BACKGROUND: Diffuse peritonitis is an acute abdominal condition characterized by high mortality. The main treatment modality is surgery, requiring a subsequent prolonged hospital stay. These patients are, among other things, at risk of developing hospital-acquired pneumonia (HAP), which considerably worsens their treatment outcomes. This study aimed to extend the existing knowledge by providing more detailed microbiological characteristics of complicating HAP in patients with secondary peritonitis, including the identification of isolated bacterial pathogens and their potential sources. METHODS: The 2015-2019 retrospective study comprised all patients with an intraoperatively confirmed diagnosis of secondary diffuse peritonitis who were classified in accordance with the quick Sepsis Related Organ Failure Assessment scoring system. RESULTS: HAP developed in 15% of patients. The 90-day mortality rates were 53% and 24% in patients with and without HAP; respectively. The most frequent pathogens responsible for HAP were Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae complex and Enterococcus faecalis. Multidrug resistance to antibiotics was found in 38% of bacterial pathogens. Clonal spread of these bacterial pathogens among patients was not detected. Rather, the endogenous characteristic of HAP was confirmed. CONCLUSIONS: The initial antibiotic therapy of complicating HAP in patients with secondary peritonitis must be effective mainly against enterobacteria, including strains with the production of ESBL and AmpC beta-lactamases, Pseudomonas aeruginosa and Enterococcus faecalis. The study further highlighted the importance of monitoring the respiratory tract bacterial microflora in patients with secondary peritonitis. The results should be used for initial antibiotic treatment of complicating HAP instances.
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Purpose: After endoscopic polypectomy, the risk factors for malignancy include positive margin, poor tumor differentiation, deep submucosal and lymphovascular invasion. Even in the presence of high-risk factors, residual disease is observed in less than 15% of samples, and even less in lymph nodes. Study aimed to evaluate results of patients after radicalization in a non-curative polypectomy in 10 year follow-up period, and to compare classical and transanal approach and their impact on quality of life and disease-free survival. Results: Cohort include 45 patients, three patients had adenocarcinoma in situ, one of them positive lymphatic nodes. Only seven (23 %) patients had 12 and more lymph nodes described. TEM cohort had significantly shorter hospital stay (median 7 vs. 11 days, p < 0.0001), significantly lower incidence of herniation (0% vs. 30%, p = 0.020), shorter distance of tumor from the anal verge (median 7 vs. 23.5, p < 0.0001), and lower number of lymph nodes (median 0 vs. 5, p < 0.0001). Overall survival was without statistical significance (p = 0.690). The group of classically operated had higher proportion of subsequent procedures and limitations (p=0.149, and p=0.540). Conclusion: Following malignant polypectomy, surgery should be considered in medically fit patients if the polypectomy margin is positive, unknown, or if the lymphovascular invasion is present. TEM surgery is an acceptable option for high-risk patients . Identifying patients requiring surgery for possible lymph node metastases is still the most important problem.
PURPOSE: The study aimed to determine a simple diagnostic test that could predict the risk of anastomotic leakage in early postoperative period. METHODS: A single-center, retrospective study was conducted. The electronic medical records of patients who underwent resection for rectal tumor between January 1, 2016, and December 31, 2021, in University Hospital Olomouc, were reviewed. The data included risk factors for leakage and laboratory parameters commonly obtained. RESULTS: The decrease in platelets was significant as for the possibility of being a marker of anastomotic leakage; OR = 0.980 (p = 0.036). A decrease of 34 or higher predicts leakage with a sensitivity of 45 % (95 % CI: 23.1–68.5 %) and specificity of 81.1 % (95 % CI: 75.2–86.1 %). Postoperative leukocyte blood level (OR = 1.134; p = 0.019) and leukocyte level on postoperative day 1 (OR = 1.184; p = 0.023) were significant predictors for leakage. WBC values ≥ 8.8 predict leakage with a sensitivity of 70.0 % (95 % CI: 45.7–88.1 %) and specificity of 55.3 % (95 % CI: 48.4–62.0 %). Hemoglobin blood level ≤ 79.5 predicts leakage with a sensitivity of 70.0 % (95 % CI: 45.7–88.1 %) and specificity of 62.2 % (95 % CI: 55.5–68.7 %). CONCLUSION: Despite the fact that the specificity and sensitivity of the followed parameters are low, they could serve as markers useful for early diagnosis or suspicion for leakage (Tab. 5, Fig. 3, Ref. 14).
INTRODUCTION: This study primarily sought to evaluate the risk factors for toxic megacolon development and treatment outcomes in Clostridium difficile-positive COVID-19 patients, secondarily to determining predictors of survival. METHODS: During the second COVID-19 wave (May 2020 to May 2021), we identified 645 patients with confirmed COVID-19 infection, including 160 patients with a severe course in the intensive care unit. We selected patients with Clostridium difficile infection (CDI) (31 patients) and patients with toxic megacolon (9 patients) and analyzed possible risk factors. RESULTS: Patients who developed toxic megacolon had a higher incidence (without statistical significance, due to small sample size) of cancer and chronic obstructive pulmonary disease, a higher proportion of them required antibiotic treatment using cephalosporins or penicillins, and there was a higher rate of extracorporeal circulation usage. C-reactive protein (CRP) and interleukin-6 values showed significant differences between the groups (CRP [median 126 mg/L in the non-toxic megacolon cohort and 237 mg/L in the toxic megacolon cohort; p = 0.037] and interleukin-6 [median 252 ng/L in the group without toxic megacolon and 1127 ng/L in those with toxic megacolon; p = 0.016]). As possible predictors of survival, age, presence of chronic venous insufficiency, cardiac disease, mechanical ventilation, and infection with Candida species were significant for increasing the risk of death, while corticosteroid and cephalosporin treatment and current Klebsiella infection decreased this risk. CONCLUSIONS: More than ever, the COVID-19 pandemic required strong up-to-date treatment recommendations to decrease the rate of serious in-hospital complications. Further studies are required to evaluate the interplay between COVID-19 and CDI/toxic megacolon.
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INTRODUCTION: Diffuse peritonitis is a serious disease. It is often addressed within urgent management of an unstable patient in shock. The therapy consists of treatment of the source of peritonitis, decontamination of the abdominal cavity, stabilization of the patient and comprehensive resuscitation care in an intensive care unit. A number of scoring systems to determine patient prognosis are available, but most of them require complex input data, making their practical application a substantial problem. OBJECTIVE: Our aim was to assess simple scoring systems within a cohort, evaluate the level of mortality, morbidity, and duration of hospital stay, followed by a comparison of the acquired data with the literature and determination of an easily implementable scoring system for use in clinical practice. MATERIAL AND METHODS: We evaluated a group of patients with diffuse peritonitis who underwent surgery in the 2015-2019 period. Medical history, surgical findings, and paraclinical examinations were used as the input for four scoring systems commonly used in practice-MPI, qSOFA, ECOG, and ASA. We compared the results between the systems and with the literature. RESULTS: Our cohort included 274 patients diagnosed with diffuse peritonitis. Mortality was 22.6%, morbidity 73.4%, with a 25.2 day average duration of hospital stay. Mortality and morbidity increased with rising MPI and qSOFA, well-established scoring systems, but also with rising ASA and ECOG, similarly to MPI and qSOFA. CONCLUSIONS: The utilized scoring systems correlated well with the severity of the condition and with predicted mortality and morbidity as reported in the literature. Simple scoring systems primarily used in other indications (i.e., ASA and ECOG) have a similar predictive value in our cohort as commonly used systems (MPI, qSOFA). We recommend them in routine clinical practice due to their simplicity.
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- časopisecké články MeSH
Introduction: Colorectal cancer is one of the most common cancers. Surgical treatment consists of radical resection with lymphadenectomy. Resection is performed laparotomically, laparoscopically or robotically. Laparoscopic operations are more time consuming, while short-term perioperative morbidity appears to be lower. Operations of the colon are costly, and laparoscopic procedures seem to be more expensive in our conditions. The costs are reduced mainly by lower postoperative morbidity and shorter hospital stay. Methods: We prospectively compared both approaches in the length of the operation, hospitalization, stay in the ICU, in the occurrence of complications and in the costs reported to health insurance companies to evaluate their cost-benefit. Results: It was shown that the duration of surgery was significantly higher in the observed period for laparoscopies (median = 119 min) than for open surgery (median = 105 min), p = 0.047. The length of hospitalization in the case of laparoscopies was 10.1 days (median = 8.5 days), in the case of open resection 11.8 days (median = 10.0 days), the value of p = 0.150, ie without a statistically significant difference. The stay in the ICU was shorter in laparoscopies (median = 3.5 days) than in open operations (median = 6.0 days), p = 0.373, therefore no statistically significant difference was found here either. There was also no statistically significant difference in other monitored parameters. Conclusion: We did not find a statistically significant difference in the main monitored parameters - in the length of hospitalization and stay in the ICU, which is probably due to the size of both groups. In the case of a higher number of operations, a difference with statistical significance would probably already be proven. We demonstrated a statistically significant difference between the two groups in the length of surgery. Furthermore, we found up to 2.75 times higher value of ZUM in the group of laparoscopic resections.
Článek poskytuje chirurgický pohled na řešení komplikací celosvětově hojně užívaného operačního výkonu, jakým je laparoskopická sleeve gastrektomie. Sleeve gastrektomie je celosvětově uznávaný bariatrický výkon. Tato operace je hodnocena jako bezpečná, nicméně i ona může být, i když v relativně malém procentu, provázena závažnými komplikacemi. Jednou z nejnebezpečnějších je staple line leak s rozvojem lokální, difúzní peritonitidy či torpidní píštěle. Řešení je svízelné a často je postupně realizováno několik způsobů ošetření, než dojde k definitivnímu zhojení pacienta. Léčbu této komplikace je možno rozdělit na čistě chirurgickou, kombinovanou či čistě endoskopickou. Neexistují nicméně dosud guidelines, jakým způsobem při této komplikaci postupovat, a je tedy terapeutický postup zvolen na základě klinických zkušeností pracoviště doplněných informacemi z dostupné literatury.
The article proposes a surgical look at solving the complications of the widely used surgical procedure worldwide, such as laparoscopic sleeve gastrectomy. Laparoscopic sleeve gastrectomy (LSG) is considered as one of the most efficient bariatric interventions in morbid obesity wordwide. Nevertheless, there are some risks and perhaps the most severe is leak along the staple line with local or diffuse peritonitis or persisting fistula. The treatment of this complication can be strictly surgical, combined or only endoscopic. However, there are no set guidelines to date as the best option of leak management. As a result, every procedure is "tailored" to a specific patient and it always depends on the experience of the respective institutionsupplemented with information available from literature.
Úvod: V kazuistickém sdělení bylo popsáno krvácení z iatrogenního poranění hrudní aorty při miniinvazivní transtorakální ezofagektomii. Kazuistika: Muž, 53 let, prodělal neoadjuvantní radiochemoterapii pro adenokarcinom jícnu s regionální lymfadenopatií. Kontrolní PET/CT po onkologické terapii popsalo pouze mírnou regresi nádoru. Pacient byl indikován k ezofagektomii cestou pravostranného torakoskopického přístupu v semipronační poloze při selektivní ventilaci levé plíce. Tumor byl separován od hrudní aorty, ale postupně při jeho uvolňování a infiltraci aorty došlo k arteriálnímu krvácení z aorty. Výkon byl ihned konvertován na klasickou pravostrannou torakotomii, na aortě byla nalezena ruptura délky 5 mm. Ve spolupráci s cévním chirurgem byla ruptura v aortě ošetřena suturou s implantací gore záplaty. Vzhledem k celkovému stavu nemocného a šokovému stavu nebyla ezofagektomie v první době dokončena. Sedmý den od primární operace byla provedena hybridní miniinvazivní transhiatální ezofagektomie. Definitivní histologické vyšetření popsalo adenokarcinom T3N3M0. Závěr: Ezofagektomie pro karcinom jícnu je náročný chirurgický výkon, u kterého nelze při resekci jícnu v dutině hrudní a břišní vyloučit krvácení v operačním poli z okolních struktur. Krvácení z aorty je ve všech případech hemodynamicky významné a je nezbytné ho urgentně chirurgicky ošetřit.
Introduction: This case report describes bleeding from an iatrogenic thoracic aortic injury in minimally invasive thoracoscopic esophagectomy. Case report: A 53-year-old man underwent neoadjuvant radiochemotherapy for adenocarcinoma of the esophagus with positive lymph nodes. PET/CT showed only a partial response after neoadjuvant therapy. Minimally invasive thoracoscopic esophagectomy in the semi-prone position with selective intubation of the left lung was performed. However, massive bleeding from the thoracic aorta during separation of the tumor resulted in conversion from minimally invasive to conventional right thoracotomy. The bleeding was caused by a five millimeter rupture of the thoracic aorta. The thoracic aortic rupture was treated by suture with a gore prosthesis in collaboration with a vascular surgeon. Esophagestomy was not completed due to hypovolemic shock. Hybrid transhiatal esophagectomy was performed on the seventh day after the primary operation. Definitive histological examination showed T3N3M0 adenocarcinoma. Conclusion: Esophagectomy for cancer of the esophagus is one of the most difficult operations in general surgery in which surgical bleeding from the surrounding structures cannot be excluded. Aortic hemorrhage is hemodynamically significant in all cases and requires urgent surgical treatment.
Úvod: Peritonitida je závažné onemocnění s ne zcela uspokojivými výsledky léčby. Terapie již tradičně spočívá v kombinaci chirurgického ošetření příčiny zánětu pobřišnice, antibiotické terapie a komplexní intenzivní péče o nemocného. Prioritou je ošetření zdroje zánětu včetně toilety dutiny břišní s následnou laváží či drenáží břišní dutiny. Existují dva možné přístupy - primární sanace dutiny břišní s prostou pooperační drenáží břišní dutiny a kvadrantová laváž, probíhající většinou po dobu 48 hodin. Vzhledem ke skutečnosti, že na většině chirurgických pracovišť jsou obě metody stále užívány, rozhodli jsme se je porovnat ve vztahu k morbiditě, mortalitě a délce hospitalizace, tedy se snahou o výslednou formu jednoduchých a dobře interpretovatelných výstupů. Metoda: V období 10/2012-4/2014 jsme operovali 55 pacientů se známkami difuzní peritonitidy. Přestože výběr metody v praxi často ovlivňuje rozsah zánětu, snažili jsme se operační metody střídat bez ohledu na typ a rozsah zánětu, aby výsledek byl co nejobjektivnější. Výsledky: Nebyl zaznamenán statisticky významný rozdíl ve sledovaných veličinách, a to ani u mortality, morbidity či v délce hospitalizace. Závěr: Na základě našich výsledků lze konstatovat, že obě metody jsou z hlediska porovnávaných veličin vzájemně zcela rovnocenné, a lze je aplikovat pro všechny typy difuzních peritonitid bez jejich vlivu na mortalitu, morbiditu nebo délku hospitalizace.
Introduction: Diffuse peritonitis is a serious disease with rather poor therapeutic results. Management traditionally consists in the surgical treatment of its etiology, combined with targeted antibiotic therapy and complex intensive care of the patient. The basic procedure includes the identification and treatment of the origin of peritonitis, followed by thorough abdominal cavity toilet, lavage and drainage. There are currently two major procedures for carrying out complex surgical care of a patient suffering from diffuse peritonitis. The first one is primary sanation of the abdominal cavity, in which toilet, peroperative lavage and postoperative drainage is performed. The second procedure involves similar steps, but postoperative irrigation with saline or another solution is performed, usually over 24-48 hours - continuous lavage. Both procedures, albeit often modified, are still used in most surgical departments in the Czech Republic; therefore, we decided to compare them in terms of morbidity, mortality and hospital length of stay. Method: We conducted a prospective randomized study involving 55 patients with peritonitis operated on from 10/2012 to 4/2014. Whenever possible, we tried to use both methods alternately method regularly to enable randomization and ensure presentable outcomes. Results: No statistically significant difference related to morbidity, mortality and hospital length of stay was recorded in our group. Conclusion: Based on our results, we can state that both methods are equal and suitable for all types of diffuse peritonitis without any impact on mortality, morbidity and hospital length of stay.
