Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

/pdf/diagnosis-and-management-of-complicated-intra-abdominal-kghvsqwnes.pdf

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

A b s t r ac t Results At 28 days, 223 of 846 patients (26.4%) in the DrotAA group and 202 of 834 (24.2%) in the placebo group had died (relative risk in the DrotAA group, 1.09; 95% con - fidence interval (CI), 0.92 to 1.28; P = 0.31). At 90 days, 287 of 842 patients (34.1%) in the DrotAA group and 269 of 822 (32.7%) in the placebo group had died (relative risk, 1.04; 95% CI, 0.90 to 1.19; P = 0.56). Among patients with severe protein C deficiency at baseline, 98 of 342 (28.7%) in the DrotAA group had died at 28 days, as compared with 102 of 331 (30.8%) in the placebo group (risk ratio, 0.93; 95% CI, 0.74 to 1.17; P = 0.54). Similarly, rates of death at 28 and 90 days were not signifi - cantly different in other predefined subgroups, including patients at increased risk for death. Serious bleeding during the treatment period occurred in 10 patients in the DrotAA group and 8 in the placebo group (P = 0.81). Conclusions DrotAA did not significantly reduce mortality at 28 or 90 days, as compared with placebo, in patients with septic shock. (Funded by Eli Lilly; PROWESS-SHOCK ClinicalTrials.gov number, NCT00604214.)

/pdf/drotrecogin-alfa-activated-in-adults-with-septic-shock-1mkg9jbqcd.pdf

Drotrecogin alfa (activated) in adults with septic shock

Causes and consequences of comorbidity: a review.

Although most patients with acute pancreatitis have the mild form of the disease, about 20–30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20–40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27–30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.

/pdf/2019-wses-guidelines-for-the-management-of-severe-acute-zz2e5or44j.pdf

2019 WSES guidelines for the management of severe acute pancreatitis

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.

Some patients are prone to persisting intraabdominal infection regardless of initial eradication of the source of infection. Our aim was to characterize patients who had to undergo relaparotomy for persisting abdominal sepsis using simple clinical parameters and to define those patients who are susceptible to benefit of aggressive surgical treatment by early and repeated reoperations to control multiple organ dysfunction syndrome (MODS) caused by ongoing intraabdominal infection. Persisting abdominal sepsis was the cause of death in all of our patients who had to undergo relaparotomy. Controlling persisting abdominal sepsis should achieve a reduction in the tremendously high mortality rate. Performing a case-control study, we retrospectively reviewed 523 consecutive patients with secondary peritonitis treated from 1986 to 1996 and focused our attention on 105 patients, in whom standard surgical treatment of secondary peritonitis failed and who had to undergo relaparotomy for persisting abdominal sepsis (study group). Overall, there was no significant difference in the postoperative mortality rate between “planned relaparotomy” and “relaparotomy on demand” (54.5% versus 50.6%). Equally clear risk estimations were given preoperatively by both the Acute Physiology and Chronic Health Evaluation (APACHE) II and the Goris scores. There was a significant difference between patients of the control group and patients of the study group with regard to preoperative APACHE II score, Goris score, age >70 years, albumin 70 years of age with secondary peritonitis extending over the entire abdomen and a greater degree of physiologic compromise (serum albumin levels 20, and existing organ failure measured by the Goris score) are at high risk for developing persistent intraabdominal infection. Our data show that timely relaparotomy provides the only surgical option that significantly improves outcome. However, aggressive surgical treatment has reached its limit in patients whose source of infection could not be controlled at the initial operation. To improve overall survival the decision to perform a relaparotomy on demand after an initially successful eradication of the source of infection must be made within 48 hr, at least before MODS emerges.

Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection.

Objectives: To assess the clinical significance of present scoring systems for prognosis and treatment in patients with secondary bacterial peritonitis and to define risk factors for patient survival and outcome not included in the scores. A secondary objective was to review our therapeutic regimens and the need for reoperation with regard to outcome. Design: Prospective observational study. Setting: University hospital, secondary referral center. Patients: From 1992 to 1995, 92 patients with secondary peritonitis were examined at the University Surgical Clinic, Vienna, Austria. The population as a whole consisted of 56 men and 36 women with an average age of 56±19 years. Forty-four percent of patients had postoperative peritonitis. Outcome Measures: Mortality, multiple organ system failure (MOSF), relaparotomy. Results: The mortality rate in patients with an APACHE II (Adult Physiology and Chronic Health Evaualtion) score of less than 15 was 4.8%, while mortality rose to 46.7% in those with a score of 15 or higher ( P =.001). The average total mortality rate was 18.5%. The prognosis for patients without organ failure or with failure of one organ system was excellent (mortality rate, 0%); quadruple organ failure, however, had a mortality rate of 90%. Initial thrombocytopenia ( 9 /L), four-quadrant peritonitis, and diabetes mellitus were associated with significantly higher mortality. Leukopenia (white blood cells, 9 /L) and inappropriate antibiotic therapy as determined by the antibiogram were mildly significant for higher mortality. The need for relaparotomy resulted in substantially higher mortality ( P Conclusions: The prognosis in peritonitis is decisively influenced by the health status of the patient at the beginning of treatment and by any concomitant risk factors. As a result, a fairly accurate prediction of the outcome of the disease can initially be made on the basis of the APACHE II score and the MOSF score according to Goris. However, the certainty that severely ill patients with high scores often die has little clinical relevance, since it does not provide any therapeutic alternatives to the attending physician. The decision to perform a relaparotomy must be made as soon as possible, at least before MOSF emerges. Already existing MOSF will lead to the "point of no return." (Arch Surg. 1996;131:180-186)

Prognosis and Treatment of Peritonitis: Do We Need New Scoring Systems?

From 1986 to 1995 a total of 97 patients > 65 years of age underwent hepatic resections at the Department of General Surgery, Hospital Lainz, Vienna, Austria. The population consisted of 39 men and 58 women with a mean age of 74.0 +/- 5.5 years. Primary neoplasia of the liver was the cause of resection in 35 patients, gallbladder cancer in 16 patients, and metastatic disease to the liver (due to colorectal cancer in 70%) in 40 patients. The rate of major resections (> or = 3 liver segments) was 96% for primary neoplasia of the liver, 70% for metastatic disease to the liver, and 50% for gallbladder cancer; the associated mortality rates were 23%, 2.5%, and 25%, respectively. The magnitude of the resection had a significant influence on survival for gallbladder cancer (p = 0.02) and for primary neoplasia of the liver (p = 0.002) but not for metastatic disease to the liver. This reflects the high rate of cirrhosis in hepatocellular and cholangiocellular carcinoma (88%) and gallbladder cancer (37.5%). Both pre- and postoperative severe liver dysfunction had a significantly higher risk for postoperative mortality and morbidity, which showed an incremental risk with age. Another organ system able to predict outcome at the beginning of treatment by its moderate severe dysfunction were the lungs. Overall, only right and extended right lobectomies carried a significantly higher risk for postoperative mortality and morbidity. Postoperative complications were recorded in 43% of our patients, with infection the most frequent problem in nearly all of these patients (95%). Pneumonia was the leading complication associated patient survival. All patients who developed pneumonia as a late complication during a complicated postoperative course died postoperatively. The postoperative Goris score of the patients who died was 6.9 +/- 2.9 (range 3-11), whereas the surviving patients' score averaged 2.2 +/- 1.9 (range 0-9), which was significantly different (p = 0.0003). None of the 54 patients with a GORIS score or = 9 died (p = 0.0001). Severe liver dysfunction rather than the extent of resection influences clinical mortality. Patients > 80 years of age with a preoperative severe liver dysfunction showed a postoperative mortality of 57%, and all of these patients developed postoperative complications. Therefore resection cannot be recommended for those patients. Cirrhosis led to an unacceptable mortality of 44% after hepatic resection of > or = 5 liver segments for primary neoplasia of the liver. Major resections cannot be recommended in the aged with gallbladder cancer because 50% of the patients died after such operations. Overall, only resection of > or = 5 liver segments with segments I to III or less remaining were found to pose a major risk for clinical mortality and morbidity, but the cause of death was preexisting liver dysfunction and cirrhosis in all of these patients. Major resections of large neoplasia of the liver can be recommended even in the aged, but a preoperative preselection of patients with respect to liver function and pulmonary function preoperatively may help lower the postoperative morbidity and mortality, especially in patients who will undergo resection of > or = 5 liver segments. Major hepatic resection for metastatic disease to the liver in the elderly carries no additional survival risk. Patients > 65 years of age and especially those > 80 years of age are more liable to succumb to postoperative organ failure and complications, especially infections.

Hepatic resection in the elderly

n = 9) should be regarded as a palliative measure. Within a short period, CT-guided aspiration led to recurrence of symptoms in seven of our patients. Standard treatment of NPHC is fenestration with widest possible excision of the cystic wall, which can be performed laparoscopically (
 n = 10) or by the conventional surgical mode (
 n = 54). One patient was initially operated by the laparoscopic technique but developed bleeding, which necessitated conversion to the open mode. Three patients underwent synchronous laparoscopic cholecystectomy. Recurrence rates were similar: 11% in the laparoscopically treated group and 13% in the group that underwent conventional open surgery. Conventional surgical treatment was always successful in cases of solitary cysts. However, in cases of multiple cysts measuring more than 5 cm, conventional surgery was followed by recurrence of symptoms in 26% of patients (7/27), who then had to undergo a second operation. Partial resection of the liver (
 n = 9) was successfully performed in cases of polycystic disease (
 n = 5) with concomitant enlargement of the organ as well as in cases of large solitary cysts of the left lobe of the liver (
 n = 4). In patients in whom we found that the cysts communicated with the ductal system (
 n = 3), we performed a cystojejunostomy to drain the bile. The complication rate was low. In addition to frequent postoperative ascites, which necessitated no further intervention, we observed infectious complications in four patients. Twenty patients (22%) expired during a mean follow-up period of 6.2 years. Interestingly, deaths were frequently associated with malignancy (11/20). After fenestration of multiple cysts measuring > 5 cm, the patients are at high risk for recurrence. Hence partial resection of the liver is an excellent therapeutic alternative in selected patients with polycystic disease and massive enlargement of the organ in whom the disease could not be controlled by simple fenestration. The results of this study show that laparoscopic fenestration should replace the conventional surgical technique as the gold standard in cases of NPHC because the laparoscopic technique is less stressful for the patient and is associated with a rate of success similar to that of the conventional technique.

Nonparasitic cysts of the liver: results and options of surgical treatment.

Background: The prognosis of colon cancer is poorest in cases of emergency presentation of this disease in the elderly. The high rate of clinical mortality in this group of patients has made it necessary to devise a specific therapeutic approach. Objective: To define the therapeutic approach used for colon cancer in the elderly. Design: A retrospective study. Setting: A secondary referral center. Patients: Ninety-nine patients with colon carcinoma that first became clinically manifested in an emergency situation were examined retrospectively. The patients had been treated from 1986 through 1995. All patients were older than 70 years. A total of 74 patients showed clinical manifestation of a colon carcinoma with an ileus, while 10 patients had tumor perforation. A further 15 patients had a perforation proximal to an obstructing tumor. Main Outcome Measures: Clinical lethality, surgical procedure, risk of comorbidity, and multiple organ system failure. Results: Any increase in comorbidity was associated with a higher clinical lethality, which was especially true for the lungs, heart, and kidney, and also for diabetes. In 44.4% of the patients with a significantly higher comorbidity ( P =.04) and a more advanced tumor stage ( P P =.02). However, the comorbidity of deceased patients who were supposed to undergo staged resection did not differ significantly from the comorbidity of those who underwent primary resection ( P =.70). The clinical lethality in patients who were managed by stoma only or by bypass anastomosis was markedly higher than that in patients who underwent primary resection (59.0% vs 43.6%). The significantly highest postoperative mortality rate was recorded in patients who underwent primary resection after colonic perforation (74%) ( P =.03),while the significantly lowest postoperative mortality rate was recorded in patients who underwent primary resection after tumor obstruction (28%) ( P P P =.004). Postoperative complications occurred in 28 (28.3%) of the patients. However, rupture of the anastomosis was observed in only 2 of these patients. Generalized disease was associated with a significantly higher rate of postoperative complications ( P =.04), which was especially true for pneumonia ( P =.003). However, no effect on survival was found for patients with Dukes disease stage D. Conclusions: The lower mortality rate following primary resection is achieved by preselection of patients. The preselection is such that patients in poor general condition who have tumors in advanced stages are not treated by resection. The significantly ( P =.03) highest postoperative mortality rate in patients who underwent primary resection after tumor perforation reflects the necessity of resection in those cases regardless of higher comorbidity. In an emergency situation, initial minimal surgery followed by staged resection is a feasible alternative to treat aged patients with a higher comorbidity and an intraoperatively established greater spread of tumor. This procedure permits delayed radical resection at the lowest rate of clinical mortality for this age group and is especially suitable for frail, aged patients in poor condition. The advantages of staged resection can be demonstrated by the fact that more patients with a higher comorbidity survive. The poor physiological adaptability of elderly patients limits their ability to compensate for postoperative organ failure and adds the risk of comorbidity. Hence, these 2 factors are associated with poor prognosis in this age group. Arch Surg. 1997;132:1032-1037

https://jamanetwork.com/journals/jamasurgery/articlepdf/596950/archsurg_132_9_018.pdf

Emergency Surgery for Colon Cancer in the Aged

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