Methodology for assessing the severity of diffuse peritonitis and prognosis of relaparotomy

INTRODUCTION. The problem of treating patients with peritonitis has always been and still remains relevant in surgery. Moreover, aspects of treating patients with tertiary peritonitis requiring repeated interventions are of particular importance. The OBJECTIVE of this work was to develop and evaluate the clinical effectiveness of a score-prognostic scale that allows to identify groups of patients with a high risk of persistent surgical infection in the abdominal cavity, in which a single intervention cannot be considered effective even despite the elimination of the primary surgical infection focus.METHODS AND MATERIALS. To achieve the goal, a correlation was evaluated between a number of factors and the likelihood of relaparotomy in a retrospective group consisting of 111 patients with secondary peritonitis. Based on the achieved data, score-prognostic scale for assessing the severity of peritonitis was developed, which allowed to formulate an algorithm of surgical tactics, which was used in the treatment of 109 patients. A group of 34 people with a high risk of tertiary peritonitis development was allocated from the number of patients – of which 20 patients had a total number of 39 planned surgical interventions.RESULTS. The use of the developed scale led to an increase in the total number of surgical interventions, however, reducing postoperative mortality by 1.7 times (p = 0.001) mainly due to improved survival rates in the group of patients with severe forms of peritonitis.CONCLUSION. The obtained results allowed to recommend the developed integral prognostic scale for assessing the severity of peritonitis for use in clinical practice.

Peritoneal Laser Doppler Flowmetry in Predicting and Diagnosing Tertiary Peritonitis

Relevance. The article is devoted to one of the most difficult and controversial problems in the treatment of intra-abdominal infection, the prediction and diagnosis of tertiary peritonitis. The technique of peritoneal laser Doppler flowmetry (PLDF) makes it possible to assess the degree of visceral microcirculation disorders in various diseases of the abdominal organs.Aim of study. To identify early, trigger indicators of peritoneal microcirculation in tertiary peritonitis, obtained by the PLDF method.Material and methods. A retrospective analysis of the results of treatment of 48 patients operated on for secondary diffuse purulent peritonitis in the clinic of general surgery of the Astrakhan State Medical University in the period from 2015 to 2019 was carried out. All patients were divided into two equal groups: the main group with subsequently developed tertiary peritonitis, and the comparison group with arrested peritonitis. The study of peritoneal microcirculation was performed at the time of laparotomy, after debridement, 24 and 48 hours later. A total of 768 scans were performed. Evaluation was carried out using the APACHE II scales , abdominal index and SOFA scale. Spearman’s rank correlation test was one of the main statistical methods.Results. Twenty-four hours after the primary operation, the values of the percentage of microcirculation, standard deviation and coefficient of variation showed a direct correlation with the development of tertiary peritonitis. According to Spearman’s criterion, the closeness of the relationship according to these indicators was: r=0.71, r=0.55, r=0.63, respectively, at p≤0.05. After 48 hours, all the studied values of microcirculation made it possible to diagnose tertiary peritonitis. The data obtained correlated with the data obtained by the systems for assessing the severity of the patient’s condition.Conclusion. 1. The generally accepted scales for assessing the severity of patients’ condition (APACHE II, abdominal index and SOFA) used in patients with diffuse purulent peritonitis do not allow predicting the risk of tertiary peritonitis 24 hours after surgery. The data obtained as a result of the scoring on the above scales becomes representative 48 hours after the initial intervention. 2. The percentage of microcirculation, standard deviation and coefficient of variation can be used as early screening indicators of peritonetal laser Doppler flowmetry to predict tertiary peritonitis 24 hours after primary surgery. 3. The whole range of indicators of peritoneal laser Doppler flowmetry allows the degree of impairment of the tissue microcirculation in patients with peritonitis to be objectively assessed even 48 hours after the initial operation and to be diagnostic criteria of tertiary peritonitis.

First reported case series of Candida krusei peritonitis secondary to a perforated viscus

Candida peritonitis is associated with high mortality and multiple organ failure. With an evolving epidemiology of candidaemia indicating an increasing prevalence of rare Candida species worldwide, consideration of multidrug-resistant fungal pathogens as a cause of abdominal sepsis is paramount. We report three cases of Candida krusei as a cause of secondary and tertiary peritonitis. These cases highlight that the early use of an echinocandin class antifungal in patients not responding to standard regimens warrants consideration.

Changes in Humoral and Cellular Immunity in Tertiary Peritonitis

The objective of the research was to give a comparative characteristic of parameters of humoral and cellular immunity in the development of secondary and tertiary peritonitis.Materials and methods. The research enrolled 109 patients with secondary peritonitis, 20 of whom developed tertiary peritonitis. Changes in humoral and cellular immunity were evaluated by serial blood tests for the determination of leukocyte count, the relative number of lymphocytes, Ig A, M, and G levels, as well as by counting the phagocytic index, the phagocytic number and the leukocyte intoxication index. The statistical processing of the obtained data was made using the STATISTICA 5.0 software (StatSoft, USA).Results. All the patients were divided into 2 groups: the group of patients with secondary peritonitis (n=89) and the group of patients with tertiary peritonitis (n=20). In the development of tertiary peritonitis, leukocytosis, relative lymphocytopenia and high values of the leukocyte intoxication index persisted during the entire observation period. In tertiary peritonitis, the phagocytic index was significantly lower only on the day of hospitalization. In the group of tertiary peritonitis, the phagocytic number decreased significantly until the 7th day after surgery. Ig A, M and G levels were lower since admission and subsequently decreased as compared to the results in the group of patients with secondary peritonitis.Conclusions. 1. Tertiary peritonitis is the most severe form of abdominal sepsis with high rates of mortality and rather difficult early diagnosis. 2. With the development of tertiary peritonitis, leukocytosis increases and relative lymphocytopenia develops. 3. The reduction in phagocytic index is indicative for the prognosis of tertiary peritonitis. 4. Ig A and M levels are significantly lower, and the leukocyte intoxication index is high at the time of hospitalization in patients who subsequently develop tertiary peritonitis.

MICROBIOLOGICAL SPECTRE OF TERTIARY PERITONITIS AS A COMPONENT OF ITS DIAGNOSTICS AND TREATMENT

The aim of the research was to investigate the microbial spectre of tertiary peritonits (TP) and its antibiotic resistance as the way to improve the diagnostics and treatment of TP. Materials and methods. Prospective research enrolled 109 patients with secondary peritonitis. Tertiary peritonitis developed in 18,3 % of cases. Samples of peritoneal exudate had been drawn upon index operation, relaparotomy and on the day of diagnosis of TP. Blood sampling was performed in patients with persistent fever, impaired consciousness, prolonged (>4 days) discharge from drainage tubes and on the 1st day of diagnosis of TP. Antibacterial susceptibility was evaluated using Hinton-Müller media. Results and discussion. Patients were divided into 2 groups: with secondary peritonitis (89) and with TP (20). In TP group, cultivation of 76,2 % of primary specimens resulted in replantable and identifiable growth, presenting a shift towards Gram-negative flora and higher incidence of Candida albicans. Following the development of TP, hemocultures were positive in 15,1 %, presented mainly by Proteus spp. and non-albicans Candida spp. Second-group carbapenems, tigecycline and piperacillin-tazobactam had shown the highest activity in pathogens of TP. Caspofungin proved to be the most potent antifungal agent, especially towards non-albicans Candida spp. Antibiotic resistance in TP group was marked in 63,8 %. Conclusions. Tertiary peritonitis is one of the most severe forms of abdominal sepsis with highest mortality. Causing pathogenic flora in case of TP is mainly Gram-negative and coccal with high rates of antibiotic resistance both in vitro and in vivo. Fungi, presented predominantly by Candida non-albicans substrains, show an increasing content in peritoneal exudate and major effect upon mortality in TP. In case of TP, a significant percent of peritoneal specimens do not provide any culture growth despite of observing stringent sampling, transportation and cultivation rules. Antimicrobial therapy of TP can never be standardized and should always be thoroughly based upon regular and proper peritoneal and blood sampling.