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Postoperative peritonitis after elective surgery
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Postoperative peritonitis after elective surgery Presentation Transcript

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