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Monday, March 31, 2014

The abdomen as a source of sepsis in critically ill patient - Surgical Treatment

Ronald C Merrell, M.D. and Rifat Latifi, M.D.

Department of Surgery, Virginia Commonwealth University, Richmond, U.S.A.

Anatomy of intra-abdominal sepsis

The abdomen may be implicated as the primary occult, secondary dependent or secondary independent source of sepsis.

In septic patients the abdomen may be implicated as the primary but
in-apparent source of the problem (primary occult); secondary dependent,
when the initial process began in the abdomen (post-operative
infection, perforation, anastomic leak et cetera); and secondary
independent, when intra-abdominal organ sustain an insult from
splanchnic hypoperfusion (table I).

Suspicion of abdomen as source of sepsis in critically ill patients.
When there is no clear cause of clinical deterioration in septic patient, or
in a patient with other multiple medical problems (pneumonia, cardiac
disease, diabetes, et cetera), the abdomen becomes a natural target of
suspicion, investigation, and reason for surgical consultation.

Anatomically and biologically, the abdomen is regarded as one unit. Embryologically
intra-abdominal organs develop from foregut (stomach, liver and biliary
tree, spleen, pancreas and duodenum); midgut (small bowel, appendix, and
right colon); and hindgut (left colon and rectum). The peritoneum
represent and organ, and can be involved with infectious or inflammatory
processes. Retroperitoneal solid organs and structures are often a
source of sepsis, which require prompt identification and treatment, if
significant morbidity and mortality is to be avoided. Consequently, the
septic patient should be approached in a stepwise fashion, in order to
identify the septic source. Depending on the patient's age, and other
concomitant risk factors, heart disease, arrhythmia, pneumonia, urinary
tract infections, vascular disease, and medication history, each system
and organ should be considered carefully.

Gastrointestinal tract including liver, gall bladder, biliary tree, and pancreas are common
sources of sepsis. Urinary system with kidney, bladder and prostate, and
gynecologic pathology are also possible causes of septic sources in
patient that is rendered septic. Systematic approach, accompanied with
biochemical, hematological and radiographic examination, will identify
or eliminate each organ from these systems as a source of sepsis.

Diagnostic approach to patient with expected abdominal sepsis

Expeditious diagnosis and therapeutic response by clearly defined algorithm may
reduce mortality of patients with suspected sepsis. Truly occult sepsis
(negative cultures, and no site identified) may in fact represent a
failure to identify an intra-abdominal source of bacterial or fungal
infection.

In critically ill and septic patient with unknown source, meningitis, purulent sinusitis, septic superficial or deep thrombophlebitis, wound infections and decubiti, perirectal abscesses,
and ischemic or infarcted limbs should be excluded. One should seek
opportunities for astute diagnosis of simple conditions.

Before proceeding, with expensive and complex investigations of the
intra-abdominal organs as a source of sepsis in critically ill patients,
after urinary and respiratory tract have been rule out, a few
infections that are more common should be excluded. These include
meningitis, purulent sinusitis, septic superficial or deep
thrombophlebitis, wound infections and decubiti, perirectal abscesses or
ischemic and infarcted limbs. If, on the other hand, patient continues
to have evidence of SIRS or full blown sepsis, but no obvious source of
infections, than the abdomen becomes a suspect, and one need to proceed
with the appropriate investigations (table II).

Diagnostic approach to critically ill with unknown source of sepsis.

Patient with primary occult abdominal pathology: Treat and search

Patient with primary occult pathology may have acute calculous or acalculous
cholecystitis, cholangitis, pancreatitis, appendicitis, diverticulitis,
subphrenic abscess, retroperitoneal abscess (perinephric, psoas or
pancreatic), sealed perforation of stomach, duodenum, gallbladder or
colon, and or bowel ischemia.

Patients, who manifest full-blown SIRS or even sepsis, may not demonstrate a source of infection readily. In these patients, the search for cause of abdominal manifestations can
be very difficult. These patients are treated and supported
concomitantly and empirically for respiratory and cardiac compromise.
The evaluation should be expeditious, well focused and the end points
resuscitation followed closely. Response to life-threatening
manifestations of infection such as shock, respiratory failure, renal
failure or cardiovascular collapse should be critically evaluated on a
minute to minute basis. This is treat and search mode (table II).

Physiologic support

The clinical and diagnostic concert of physiologic support and treatment:
define and follow the physiologic endpoints of resuscitation.

Restoration and maintenance of optimal organ perfusion is key factor in both
minimizing the initial ischemia-induced injury as well as decreasing the
late consequences of the stress response. Early and late physiologic
end points should be clearly defined. During early stress response or
early sepsis, cardiac index > 4, wedge 12–16 mmHg, O2 delivery and
consumption 1.5 times normal should be maintained, as well as the anion
gap should be normalized. Yet, since there is no conclusive evidence
that tissue oxygenation dept exist in patient with sepsis, and there is
no evidence that supranormal levels of oxygenation are more effective in
reducing morbidity and mortality (grade C recommendation), the
resuscitation should be aimed at hemodynamic stabilization and tissue
perfusion improvement. General perfusion, based on blood pressure and
urine output, may appear adequate, but impairment of splanchnic
perfusion may exist. Gastric tonometry measurements appears to be a
useful marker of splanchnic perfusion. Persistent splanchnic
hypoperfusion, as expressed by low gastric mucosal pH (pH╬╣) and
inability to correct gastric pHi, has been associated with
increased mortality and development of MOF, although large scale
randomized clinical trials with high levels of evidence is lacking. Use
of gastric pHi as a tool for resuscitation currently cannot be
recommended (grade C). Maintaining arterial O2 saturation, volume
expansion with fluid or blood and blood products, and judicious use of
inotropes, are methods to maintain perfusion, while the search for
intra-abdominal septic focus is underway. Identification and correction
of basic cellular dearrangements is the priority in these patients.

A difficult patient

The search for septic source may be very difficult in a patient, who is on a
respirator, sedated, obtunded, or paralyzed with medication.

There may be few details from the history, from the family or friends, and
often these patients do not have well documented medical history in the
chart. Worse, patients is found in 2–3 powerful vasopressors to maintain
blood pressure, with severely compromised liver or kidney function, and
now present with a distended abdomen, and a picture of possible
intra-abdominal catastrophe. The most senior member of the consulting
team should perform a thorough physical examination, including rectal
exam.

Review of chest x-rays, urine, blood, sputum, and other
cultures, as well as review of the hemograms, and all biochemical
indices available, should be the first phase of the evaluation, and will
identify a likely source in greater than 85% of patients. When faced
with a patient who has developed SIRS with respiratory failure and a
picture of adult respiratory distress syndrome (ARDS), and who has
findings of positive blood culture for a putative enteric organism, then
the abdomen becomes certainly a logical suspect harboring the septic
focus. Often times though, this scenario is complicated in the patient
who in addition to positive blood cultures, has positive sputum cultures
and radiographic evidence of pneumonia, yet the clinical conglomerate
is complicated with lactic acidosis, leukocytosis, failing kidneys and
worsening abdominal exam.

Diagnostic studies (table II)

In a case of patient with a septic picture but with no clear evidence of
intra-abdominal infection, one should start with the routine-3-way
abdominal film, bearing in mind very low yield of this diagnostic test.
In a series of 143 patients with surgically proven abdominal abscess,
abdominal films were of value in only 15% of patients. Due to low level
of associated clinical confidence, this study, unless it demonstrates
free air or intestinal obstruction, rarely is the sole basis upon which a
clinical decision for operation is made. While some authors have
reported up to 50% level of diagnostic value for this study, the
availability of other techniques makes this study less favorable (grade
C).

If this study is of no diagnostic value, than one should
proceed with ultrasound (US) to exam liver, gall bladder, biliary tree,
pancreas, pelvis, and pelvic organs. US have high sensitivity for liver
and pelvic pathology. The use of US in diagnosing intra-abdominal
abscesses may have an accuracy exceeding 90% in experienced hands (grade
A, B). It is portable, can be performed at bed site, it is reproducible
and can be repeated easily. Major drawbacks are ileus, obesity and
inexperience of the operator. Depending on the suspected pathology, a CT
scan of the abdomen with oral and intra-venous contrast, may be the
next step in the diagnostic work up, if ultrasound negative or
non-diagnostic.

Cholangitis may present with Charcot's triad (right upper quadrant pain, fever, and jaundice), or Reynolds's pentad (Charcot's triad plus shock and mental status changes).

If acute cholecystitis is expected, but US is not diagnostic, one should obtain a
morphine injected HIDA scan as the most definitive study to diagnose
cystic duct occlusion (grade A, B).

In a patient with pain out of
proportion to physical findings, metabolic acidosis, leukocytosis,
lactate dehydrogenase elevation, ischemia of the bowel should be very
high on the list. Intestinal vascular catastrophes (arterial or venous)
will have grave consequences if not identified early and treated
effectively. Because, even a small area of necrosis may prove fatal
because of prolonged observation, a patient with correctable pathology
may die for a lack of well-timed and well-executed laparotomy.

In these patients a CT scan may, or may not be of diagnostic value (grade
C). As a rule, a CT scan will demonstrate an ileus pattern of the small
bowel, and a bowel wall edema (fig. 1). When pneumatosis intestinally is present, this is a late sign of infarcted bowel (fig. 2).
When ischemia of the intestines is expected, in the face of normal or
non-diagnostic CT scan, three-vessel abdominal angiogram should be
performed.



Figure 1

A CT scan of a 33-year-old-female who sustained a myocardial infarction, for
which she underwent angiplasty and coronary stent placement. Five days
after the procedure, she was complaining of right flank pain associated
with abdominal distention, and increased (more...)

Figure 2

Same patient, two days later, now in multiple organ system failure. A repeat
CT scan demonstrates diffuse air fluid levels of small and large bowel,
without wall thickening, findings consistent with an ileus. On surgical
exploration, two hours after this (more...)
Increase
of pancreatic enzymes in the right clinical setting will add to
suspicious and diagnosis of pancreatitis, which can be confirmed by a CT
scan or US. Increasingly, a spiral CT is becoming the preferred
technique for evaluating the pancreas. Certainly a CT scan is the
preferred diagnostic method for diverticulitis, perinephric abscesses,
or liver abscesses.

In septic patients who are immunocompromised
(high-risk trauma, severe burns, transplant patients, cancer patients
undergoing chemotherapy, AIDS patients, and those with diabetes),
diagnostic and therapeutic approaches may not be straightforward. Their
presentation may be atypical.

In very critically ill patients, the choice of diagnostic study is very difficult. Transferring the patient
away from the ICU for a CT scan may be a dangerous undertaken. In these
situation one can utilize other studies such as abdominal paracentesis
or diagnostic peritoneal lavage. A negative or positive DPL is helpful. A
return from DPL will differentiate blood from the ascites and from an
inflammatory or infectious exudate. The lavage will also differentiate
primary from the secondary peritonitis. Aspiration of fecal material,
bile, or bloody fluid will warrant surgical exploration. Isolation of
anaerobic flora, may also be an indication for laparotomy.

The usefulness of endoscopy in critically ill septic patients depends on the
suspected organ. An ERCP may be diagnostic and therapeutic for biliary
and pancreatic diseases, while sigmoidoscopy or colonoscopy may diagnose
ischemic colitis, and should be used in appropriate clinical settings.

Most nuclear studies have limited role in critically ill patients, as their are cumbersome, inconclusive and expensive.

Other than HIDA scan that is a diagnostic test of choice for acute
cholecystitis (grade A, B) and VQ scan for pulmonary embolus, most
nuclear studies have limited role in critically ill patients, as their
are for the most part cumbersome, inconclusive and add to more expenses.
Gallium-67 citrate is concentrated in areas of inflammation; thus, it
is thought that this isotope scan may have potential value in diagnosing
even small abscesses. However, due to concentration of gallium in the
areas of inflammation as well as the uptake of the isotope in the
postoperative area, false positive scans are common and difficult to
interpret. Additionally it takes 48 hours for the isotope to
concentrate, and requires mechanical bowel preparation to eliminate the
intraluminal background, thus making it less desirable and practical.

The indium-111-labeled leukocyte scan although has greater specificity and
image re-solution than gallium scan, and is relatively simple to
perform, it is also not suggested to be used in post operative patient
due to leukocyte aggregation in other areas of inflammation (grade C).

In cases when “standard” clinical, biochemical and radiological diagnostic
studies are exosted, and the abdomen is still suspect by exclusion, it
is justifiable to explore the abdomen as a diagnostic endeavor of
desperation. Laparoscopic diagnostic exploration in the setting of ICU
may be a method of choice, shorter of open traditional abdominal
exploration, although the evidence is still lacking (grade C). Few
non-randomized, case series reports with mixed group of patients with
peritonitis, minimally invasive diagnostic and therapeutic technique
have reported favorable results, while the experience with open approach
has mixed reports (grade C).

Patient with secondary dependent pathology

Patients with secondary, dependent pathology is in postoperative state, treated
in ICU, or return to ICU because of comorbid diseases or for unexpected
clinical or aprupt decline and worsen SIRS.

This may follow surgery upon a hollow viscus, in which the possibility of anastomotic
leak or abscess should be considered. In of such patients, non-abdominal
sources of sepsis such as pneumonia, urinary tract infections, blood
stream line infections, evaluation should be done as outlined on tables II and III.
Precipitous re-operation in the abdomen might not be appropriate, but
should not be delayed either, in proper clinical setting. If the abdomen
is still the leading candidate after excluding other possibilities, the
imaging sequence is invoked.

Diagnostic approach to postoperative patient with SIRS.
Water soluble contrast studies should be used for accessible anastomosis of
the esophagus, stomach and rectum and lower colon, while use of barium
is not advised. Endoscopy, on other hand is not advocated in assessment
of fresh anastomosis. Wound infection may be easily missed if patient is
not examined carefully. A triple contrast CT scan or delayed re-scans
are useful techniques in diagnosing low colon anastomic leak.

In patient who is post cholecystectomy or other biliary or liver surgery,
the presentation of SIRS mandates exclusion of biliary tree leak or
obstruction, which can be done with US, HIDA scan, ERCP or percutaneous
transhepatic cholangiography (PTC). The advantages of latter modalities
are in the ability to provide therapeutic options.

Intestinal ischemia may rapidly progress to full-thickness infarction, and dramatic
clinical deterioration. This may happen due to obstruction or during
low flow state in a compromised elderly patient, due to arterial or
venous occlusion. Small bowel ischemia or necrosis should be suspected
in a patients who present with rapid clinical deterioration, who has had
rapid advancement of tube feeds, in the face of inadequate
resuscitation, such as trauma patients. If intestinal ischemia is
suspected than patient should be promptly resuscitated and operated
upon. Angiography should be performed in proper clinical setting, and
the heart should be examined for the source of emboli. Clinical
examination and biochemical response to ischemia is particularly
unreliable in elderly patients. Measurements of splanchnic perfusion,
with gastric tonometry may have some diagnostic value in these settings.
Following operation for intestinal ischemia, these patients are great
candidates for further infarction and planned re-exploration may be
warranted.

Patient with secondary independent pathology

Acalculous cholecystitis, small and large bowel ischemia with or without
perforation, and pancreatitis, are the most common and life-threatening
complications in severely ill patients recovering from variety of
medical or surgical procedures outside the abdomen. Typically, these
patients have had a prolonged episode of hypotension due to myocardial
infarction or sepsis from urinary tract, blood stream line sepsis or
during a surgical procedure such as cardiovascular surgery. Patients
with cardiac arrhythmia or ventricle clot may emit emboli that can
infarct the bowel. Furthermore, hypotension may permitt thrombosis of a
compromised vascular bed in the intestinal tract.

Acute cholangitis

Patient with cholangitis may present with Charcot's triad (right upper quadrant
pain, fever, and jaundice), or Reynolds's pentad (Charcot's triad plus
shock and mental status changes). Once the diagnosis is established,
most patients will respond to intravenous hydration and antibiotics,
allowing non-emergent decompression of biliary tract. If, however
patient fails to respond to such measures, endoscopic or transhepatic
emergent decompression is indicated. In case of difficult or prohibitive
anatomy or failed ERCP, an emergent open decompression of common bile
tract is indicated, while aggressive resuscitation with intravenous
fluid and antibiotics is underway, if mortality is to be avoided.

Factors that are associated with poor prognosis in patients with acute
cholangitis are: old age, female sex, acute renal failure, acidosis,
hyperbilirubinemia, hypoalbuminemia, cirrhosis, concomitant medical
problems, malignant obstruction or the presence of liver abscesses.

Acute acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is associated with complicated and
emergent vascular surgery. In one series of surgery for ruptured
aneurysm, there was a 13.6% incidence of AAC, while in elective AAA
repair the incidence of AAC is 0.1%. Angiografic studies have
demonstrated that AAC is characterized by arterial occlusion and absent
venous filling, while in acute calculous cholecystitis gall bladder wall
is characterized by arterial dilatation and venous filling.

AAC shows a striking predilection to occur in trauma and burn patients, with
nearly 90% of patients who develop cholecystitis have AAC. Other
setting where AAC may be seen are malignancy of the porta hepatis,
during hepatic infusion of chemotherapy and after therapy with
interleukin (IL)-2 and lymphokine activated killer cells for metastatic
renal cell carcinoma. Other conditions associated with AAC may be stent
placement for biliary obstruction, bone marrow transplantation,
disseminated Candida infections, systemic leptospirosis, Salmonella in
the biliary tree, and in patients with diabetes, tuberculosis, AIDS, and
patients with cytomegalovirus infection, microsporida and
cryptosporidia. AAC should also be suspected in critically ill patients
who are supported by TPN and render septic with no other obvious source.

Although AAC is a relatively rare condition (0.19% of all SICU patients),
nonetheless 14% of patients with acute cholecystitis have AAC. Patients
with AAC have very high mortality (41%). In one series, most of cases
with AAC (63%) occurred in patients recovering from major non-biliary
operations and 52% (14/24 patients) were critically ill that were
treated in the ICU.

The presenting symptoms of AAC are not
specific (abdominal pain in 78%, right upper quadrant pain in 56%, fever
37%, leukocytosis 70%). Of 25 patients with AAC, 20% had normal liver
function test, while 64% had elevated bilirubin, 40% alkaline
phosphatase, 40% alanine aminotransferase and 13% aspartate
aminotransferase. Delay in diagnosis of AAC is almost a rule, and
results in gangrene (63%), perforation (15%) or abscess formation (4%).

The diagnosis of AAC principally should be made by HIDA scan, which has a
sensitivity of almost 100%, but has a high false positivity, making this
test imperfect. US has a very low sensitivity rate (29%), while CT scan
has a sensitivity of 67%. Thickened gall bladder wall (> 4 mm),
pericholecystic fluid, subserosal edema, intramural gas, sloughed
mucosa, complete lack of response to choecystokinin (CCK), and a
positive sonographic Murphy's sign are major radiographic criteria. The
presence of sludge, distentions of the gall bladder and partial response
to CCK are considered minor criteria.

Acute pancreatitis

Acute pancreatitis is diagnosed clinically and by CT scan or US. Its
management mostly is conservative with nutrition, intravenous fluid
support and antibiotic (when appropriate) and is discussed extensively
elsewhere in this book. For patient who is treated with nonoperative
treatment for pancreatitis, clinical deterioration mandates a CT scan
and evaluation for necrosis, abscess, or infected pseudocyst. In these
cases CT, guided aspiration biopsy of the peripancreatic fluid is
mandatory. Developments of a sequestrum or infected necrosis, as well as
the presence of pancreatic abscess require open drainage and
necrosectomy. Attempts for percutaneous aspiration of the infection
should be avoided.

Trauma patients with sepsis and MOF

The incidence of intra-abdominal infections following trauma has been
decreased significantly in recent years, as well as role precipitating
MOF. However, if trauma patients upon admission are hypotensive, the
rate of infection may be as high as 30%. In a prospective study of 457
patients with major trauma (ISS > 15) intra-abdominal abscesses
occurred in only 13 patients, while only in 9 patients abscess was
associated with MOF, although in 3 patients the abscess did not appear
to play a role in the pathogenesis of MOF. In trauma patients that
become septic, a major missed injury need to be excluded primarily,
while other causes such as UTI, pneumonia, AAC need to be investigated
accordingly. One should bear in mind when treating with antibiotics
trauma patients who have undergone massive resuscitation that, based on
experimental data, the clearance and the steady state of antibiotics is
altered, thus the magnitude of dosing should be adjusted.

Treatment options of intra-abdominal pathology in critically ill patients

Traditional approach

The principle treatment of intra-abdominal source of sepsis in critically
ill patients is control of the underlying cause of the source it self.
Thus, the effective treatment of abdominal sepsis requires surgical
control of the leakage from the hollow viscus, removal of infected or
necrotic contaminated tissue, drainage of the pus or release of the
obstructed biliary tree. Although, these principles of control of the
septic source by prompt extraperitoneal drainage have not changed for
centuries, the means, optimal techniques, timing and combination of
different approaches has evolved. Nonetheless, mechanical control of the
septic source remains the cornerstone of the therapy, although
occasionally antibiotic therapy and physiologic support may achieve
temporary control of cholecystitis, diverticulitis or peritonitis
related to peritoneal dialysis.

Secondary peritonitis is associated with a significant cytokines release that is
compartmentalized in the peritoneal cavity, and the magnitude of this
release reflects the severity of the process and prognosis. The extent
of an intra-abdominal infection determines the magnitude of the
peritoneal response. In critically ill and septic patients undergoing
relaparotomy for severe secondary peritonitis endotoxin, tumor necrosis
factor alpha, interleukin-1, interleukin-6, elastase, and neopterin were
found significantly higher in the peritoneal cavity then in plasma.
When these patients underwent relaparotomy, the level of these cytokines
was decreased significantly in survivors.

This local decrease of inflammatory response, may be best achieved with mechanical control by
reducing the load of cytokines and other inflammatory substances and by
preventing further production of them, thus removing the source it self.
In ability to control or decrease significantly or interrupt the local
inflammatory response is associated with non-survival of these patients.
Successful control of septic source reduces the bacterial load and
prevents recurrent infections. A prospective, open, consecutive
multi-center nonrandomized trial examined different management
techniques and outcome in 239 patients with severe peritonitis and
APACHE score > 10. Overall, mortality was 32%. There were no
statistical significant differences in mortality between closed abdomen
techniques and those treated with variations of open abdomen technique.
Patients who underwent planned re-laparotomy had a mortality of 42%
(35/83 patients), while those who did not undergo planned re-operation
had a mortality rate of 27% (42/156). It is not clear which patients
need to undergo planned re-laparotomy, and who will benefit from planned
re-laparotomy, since there is a lack of prospective randomized study of
management of high risk patients following initial operation for
intra-abdominal infection (grade C). In another study, although there
was no difference between treatments groups as far as mortality and the
necessity for unplanned re-laparotomy, the incidence of infectious
postoperative complications such as anastomotic leaks and septicemia, as
well as post operative MOF was increased in patients undergoing planned
re-laparotomy.

Some have suggested continuos postoperative irrigation of the peritoneal cavity in selected patients, although there are no differences between planned re-laparotomy and continuous lavage.
Since each re-opening of the abdomen triggers powerful inflammatory
response, we favor re-laparotomy on demand, unless dealing with
narcotizing infected pancreatitis, or second look laparotomy when
suspected ischemia, following resection of gangrenous bowel

Early decompression of abdominal compartment syndrome, as manifested by renal,
cardiac, pulmonary, hepatic dysfunction and decreased visceral
perfusion, as well as by increase of intra-abdominal pressure above
15–20 torr with advanced operations such as abdominostomy, mesh
abdominostomy and staged abdominal repair abdominostomy (STAR) may prove
life saving. Indications for STAR have been established and include:
hemodynamic instability precluding definitive repair, excessive
peritoneal edema, inability to eliminate or control the source of
infection, incomplete debridement of necrotic tissue, uncertainty about
the viability of remaining bowel, uncontrolled bleeding, and the need
for packing and resuscitation of cold, acidotic and coagulopathic
patients and massive abdominal wall loss.

At times, the definitive control of the septic focus by resection, excision, closure of hollow
viscus or drainage of the abscess is performed successfully, but in a
number of patients peritonitis persist. In these patients, options are
re-laparotomy on demand or planned re-laparotomy. For the lack of
definitive data, the choice as what to do next belongs to the surgeon.
In any event, attempts should be made to prevent development of tertiary
peritonitis, which is considered a complication, rather then a specific
disease.

Minimally invasive techniques: laparoscopy

The tradition to open every septic abdomen has been challenged with the
ability to clearly identify and localize radiographically the source of
intra-abdominal pathology. In patients with unknown but presumed of
abdominal sepsis such as females of childbearing age, obese,
immunocompromised, or septic patients on steroids, laparoscopy provides
excellent tool for methodical assessment of entire abdominal cavity. In
one study this technique was applied in 145 surgical patients.
Successful identification and laparoscopic operative treatment was
achieved in 96%. In 87 cases the diagnosis of appendicitis was
established and appendectomy was performed. Furthermore, formal
diagnostic exploratory laparoscopy was safe and effective in this study,
although caution is suggested in cases when diminished or increased
volume of abdominal space exist. Addition of laparoscopic ultrasound was
valuable in diagnosis of hepatic, intra splenic or retroperitoneal
masses. The diagnostic and therapeutic versality of laparoscopy may
minimize the extensive pre operative work up and significantly shorten
postoperative course.

In a most recent study, laparoscopy was diagnostic in 100% and therapeutic in 87.9% of 107 patients with peritonitis. In 40% of cases, ruptured appendicitis and intestinal
obstruction were found in equal numbers (20 each). Perforated
cholecystitis was present in 15 patients. In 12% of patients,
laparoscopy was converted into open procedure. In this series, the
mortality was 4.6%, with complication occurring in 14% of patients, 7.4%
of them requiring re-operation. Most of the complications, however,
were minor, with only one requiring operative intervention. Of those
converted to an open technique, only two were due to, one intestinal
injury, and one to bleeding. Most of the conversions were due to
technical and inexperience of the surgeon.

Laparoscopic procedures in patients with acute peritonitis should be carried out by experience
surgeons and expertise in performing advanced laparoscopic skills and
not merely diagnoses of a condition. The ability of laparoscopy to fully
explore the abdomen, and intervene therapeutically as indicated, is
probably the biggest advantage of this technique. In addition to the
ability to apply this technique in the operating room, laparoscopy may
be applied in the intensive care unit, although it may be difficult to
perform definitive procedure in the ICU, requiring the second procedure.
The development of 2-mm laparoscopic cameras and the ability to perform
this under local anesthesia may further improve the acceptability of
this technique as a diagnostic tool in ICU septic patients with no known
source. In addition examination of pelvic organs can be greatly improve
with laparoscopy, while the uterus and the ovaries are manipulated
trans-vaginally. Among other advantages of laparoscopic techniques
approaches is reduced immunosuppression observed in response to the
surgical trauma and all other advantages of minimally invasive surgical
technique.

Percutaneous radiographically directed techniques

Percutaneous drainage of intra-abdominal abscess with CT or US guided technique has
become a method of choice in the management of postoperative abscesses
and collections. It clearly has its advantages. When successful it
avoids the re-operation, and minimizes the morbidity of the operation
(possibility of fistula, bowel injury, wound complications). This
technique is being adopted even for the primary abscesses. Such as
diverticular abscess, appendices abscess.

Percutaneous cholecystostomy (PC) has been shown to be a viable alternative procedure
in acute cholecystitis in critically ill and elderly patients in whom
emergent cholecystectomy is associated with prohibitive risks. This
procedure was applied prospectively and successfully to 38 patients age
greater than 80 years old. Of these patients, 25 had acute calculous
cholecystitis, while 13 had AAC. Prompt clinical improvement was de-
monstrated in 95% of patients, while the morbidity and mortality was
only 3% respectively, although 21% of them had evidence of severe acute
cholecystitis associated with septic shock, respiratory syndrome,
disseminated intravascular coagulopathy, or acute renal failure. Once
improved from their acute illness 10 patients underwent elective
cholecystectomy, while 12/13 patients with AAC had no recurrent
cholecystitis after catheter was removed, during the follow up of 1.8
years. One patient with recurrent AAC died in this series. After
drainage, acute calculous cholecystitis relapsed in 33% of patients.
This and other studies suggest that cholecystostomy is simple, safe,
effective and may be a definitive procedure for AAC in this group of
patients, although there are no RCT to recommend this therapy in
patients with AAC (grade C).

Summary

Despite significant clinical and technological advances in physiologic
monitoring of critically ill and septic patients, intra-abdominal sepsis
continuos to be associated with high rate of morbidity and mortality.
While the true incidence of abdomen as a source of sepsis is not known,
intra-abdominal infections are present in up to 25% of patients with
MOF. Sepsis has a death rate as high as 50%. If, on the other hand,
patients progress into multiple organ failure (MOF) with more than three
organ systems, the mortality may approach 100%. Identifying and
correcting abdominal septic source in critically ill patient in timely
fashion, may represent a difficult task, unless systematic, evidence
based and thorough multispecialty approach is practiced.

References

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