A differentiated approach to repeat small-bowel anastomoses in patients with postoperative peritonitis: a prospective co
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ORIGINAL ARTICLE
A differentiated approach to repeat small-bowel anastomoses in patients with postoperative peritonitis: a prospective cohort study Andrey N. Zharikov1 · Vladimir G. Lubyansky1 · Andrey A. Zharikov1 Received: 1 November 2018 / Accepted: 30 January 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2019
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
Introduction Postoperative peritonitis distinguishes itself by severe course and difficult surgical treatment, with high mortality rates ranging from 15 to 70% [1–3]. This is attributed to the specifics of etiology, pathogenesis, clinical implications and imperfect approaches to surgical management [4, 5]. The most common causes of postoperative peritonitis include intestinal anastomotic leakage, spontaneous small-bowel perforations, abdominal abscesses, and ongoing intestinal * Andrey N. Zharikov [email protected] 1
Chair of Neymark Departmental Surgery and Hospital Surgery, Altai State Medical University, Prospect Lenina 40, Barnaul, Altai
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