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Background: Secondary peritonitis remains associated with high mortality and morbidity rates. Treatment of secondary peritonitis is still challenging even in the era of modern medicine. Surgical intervention for source control remains the cornerstone of treatment besides adequate antimicrobial therapy and when necessary intensive medical care measures and resuscitation. A randomized clinical trial showed that relaparotomy on demand (ROD) after initial emergency surgery was the preferred treatment strategy, irrespective of the severity and extent of peritonitis. Results and discussion: The effective and safe use of ROD requires intensive monitoring of the patient in a setting where diagnostic tests and decision making about relaparotomy are guaranteed round the clock. The lack of knowledge on timely and adequate patient selection, together with the lack of use of easy but reliable monitoring tools seem to hamper full implementation of ROD. The accuracy of the relaparotomy decision tool is reasonable for prediction of the formation of peritonitis and necessary selection of patients for computed tomography (CT). The value of CT in the early postoperative phase is unclear. Future research and innovative technologies should focus on the additive value of CT after surgical treatment for secondary peritonitis and on the further optimization of bedside prediction tools to enhance adequate patient selection for interventions in a multidisciplinary setting. [ABSTRACT FROM AUTHOR]

Investigates the course of interleukin-6 and tumor necrosis factor (TNF) after surgery in bile duct-ligated rats (BDL) treated with the without an enteral endotoxin binder cholestyramine. Determination of endotoxin in rat plasma; Suggestion of endotoxin tolerance for TNF production in obstructive jaundice; Cytokines.

Investigates the course of interleukin-6 (IL-6) and tumor necrosis factor (TNF) after surgery in bile duct-ligated (BDL) rats treated with and without cholestyramine. Endotoxin plasma, plasma TNF and plasma IL-6 levels; Influence of cholestyramine treatment on TNF and IL-6 levels; Indication of the lack of postoperative plasma TNF response in the BDL-saline-treated rats.

This letter to the editor comments on the editorial "WHO's Patient Safety Checklist for Surgery" from the July 5, 2008 issue of this journal.

Aims: The surgical treatment strategy of secondary peritonitis is still an unresolved issue largely due to lack of sufficient data. In similar clinical situations, some surgeons perform a planned relaparotomy after 1 or 2 days, while others only perform a relaparotomy when the patient deteriorates or shows lack of improvement. Many patients undergo multiple (planned) laparotomies for peritoneal lavage accompanied by a high risk of complications, although there are insufficient data to indicate which policy indeed contributes to recovery and survival. We addressed this dilemma in our own series. Methods: The clinical data of 235 patients who received an emergency laparotomy for secundary peritonitis were examined retrospectively. Mortality and morbidity results of 148 patients receiving at least one relaparotomy were analyzed by comparison of planned relaparotomy (PR, n = 77) and relaparotomy on demand (OD, n = 71). Results: An increased mortality was found for the PR group compared to the OD group (34.2 per cent versus 26.8 per cent, logrank P = 0.055); which was predominantly seen in the APACHE II category of 11–20 points (admission score). Surgical complications (fistula, abscess) tended to be more frequently found in the OD group, although no difference was found for incisional hernia as a long-term complication. Conclusions: Our data indicate a tendency towards an increased mortality after planned relaparotomy, although surgical complications may be increased after relaparotomy on demand. To obtain long-awaited prospective data, we have started a multicentre, randomized trial comparing these two surgical treatment strategies. [ABSTRACT FROM AUTHOR]

Chronic pancreatitis is an inflammatory disease of the pancreas with abdominal pain as the most prominent symptom. Adequate treatment of patients with chronic pancreatitis remains a major challenge, mainly because of the lack of evidence-based treatment protocols. The primary goal of treatment is to achieve long-term pain relief, control of the complications associated with the disease, and to restore the quality of life. Currently, a conservative step-up approach is often used for the treatment of pain; progression to severe and intractable pain is considered necessary before invasive treatment is considered. Recent studies, however, suggest that surgical intervention should not be considered only as last-resort treatment, since it can mitigate disease progression, achieve excellent pain control, and preserve pancreatic function. In this review, we present a state-of-the art overview of endoscopic and surgical treatment options for patients with painful chronic pancreatitis, and elaborate on the timing of surgery. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives Quality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay. Methods An antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol. Results Between 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6–11.5) versus intervention 10.1 days (95% CI 8.9–11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0–3.0), p < 0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance. Conclusions Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist. [ABSTRACT FROM AUTHOR]