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A differentiated approach to repeat small-bowel anastomoses in patients with postoperative peritonitis: a prospective cohort study

  • Andrey N. ZharikovEmail author
  • Vladimir G. Lubyansky
  • Andrey A. Zharikov
Original Article
  • 40 Downloads

Abstract

Background

Postoperative peritonitis still remains the cause of a high mortality rate in emergency abdominal surgery. Here we aimed to evaluate the efficacy of different surgical strategies for small-bowel perforations that resulted in postoperative peritonitis.

Methods

Surgical management results for 140 patients with postoperative peritonitis due to small-bowel perforations, necrosis and anastomotic leakage were comparatively analyzed. Using the APACHE-II and MPI scoring systems, different surgeon attitudes were examined in three patient groups (primary anastomosis, delayed anastomosis, and enterostomy).

Results

The surgical approach in patient group I (n = 47, APACHE-II 11.7 ± 1.2, MPI 14.7 ± 1.3) involved the closure of small-bowel perforations or small-bowel resection to place primary anastomosis. The mortality rate was 17%. Patient group II (n = 48, APACHE-II 16.8 ± 0.7, MPI 19.3 ± 0.3) underwent delayed small-bowel anastomosis during planned relaparotomies. The mortality rate was 18.8%. Because patients in patient group III (n = 45, APACHE-II 22.3 ± 1.3, MPI 24.6 ± 1.2) were in very critical condition, anastomoses were not placed after bowel resection, and the surgical procedure was completed with enterostomy. The highest mortality rate of 37.8% was documented in this patient group.

Conclusion

The differentiated surgical approach undertaken herein using delayed small-bowel anastomosis in more serious patients with postoperative peritonitis was able to mitigate the risk of recurrent anastomotic leaks and was not accompanied by a considerable rise in mortality. The mortality for primary repair and delayed primary closure was basically the same (17.0% and 18.8%, p = 0.03); however, delayed anastomosis in the patients with postoperative peritonitis at higher APACHE-II and MPI scores for severity of illness showed 15.1% less complications in the form of anastomotic leaks (p = 0.04).

Keywords

Postoperative peritonitis Small-bowel anastomotic leakage Nontraumatic small-bowel perforation Delayed anastomosis Primary anastomosis 

Notes

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

This study was approved by the Ethics Committee of the Altai State Medical University and informed consent was obtained from all patients who agreed to participate in the study. All the Ethics Committee members (100%) unanimously approved this study.

Research registration unique identifying number (UIN)

ClinicalTrials.gov ID: NCT03690687.

References

  1. 1.
    Torer N, Yorganci K, Elker D, Sayek I. Prognostic factors of the mortality of postoperative intraabdominal infections. Infection. 2010;38:255–60.  https://doi.org/10.1007/s15010-010-0021-4.CrossRefGoogle Scholar
  2. 2.
    Sartelli M, Griffiths EA, Nestori M. The challenge of post-operative peritonitis after gastrointestinal surgery. Updates Surg. 2015;67(4):373–81.  https://doi.org/10.1007/s13304-015-0324-1.CrossRefGoogle Scholar
  3. 3.
    Bensignor T, Lefevre JH, Creavin B, Chafai N, Lescot T, Hor T, Debove C, Paye F, Balladur P, Tiret E, Parc Y. Postoperative peritonitis after digestive tract surgery: surgical management and risk factors for morbidity and mortality, a cohort of 191 patients. World J Surg. 2018;42(11):1–10.  https://doi.org/10.1007/s00268-018-4687-6.CrossRefGoogle Scholar
  4. 4.
    Lock JF, Eckmann C, Germer CT. Characteristics of postoperative peritonitis. Der Chirurg. 2016;87(1):20–5.  https://doi.org/10.1007/s00104-015-0110-0.CrossRefGoogle Scholar
  5. 5.
    Johnson CC, Baldessarre J, Levison ME. Peritonitis: update on pathophysiology, clinical manifestations, and management. Clin. Infect. Dis. 1997;24(6):1035–45.  https://doi.org/10.1086/513658.CrossRefGoogle Scholar
  6. 6.
    Afridi SP, Malik F, Ur-Rahman S, Shamim S, Samo KA. Spectrum of perforation peritonitis in Pakistan: 300 cases Eastern experience. World J Emerg Surg. 2008;3:31.  https://doi.org/10.1186/1749-7922-3-31.CrossRefGoogle Scholar
  7. 7.
    Babu RG, Malolan A, Chowdary PB. Ileostomy for non-traumatic ileal perforations: Is this the beginning of the end? Clin Diagn Res. 2016;10(3):23–6.  https://doi.org/10.7860/JCDR/2016/18461.7473.Google Scholar
  8. 8.
    Khalid S, Burhanulhuq, Bhatti AA. Non-traumatic spontaneous ileal perforation: experience with 125 cases. J Ayub Med Coll Abbottabad. 2014;26(4):526–9.Google Scholar
  9. 9.
    Yanar H, Taviloglu K, Ertekin C, Ozcinar B, Yanar F, Guloglu R, Kurtoglu M. Planned second-look laparoscopy in the management of acute mesenteric ischemia. World J Gastroenterol. 2007;13(24):3350–3.CrossRefGoogle Scholar
  10. 10.
    Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg. 2012;36(3):497–510.  https://doi.org/10.1007/s00268-011-1203-7.CrossRefGoogle Scholar
  11. 11.
    Pauly S, Schulze FP, Horstmann O, Becker H, Grade M, Ghadimi M. Value of one-stage surgical treatment of diffuse peritonitis (relaparotomy on demand): a single-center analysis. Zentralbl Chir. 2013;138(3):289–94.  https://doi.org/10.1055/s-0032-1328006.CrossRefGoogle Scholar
  12. 12.
    Van Ruler O, Mahler CW, Boer KR, et al. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. 2007;298(8):865–72.  https://doi.org/10.1001/jama.298.8.865.CrossRefGoogle Scholar
  13. 13.
    Scriba MF, Laing GL, Bruce JL, Sartorius B, Clarke DL. The role of planned and on-demand relaparotomy in the developing world. World J Surg. 2016;40(7):1558–64.  https://doi.org/10.1007/s00268-015-3379-8.CrossRefGoogle Scholar
  14. 14.
    Banasiewicz T, Dziki A, Lampe P, Lorenc Z, Szczepkowski M, Zieliński J, Wallner G. Anastomotic leaks in gastrointestinal surgery and their prevention. Pol Przegl Chir. 2017;89(2):49–56.  https://doi.org/10.5604/01.3001.0009.8979.CrossRefGoogle Scholar
  15. 15.
    Morse BC, Simpson JP, Jones YR, Johnson BL, Knott BM, Kotrady JA. Determination of independent predictive factors for anastomotic leak: analysis of 682 intestinal anastomoses. Am J Surg. 2013;206(6):950–5.  https://doi.org/10.1016/j.amjsurg.2013.07.017.CrossRefGoogle Scholar
  16. 16.
    Shogan BD, Belogortseva N, Luong PM, et al. Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal anastomotic leak. Sci Transl Med. 2015;7(286):286ra68.  https://doi.org/10.1126/scitranslmed.3010658.CrossRefGoogle Scholar
  17. 17.
    De Graaf JS, van Goor H, Bleichrodt RP. Primary small bowel anastomosis in generalized peritonitis. Eur J Surg. 1996;162(1):55–8.Google Scholar
  18. 18.
    Ordonez CA, Puyana JC. Management of peritonitis in the critically ill patient. Surg Clin North Am. 2006;86(6):1323–49.CrossRefGoogle Scholar
  19. 19.
    Kotze PG, de Barcelosa IF, Ropelato RV, Coy CSR. Human fibrinogen and thrombin patch for extraluminal protection of intestinal anastomosis. J Coloproctol. 2013;33(3):174–8.  https://doi.org/10.1016/j.jcol.2013.08.004.CrossRefGoogle Scholar
  20. 20.
    Demmel N, Muth G, Maag K, Osterholzer G. Prognosescoresbei peritonitis: Mannheimer Peritonitis-Index oder APACHE II? Langenbecks Archiv für Chirurgie. 1994;379:347–52.  https://doi.org/10.1007/BF00191581.Google Scholar
  21. 21.
    Budzyński P, Dworak J, Natkaniec M, Pędziwiatr M, Major P, Migaczewski M, Matłok M, Budzyński A. The usefulness of the Mannheim Peritonitis Index score in assessing the condition of patients treated for peritonitis. Pol Przegl Chir. 2015;87(6):301–6.  https://doi.org/10.1515/pjs-2015-0058.Google Scholar
  22. 22.
    Khan A, Hsee L, Mathur S, Civil I. Damage-control laparotomy in nontrauma patients: review of indications and outcomes. J Trauma Acute Care Surg. 2013;75:365–8.  https://doi.org/10.1097/TA.0b013e31829cb65e.CrossRefGoogle Scholar
  23. 23.
    Becher RD, Peitzman AB, Sperry JL, Gallaher JR, Neff LP, Sun Y, Miller PR, Chang MC. Damage control operations in non-trauma patients: defining criteria for the staged rapid source control laparotomy in emergency general surgery. Nord J Emerg Surg. 2016;11:10.  https://doi.org/10.1186/s13017-016-0067-4.CrossRefGoogle Scholar
  24. 24.
    Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in nontrauma patients. World J Surg. 2015;39:912–25.  https://doi.org/10.1007/s00268-014-2883-6.CrossRefGoogle Scholar
  25. 25.
    Mutafchiyski VM, Popivanov GI, Kjossev KT, Chipeva S. Open abdomen and VAC® in severe diffuse peritonitis. J R Army Med Corps. 2016;162(1):30–4.  https://doi.org/10.1136/jramc-2014-000386.CrossRefGoogle Scholar
  26. 26.
    Strobel O, Werner J, Büchler MW. Surgical therapy of peritonitis. Chirurg. 2011;82(3):242–8.  https://doi.org/10.1007/s00104-010-2015-2.CrossRefGoogle Scholar
  27. 27.
    Caronna R, Boukari AK, Zaongo D, Hessou T, Gayito RC, Ahononga C, Adeniran S, Priuli G. Comparative analysis of primary repair vs resection and anastomosis, with laparostomy, in management of typhoid intestinal perforation: results of a rural hospital in northwestern Benin. BMC Gastroenterol. 2013;13(1):102.  https://doi.org/10.1186/1471-230X-13-102.CrossRefGoogle Scholar
  28. 28.
    Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD. Acute mesenteric ischemia: a clinical review. Arch Intern Med. 2004;164(10):1054–62.CrossRefGoogle Scholar
  29. 29.
    Kiewiet JJ, van Ruler O, Reitsma JB, Boermeester MA. Treatment of secondary peritonitis: slow progress. Ned Tijdschr Geneeskd. 2009;153:A386.Google Scholar
  30. 30.
    Schikata S, Yamagishi H, Taji Y, Shimada T, Noguchi Y. Single-versus two-layer intestinal anastomosis: a meta-analysis of randomized controlled trials. BMC Surg. 2006;6:1471–6.  https://doi.org/10.1186/1471-2482-6-2.Google Scholar
  31. 31.
    Shaw RS. The ``second look’’ after superior mesenterial embolectomy or reconstruction for mesenteric infarction. current surgical management. Philadelphia: W. B. Sounders Company; 1965.Google Scholar
  32. 32.
    Schneider TA, Longo WE, Ure T, Vernava AM. Mesenteric ischemia. Acute arterial syndromes. Dis Colon Rectum. 1994;37:1163–74.  https://doi.org/10.1007/BF02049824.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Chair of Neymark Departmental Surgery and Hospital SurgeryAltai State Medical UniversityBarnaulRussia

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