1999, 189:554-9<br />
  34. 34. Early prediction of anastomotic leakage after colorectal surgery by measuring peritoneal cytokines: prospective study.<br />34 pts, interleukin (IL)-6, IL-10 and tumor necrosis factor-alpha were measured<br />Clinically evident AL in 4 patients (11.7%)<br />Positive correlation between AL and peritoneal cytokine levels<br />The peritoneal cytokine levels can be an additional diagnostic tool that can support the early prediction of AL in colorectal surgery.<br />Uğraş B, Int J Surg 6;2008:28-35<br />
  35. 35. Diagnostictools<br />
  36. 36. AXR<br />look for free gas, bowel obstruction, or subtle signs ofintestinalischaemia<br />water-soluble contrast studies can show leaks <br />injection of contrast into drains, fistulae or sinus tracts may help demonstrate anatomy of complex infectios and help monitor adequacy of abscess drainage <br />
  37. 37. Ultrasound<br />advantage of being portable and almost risk-free <br />useful for: <br />identifying abscesses and fluid collections <br />guidance of percutaneous drainage procedures <br />detection of free fluid <br />evaluation of biliary tree <br />disadvantages: <br />operator dependent <br />difficult to perform in patients who have abdominal dressings or paralytic ileus<br />
  38. 38. CT abdomen<br />with use of IV and oral or rectal contrast most causes of secondary peritonitis can be readily diagnosed requires movement of potentially unstable patient out of ICU <br />relative contraindications: <br />renal dysfunction: contrast may aggravate renal dysfunction <br />paralytic ileus<br />aspiration<br />a negative CT generally indicates a very low probability of a process that can be reversed by surgical intervention, however bowel ischaemia cannot be excluded, particularly in the early stages <br />
  39. 39. Osofagojejunostomyleakageafter total gastrectomy<br />
  40. 40. Anastomosisleakageafterileostomyclosure<br />
  41. 41. Leakageaftercolocolicanastomosis<br />
  42. 42. Perforatedappendicitis /pocollection<br />
  43. 43. pomultipleabscessaftercholecystectomyandliverresectionforgallbladdercancer<br />
  44. 44. FluidcollectionafterWhippleoperation<br />
  45. 45. TheMannheimperitonitisindex->Most popular scoringsystem<br /><ul><li>Prognosticparamater
  46. 46. Effectiveforpredictingmortalityfromsecondaryperitonitis
  47. 47. Helps to guidedecisionforearlysurgery</li></li></ul><li>Acute Physiology and Chronic HealthEvaluation II(APACHEII) scoringsystem<br />Severity of the systemic responseto intraabdominal infection <br />Organism’s physiologic statuscan be estimate<br />
  48. 48. Management ofIntra-AbdominalInfections<br />Combinationof modalities:<br />Appropriatesystemicantimicrobialtherapy<br />Physiologicalresuscitation, support of vitalfunctions:<br />Bloodpressure/fluidreplacement<br />Monitorheart rate<br />Monitor urine out put (0.5 ml/kg/hr)<br />“Sourcecontrol”<br />Prompt drainage of abscess (secondary peritonitis) and/ordebridement<br />The type and extent of surgery depends on the underlying disease process and the severity of intra-abdominal infection. <br />Resection of perforated colon, small intestine<br />Repairof trauma<br />
  49. 49. Goals of Antimicrobial Therapy forIntraabdominalInfections<br />Adjunct to the use of appropriatesource control <br />Hastenelimination of infectingmicroorganisms<br />Shorten clinical manifestations of infection<br />Minimize risk of recurrent infection<br />Begun when diagnosis is suspected<br />Anticipate pathogens most likely to beencountered at site of infection<br />
  50. 50.
  51. 51.
  52. 52. Marshall description of sourcecontrol <br />drainage of abscesses or infected fluid collections, <br />debridement ofnecrotic infected tissue, <br />definitive measures to control a source of ongoing microbialcontamination <br />to restore anatomy and function.<br />Marshall JC. MicrobesInfect 2004;6:1015–25.<br />
  53. 53. Source control<br />
  54. 54. Drainage<br />percutaneous ultrasound or CT guided drainage is initial intervention of choice for management of localized, radiologically defined infectious foci <br />can also be used as a temporary decompress infected retroperitoneal collections in patients with necrotizing pancreatitis<br />
  55. 55. Percutaneousabscessdrainage<br />Prerequisites<br />≤3 abscesses, preferably single abscess<br />abscess(es) unilocular<br />safepercutaneousapproach<br />low viscosity of content, little debris<br />Success<br />excellent: liver and periappendicealabscesses<br />fair: postoperative, peridiverticular<br />poor: pancreatic<br />outcome predictors in highly selected patients<br />neg.: abscesses containing yeast, pancreatic origin<br />pos.: postoperativeabscesses<br />Montgomery, Clin Infect Dis 1995; 23: 28<br />Cinat et al., ArchSurg 2002; 137: 845<br />
  56. 56. po 6 thdayafter LAR<br />
  57. 57.
  58. 58.
  59. 59. Stenosis at anastomosis on 4th cm <br />
  60. 60. Indications for surgical drainage<br />failure of percutaneous drainage <br />collections with a significant solid tissue component requiring debridement <br />simultaneous management of a source of ongoing contamination <br />when local peritoneal defences have not contained the infectious focus, resulting in generalized peritonitis <br />
  61. 61. Debridement<br />in contrast to drainage which removes the liquid component of an infection, debridement is the physical removal of infected or necrotic solid removal <br />less frequently required in patients with intra-abdominal infection <br />main indications in this setting: <br />intestinal infarction <br />infected peripancreatic necrosis <br />
  62. 62.
  63. 63.
  64. 64. Scheduledrelaparotomy vs repeatlaparotomy<br />Scheduledrelaparotomy every 36to 48 hours vs repeat laparotomy based on clinical indications in 232 patients <br />Scheduled relaparotomy did not result indecreased mortality or major morbidity, and was associated with increased costsand use of health care resources. <br />Mandatoryrelaparotomy does not appearto be beneficial for most patients who have diffuse, secondary peritonitis in theabsence of a clear indication for the procedure.<br />Van Ruler O, et al. JAMA 2007;298:865–73.<br />
  65. 65.
  66. 66. Plannedrelaparatomy<br />Earlydetection of persistentinfection<br />Limitidadhesionformation<br />Relaparotomy on demand<br />Preventunneccessaryoperations<br />May allow to developcontainedinfectionaccessible to percutaneousinterventionaltechniques<br />
  67. 67. Intestinalischemia “secondlook”<br />
  68. 68.
  69. 69. Anastomotic leakage (AL)<br /><ul><li>Anastomotic leakage occurs in 5 - 15% after colorectal surgery
  70. 70. Leads to substantial morbidity and mortality
  71. 71. Many factors determine AL
  72. 72. Patient related
  73. 73. Surgery (treatment) related</li></li></ul><li>Risk factors for AL<br />Multivariate analysis<br />Male sex increased risk of AL 13 fold in LAR or PCA<br />Lower than 10 cm anastomoses (3,5 fold increase compare with higher than 10 cm)<br />ASA group 4 (2,5 fold increase risk of AL to compare with ASA 1-3<br />D.Pavalkis, Medicina,2001, 39:421-425<br />
  74. 74. Definationandgrading of severity<br />foranastomoticleakage<br />Surgery, March, 2010<br />
  75. 75. Management of AL<br />Management should be individualized to accommodate patient’sneeds. <br />Available strategies: observation andbowel rest, percutaneous drainage, colonic stenting, andsurgical revision, diversion, or drainage. <br />
  76. 76. With a small degreeof contamination, right-sided colonic leaks-> can oftenbe re-anastomosed<br />With more extensive contamination-> resection with ileostomy and mucous fistula orcreation of a Hartman’s pouch should be used. <br />
  77. 77. Managementof left-colon leaks depends on the level of the anastomosis.<br />Intraperitoneal leaks should be resected with theends brought out as ostomies, if possible. <br />Extremely lowanastomotic leaks should be extensively drained with proximalcomplete diversion with either an ileostomy or colostomy.<br />
  78. 78. Management of anastomotic leaks in an era ofexpandingtechnology- alternatives to surgery<br />Stends<br />Clipapplications<br />Pluggingwithsealants<br />VAC<br />
  79. 79. Stents<br />Small dehiscence (less than 30% of the circumference) can bemanaged successfully with clips, fibrin glue injection, or stent insertion<br />Dehiscence of 30% to 70% of the circumference requires endoscopicinsertion of stent <br />Larger dehiscence or total dehiscence of anastomosisrequire surgery<br />
  80. 80. Clipapplication<br />Three types of clip devices are commercially available: <br />Olympus ‘‘QuickClip”,<br />Wilson-Cook ‘‘Tri Clip”,’’ and <br />Boston Scientific ‘‘Resolution Clip”<br />
  81. 81. Pluggingwithsealants<br />Currently available sealants for endoscopic use:<br />Fibrin glue, <br />Cyanoacrylates,and<br />Surgissis<br />
  82. 82. Fibrin glue<br />
  83. 83. Video<br />VAC& anastomoticleakage<br />
  84. 84.
  85. 85. Anastomosisleakage<br />4 thday<br />
  86. 86. 28 thday<br />21th day (1 ml fibrin glue)<br />
  87. 87. Takehome<br />Earlydiagnosis / earlysourcecontrol<br />Antibiotics<br />Drainage, debridemen<br />Conservativemethods (Clips, stends, fibrin glue, VAC)<br />Surgery<br />
  88. 88. Thanks to<br />Arzu Poyanlı, Prof Dr, <br />From İstanbul Faculty of MedicineDepartment of Radiology<br />Türker Bulut, Prof Dr,<br />From İstanbul Faculty of MedicineDepartment of General Surgery<br />

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