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

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)

15. Infections of thewalls of viscera (cholys, appy)

17. Missedpads

18. Meckel’sdiverticulitis

19. Hemostatic powderandpads

20. Remmantapandisitis

21. Inflammatuaryboweldiseases

24. 1st 4hrs ----> aerobic E. coli, etc

27. Causativebacteria CommonBacteria: E. coli Enterococcusfaecalis Klebsiellaspeices Staphylococci MRSA P. aeruginosa Proteusspeices Bacteroidessp.

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

32. Typicallyoccurs 5-7 days, but may be muchwiderAlves 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

46. Effectiveforpredictingmortalityfromsecondaryperitonitis

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

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

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

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.

66. Plannedrelaparatomy Earlydetection of persistentinfection Limitidadhesionformation Relaparotomy on demand Preventunneccessaryoperations May allow to developcontainedinfectionaccessible to percutaneousinterventionaltechniques

67. Intestinalischemia “secondlook”

70. Leads to substantial morbidity and mortality

71. Many factors determine AL

72. Patient related

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

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