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Background: Antimicrobial drug resistance in community-acquired (CA) infections is a growing problem. Knowing the local epidemiology is essential to design empirical antibiotic therapy. Therefore, ...

Surgical mesh infections from ventral hernia repairs are common in obese patients. Definitive management includes the surgical removal of mesh; however, obese patients are often poor surgical candidates with limited therapeutic options. We report the case of a 64-year-old male with an abdominal wall seroma secondary to an infected surgical mesh. This was on a background of multiple abdominal wall reconstructions for previous strangulated ventral hernias. A nonoperative novel approach utilizing bromelain percutaneously in conjunction with antibiotics successfully resolved the infected seroma. The purpose of this case is to detail the potential clinical application of bromelain in surgical site infections involving surgical prosthesis. We illustrate the successful use of bromelain as a nonoperative alternative for abdominal infections or when all other surgical and conservative therapies have been exhausted.

PURPOSE: The aim of this study was to evaluate the highly elevated CRP levels at admission as a mortality predictor in patients with complicated intra-abdominal infections (cIAIs). METHODS: This retrospective study involved 78 adult patients with diagnosis cIAIs admitted to the Department of Surgical Diseases at a University Hospital Stara Zagora from January 2017 to October 2018. CRP concentrations, white blood cells (WBC) count, qSOFA score and SIRS criteria were determined at admission. We compared their prognostic performance using the area under receiver operating characteristics (AUROC) curves and analyzed the coordinates of the curves. RESULTS: Of the 78 enrolled patients twenty (25.6%) died during hospitalization. ROC Curve analysis revealed CRP as the best mortality predictor (AUROC = 0.787). The pairwise comparison of ROC curves showed prognostic superiority of CRP compared to WBC (AUROC = 0.787 vs. 0.511, p = 0.0194) and SIRS (AUROC = 0.787 vs. 0.579, p = 0.0315) in outcome prediction. The identified sensitivity and specificity for CRP cut-off value = 210 mg/L were 75.0% and 81.0%, respectively. CONCLUSION: We found highly elevated CRP levels at admission as a significant prognostic biomarker in patients with cIAIs.

Drug-induced hemolytic anemia (DIHA) is a rare complication of drug therapy and usually underdiagnosed. Cefoperazone/sulbactam is a compound prepared from the third generation of cephalosporin and β-lactamase inhibitor. There are limited data of DIHA induced from cefoperazone/sulbactam. A 93-year-old female patient, who had an operation on the biliary tract 3 months ago, was admitted to our hospital with an abdominal infection. After cefoperazone/sulbactam was given as anti-infection treatment, the patient developed hemolytic anemia on the third day. Cefoperazone/sulbactam was discontinued and replaced with meropenem. Subsequently the level of red blood cells, hemoglobin, and hematocrit returned to normal. Clinicians should pay attention to monitoring the possible adverse reactions during the use of cefoperazone/sulbactam and should be aware of the occurrence of DIHA, so as to give timely treatment.

Background: Optimal treatment of intra-abdominal infections (IAIs) is multifaceted, typically requiring surgical intervention and antimicrobial therapy. Treatment of IAIs aligned with the ...

Background Acute esophageal necrosis (AEN) is a rare entity associated with diabetic ketoacidosis (DKA). The pathogenesis is thought to be linked to low volume state, microvascular disease, impaired gastric and esophageal motility increasing acid reflex, all rendering the esophagus prone to injury. Aims We report a case of AEN as a complication of DKA in a patient without any overt gastrointestinal bleeding (GIB), along with a literature review. Methods Keywords “esophageal necrosis” and “diabetic ketoacidosis” were used in MEDLINE and BASE to retrieve English articles reporting cases of AEN in DKA. Results A 63 year old male with history of hypertension, dyslipidemia and non-insulin dependent diabetes mellitus presented to Emergency with 5 day history of severe epigastric pain, dysphagia to solids and liquids, nausea and vomiting (without any overt GIB). Most recent HbA1c was 8.4%. His diabetes was managed with metformin and semaglutide. Bloodwork revealed a hemoglobin of 165g/L and leukocytes of 17.9x109/L. Chemistries showed an anion gap of 25 with bicarbonate of 5mmol/L. Venous blood gas showed acidemia (pH=7.02). B-hydroxybutyrate level was 10.2mmol/L. Urinalysis was negative for leukocytes or nitrites. An abdominal CT ruled out bowel obstruction or intra-abdominal infection/abscess as the source of his discomfort but demonstrated circumferential wall thickening of the distal esophagus. No other triggers were found for this patient’s DKA except perhaps a recently started ketogenic diet. After resolution of DKA, he continued to experience severe epigastric pain, reflux symptoms, and dysphagia. An esophagogastroduodenoscopy (EGD) was performed, which showed AEN with circumferential black, necrotic inflammatory changes in the mid to distal esophagus. Erosions were seen in the body and antrum of the stomach, and multiple clean based ulcers were seen in the duodenum. Patient was started on an insulin regimen prior to discharge. Review of literature shows a total of 13 cases of AEN in DKA, with only one case where the patient did not present with any clinical bleeding. Risk factors for AEN include, hypertension, diabetes mellitus, malignancy, male gender, older age, chronic kidney disease, alcohol abuse and cardiovascular disease. While no medications have been linked to AEN, our patient was recently started on semiglutide, which has been implicated in impaired gastric emptying and increased GERD symptoms. This may further explain why the patient developed AEN. Conclusions AEN is a rare entity, especially in the context of DKA. Usually patients present with overt GIB; however, on occasion dysphagia, nausea, and vomiting can be the predominant symptoms. Hence, the threshold to perform EGD in patients with DKA should be low, given their low volume state and potentially impaired gastrointestinal motility due to microvascular disease or medications, putting them at higher risk for AEN. Funding Agencies None

Background: Anastomotic leak is among the most dreaded complications in patients undergoing colorectal surgery. We have discovered that in rodents, collagenase-producing bacteria, particularly Enterococcus faecalis, promotes anastomotic leak by degrading healing anastomotic tissue. Yet, it is unclear if these organisms play a role in humans. Patients and Methods: Patients undergoing colorectal resection at the University of Chicago from July 2014 through June 2019 who developed a post-operative infection were stratified into infections that resulted from an anastomotic leak, a Hartmann pouch stump leak, or a deep infection without an associated staple line leak. Results: Forty-two patients had available culture data. Of these patients, 19 were found to have an anastomotic leak, 7 had a stump leak, and 16 had a deep infection that was not associated with a staple line. Enterococcus faecalis was identified in 24% of all infections and was associated with the development of anastomotic leak (p = 0.029). When the organisms were classified into their known ability to produce collagenase, 74% of patients with an anastomotic leak were colonized with collagenase-producing organisms, compared with only 28% of patients with a deep infection or stump leak (p = 0.022). Antibiotic-resistant organisms were more common in patients with anastomotic leak (p = 0.01). Conclusions: Collagenase-producing and antibiotic-resistant organisms are more prevalent in anastomotic leak infections compared with other deep or organ/space infections. This lends evidence to a bacterial driven pathogenesis of leak and suggests that targeting these organisms may be a novel strategy to reduce this complication.

Diffuse large B-cell lymphoma (DLBCL) is one of the most common non-Hodgkin lymphomas. It has no typical or specific clinical features. DLBCL revealed by an abscess is a rare entity. CT is sensitive in detecting splenic abscesses, and it can define the exact location and extent of the abscess as well. The splenic abscess is associated with typhoid fever, AIDS, abdominal infections, pneumonia, bacterial endocarditis, and urogenital infections, parasitic abscesses, organ transplantation, or neoplastic diseases. DLBCL is not usually related to its etiology. Elective open splenectomy, both diagnostic and therapeutic, is the gold standard method of management today and has low morbidity and mortality rates, with even lower rates for laparoscopic splenectomy. The diagnosis of DLBCL is based on the anatomopathological and immunohistological examination. We report a case of a man with a splenic abscess initially treated as an abscess of bacterial origin; however, the lack of improvement in his condition led us to perform a splenectomy, and the anatomopathological study revealed a DLBCL.

Aim To uncover the practical efficacy of intra-operative peritoneal fluid sampling and the impact on antibiotic prescription and clinical outcomes in patients undergoing emergency surgery due to intra-abdominal infections. Method Our retrospective study included all patients undergoing emergency surgery for intra-abdominal infections at Southend University Hospital over 6 months (January – July 2019). Data was collected from electronic patient records, case notes and microbiology reports and included the following information: patient age demographics; type of infection; peritoneal fluid sampling indication; samples taken; details of swab culture report including organisms grown and antibiotic sensitivity; clinical course and incidence of subsequent intra-abdominal infection to include readmission and/or further procedures; the type, duration and route of antibiotic prescribed and duration of hospital stay. This audit was approved by the Departmental Audit Lead. Results 441 patients undergoing emergency surgery for intra-abdominal infection were identified. After exclusions, intra-operative peritoneal fluid samples were indicated in 77 patients (mean age 39.4 years). Of these only 3 had samples taken (3.9%). The most common organisms isolated were mixed anaerobes followed by Streptococcus angiosus. The most common antibiotic sensitivity was Metronidazole and Penicillin. One readmission occurred due to an intra-abdominal tubo-ovarian abscess. Conclusions The study shows that the current practice in our hospital regarding intra-operative peritoneal fluid sampling in intra-abdominal infections reflects the present widely held attitudes regarding its reduced practical utility. Abandoning routine sampling had no significant impact on the clinical course and may be more cost-effective. The study may help surgeons reflect on changing perspectives on this traditional practice.

Background Digestive tract reconstruction in totally laparoscopic total gastrectomy can be divided into two types: instrument anastomosis and hand-sewn anastomosis. This study explored the feasibility and safety of hand-sewn sutures in esophagojejunostomy of totally laparoscopic total gastrectomy, compared with instrument anastomosis using an overlap linear cutter. Methods This retrospective cohort study was conducted from January 2017 to January 2020 at one institution. The clinical data of 50 patients who underwent totally laparoscopic total gastrectomy, with an average follow-up time of 12 months, were collected. The clinicopathologic data, short-term survival prognosis, and results of patients in the hand-sewn anastomosis (n=20) and the overlap anastomosis (n=30) groups were analyzed. Results There were no significant differences between the groups in sex, age, body mass index, American Society of Anesthesiologists score, tumor location, preoperative complications, abdominal operation history, tumor size, pTNM stage, blood loss, first postoperative liquid diet, exhaust time, or postoperative length of hospital stay. The hand-sewn anastomosis group had a significantly prolonged operation time (204±26.72min versus 190±20.90min, p=0.04) and anastomosis time (58±22.0min versus 46±15.97min, p=0.029), and a decreased operation cost (CNY 77,100±1700 versus CNY 71,900±1300, p Conclusion The hand-sewn anastomosis method of esophagojejunostomy under totally laparoscopic total gastrectomy is safe and feasible and is an important supplement to linear and circular stapler anastomosis. It may be more convenient regarding obesity, a relatively high position of the anastomosis, edema of the esophageal wall, and short jejunal mesentery.

Sepsis is a common consequence of infection, associated with a mortality rate > 25%. Although community-acquired sepsis is more common, hospital-acquired infection is more lethal. The most common site of infection is the lung, followed by abdominal infection, catheter-associated blood steam infection and urinary tract infection. Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens. To reduce mortality, it is necessary to give immediate, empiric, broad-spectrum therapy to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship. Biomarkers such a procalcitonin can provide decision support for antibiotic use, and may identify patients with a low likelihood of infection, and in some settings, can guide duration of antibiotic therapy. Sepsis can involve drug-resistant pathogens, and this often necessitates consideration of newer antimicrobial agents.

Laparoscopic cholecystectomy is a routinely performed surgery nowadays. However, it is associated with certain complications. Gall bladder perforation during the procedure can result in spilled and lost gallstones. Lost gallstones most commonly cause intra-abdominal infection. However, very rarely, they can be associated with troublesome retroperitoneal abscess formation. We present a case where a lost gallstone caused a retroperitoneal abscess formation and was retrieved from a back abscess in the right paraspinal region.

Background Anastomotic leakage is one of the most serious postoperative complications of rectal cancer. Prophylactic ileostomy has been widely used to reduce the risk and severity of complications of anastomotic leakage. However, prophylactic ileostomy itself has some complications, and ileostomy high output syndrome (HOS) is one of them. This study was performed to explore the risk factors of HOS in ileostomy. Methods A total of 114 patients with HOS were screened out from 494 eligible ileostomy patients in the last 5 years. The relationship between HOS and the clinicopathological data was analyzed using the Chi-square test and Fisher’s exact probability. Multivariate analysis was performed by logistic regression. Results The incidence of HOS was 23.07% in this study. Dehydration was the most common symptom of HOS (37.7%). There was no clear correlation between HOS occurrence with sex, age, gross typing, histological grade, tumor location, lymph node metastasis, and TNM stage (p > 0.05). The incidence of HOS was 14/18 in inflammatory bowel disease patients, 18/28 in diabetes mellitus patients, and 23/72 in neoadjuvant chemoradiotherapy patients, 13/17 in total colectomy and abdominal infection patients. Multivariate analysis showed that they are risk factors for HOS (p Conclusion HOS occurred occasionally but rarely studied and lacks attention. Inflammatory bowel disease, diabetes mellitus, neoadjuvant radiotherapy chemotherapy, total colectomy and abdominal infection are the risk factors for HOS.

Introduction: The principles management of complicated intra-abdominal infections are source control and antibiotic therapy. The main problem in its implementation is the slow handling time and inadequate antibiotic therapy, which leads in an increase in mortality in complicated intra-abdominal infections. Early empirical antibiotics are based on the pathological location and community microbial pattern. This study is aimed to evaluate microbial pattern at H. Adam Malik General Hospital between January 2017 and October 2019. Methods: This is a retro-prospective observational descriptive study. Results: There were 37 patients who met the inclusion criteria. The most common microbial pattern in this study was gramnegative bacteria, which was 62.1%. The most common gram-negative bacteria found were E.coli (32.4%), followed by Klebsiella pneumonia (24.3%). While the most common gram-positive bacteria found was Staphylococcus haemolyticus (8.1%). Conclusion: The most common microbial pattern found in this study was gram-negative bacteria, where the most common gram-negative bacteria was E. coli. The most common gram-positive bacteria was Staphylococcus haemolyticus

This event reflects the author's involvement in internationally recognized education and training models, as ATLS, ETC, and DSTC, and UEMS Boards of Emergency SurgeryDo different countries need very different things? I don’t think so, for the simple reason that in Europe and about the challenges we face, with regard to trauma and other medical and surgical emergencies, similarities are much greater than differences.• We all agree on the need for a trauma system “to assure that patients (…) seamlessly receive the proper care, in the proper locations, with proper interventions and, if necessary, transfer to a hospital able to provide the best and most appropriate care” (www.aast.org).• We all agree that teamwork is necessary for prehospital care, transportation, emergency room care, intensive care, surgery, and in/post-hospital rehabilitation.• We all agree on the need for trauma registries with, as much as possible, global follow-up of patient's course.• And finally, we all agree that it is necessary to educate, how to prevent and how to treat.This is also apparent from the recommendations of the European Trauma Course Organization (ETCO) about equipment and facilities: complete trauma team, trauma admission bay close to the ambulance entrance, enough space and adequate lighting, the adjacent operating room to allow emergency procedures, standardequipment for the initial management of major trauma, immediate availability of additional equipment as difficult airway equipment, X-ray, ultrasound machine, surgical instruments, readily available bloodproducts and massive transfusion equipment, co-located CT scanner to allow immediately imaging and access to angiography and interventional radiology, 24 hours a day within 30-60 minutes of request.

Background: Infection analysisamongst malignant cancer patients remains elusive. The objective of this study is to investigate the characteristics of both infection and anti-infection treatments in patients group with malignant cancer. Methods: We retrospectively studied the clinical data of 148 patients with malignant cancer and 171 benign patients enrolled in the pharmacist consultation from April 2015 to April 2017. Statistical analysis was performed by chi-square test to compare the classification of primary disease, sites of infection, composition of pathogenic bacteria, and the effectiveness of drug treatment. P value

Несмотря на развитие оперативной техники, внедрение современных методов диагностики и лечения, появление новых антимикробных препаратов, лечение больных с распространенными формами гнойной инфекции брюшной полости остается одной из актуальных проблем современной хирургии в связи с сохраняющимся высоким уровнем летальности и большим числом послеоперационных осложнений [2, 4–6, 9, 32].

Background Abdominal drainage allows for timely detection of hemorrhage, but it cannot prevent hemorrhage. Whether routine abdominal drainage is needed during bariatric procedures remains controversial. Few reports describe the role of abdominal drainage in the diagnosis and treatment of abdominal hemorrhage in bariatric surgery. Case summary Six cases of hemorrhage after bariatric surgery were described, including three cases with and three without abdominal drainage during the first surgery. The hemorrhage in five of the six cases was controlled by conservative treatment. Abdominal hemorrhage was found through the drainage tube on the day of the operation in the three patients with abdominal drainage during the first surgery. Emergency treatment was initiated, and their conditions gradually stabilized within 48 h. No patients required a reoperation. Abdominal hemorrhage was found later in the patients without abdominal drainage. Although the hemorrhage was controlled by conservative treatment in two cases (1 and 2), reoperation and percutaneous drainage were performed for abdominal infection and pelvic hemorrhage. An obsolete encapsulated effusion that may require treatment in the future was left in the abdominal cavity of a patient (Case 1). Conclusion The possibility of controlling abdominal hemorrhage after bariatric/metabolic surgery by conservative treatment is high. When hemorrhage occurs, abdominal drainage can reduce the probability of reoperation by reducing the formation of blood clots behind the stomach.

Complicated intra-abdominal infections (cIAIs) remain a serious challenge because of their unacceptably high mortality rates. Among different prognostic scoring systems quick-sequential organ failure assessment (qSOFA) score is the most recent. However, as mortality predictor in surgical patients, qSOFA showed lack of sensitivity. The aim of this study was to find prognostic superiority of our new qSOFA-CRP score in patients with cIAIs.We retrospectively analyzed 78 patients presented to ED and admitted to Department of Surgical Diseases between January 2017 and October 2018 with diagnosis cIAIs. CRP levels, qSOFA score and systemic inflammatory response syndrome (SIRS) were established at admission. We analyzed area under receiver operating characteristics (AUROC) curves of SIRS, qSOFA and qSOFA-CRP and performed a comparison to explore their prognostic values.The identified in-hospital mortality was 25.6%. qSOFA-CRP score showed the best prognostic performance compared to qSOFA alone (AUROC = 0.818 vs. 0.746,qSOFA-CRP score showed better prognostic value than quick-SOFA alone in patients with cIAIs.

Purpose In Europe, intravenous fosfomycin (IV) is used particularly in difficult-to- treat or complex infections, caused by both Gram-positive and Gram-negative pathogens including multidrug-resistant strains. Here, we investigated the efficacy and safety of intravenous fosfomycin under real-life conditions. Methods Prospective, multi-center, and non-interventional study in patients with bacterial infections from 20 intensive care units (ICU) in Germany and Austria (NCT01173575). Results Overall, 209 patients were included (77 females, 132 males, mean age: 59 +/- 16 years), 194 of which were treated in intensive care (APACHE II score at the beginning of fosfomycin therapy: 23 +/- 8). Main indications (+/- bacteremia or sepsis) were infections of the CNS (21.5%), community- (CAP) and hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP, 15.3%), bone and joint infections (BJI, 11%), abdominal infections (11%), and bacteremia (10.5%). Most frequently identified pathogens were S. aureus (22.3%), S. epidermidis (14.2%), Enterococcus spp. (10.8%), E. coli (12.3%) and Klebsiella spp. (7.7%). At least one multidrug-resistant (MDR) pathogen was isolated from 51 patients (24.4%). Fosfomycin was administered with an average daily dose of 13.7 +/- 3.5 g over 12.4 +/- 8.6 days, almost exclusively (99%) in combination with other antibiotics. The overall clinical success was favorable in 81.3% (148/182) of cases, and in 84.8% (39/46) of patients with >= 1 MDR pathogen. Noteworthy, 16.3% (34/209) of patients developed at least one, in the majority of cases non-serious, adverse drug reaction during fosfomycin therapy. Conclusion Our data suggest that IV fosfomycin is an effective and safe combination partner for the treatment of a broad spectrum of severe bacterial infections in critically ill patients.

Laparoscopic and endoscopic cooperative surgery (LECS) is a procedure combining laparoscopic gastric resection with endoscopic submucosal dissection for local resection of gastric tumors with appropriate, minimal surgical resection margins. The LECS concept was initially developed from the classical LECS procedure for gastric submucosal tumor resection. Many researchers reported that classical LECS was a safe and feasible technique for resection of gastric submucosal tumors, regardless of tumor location, including the esophagogastric junction. Recently, LECS was approved for insurance coverage by Japan's National Health Insurance plan and widely applied for gastric submucosal tumor resection. However, the limitations of classical LECS are the risk of abdominal infection, scattering of tumor cells in the abdominal cavity, and tumor cell seeding in the peritoneum. The development of modified LECS procedures, such as inverted‐LECS, non‐exposed endoscopic wall‐inversion surgery, a combination of laparoscopic and endoscopic approaches to neoplasia with a non‐exposure technique, and closed‐LECS, has almost resolved these drawbacks. This has led to a recent increase in the indication of modified LECS to include patients with gastric epithelial neoplasms. The LECS concept is also beginning to be applied to tumor excision in other organs, such as the duodenum, colon and rectum. Further evolution of LECS procedures is expected in the future. Sentinel lymph node mapping could also be combined with LECS, resulting in a portion of early gastric cancers being treated by LECS with sentinel node mapping.

Background: Klebsiella pneumoniae has gained notoriety because of its high antibiotic resistance and mortality. We compared the clinical features and outcomes of polymicrobial bacteremia i...

To assess risk factors for 28-day mortality and cost implications in intensive care unit (ICU) patients with complicated intra-abdominal infections (cIAIs).Single-center retrospective cohort study of prospectively collected data analysing ICU patients with a microbiologically confirmed complicated intra-abdominal infections.137 complicated intra-abdominal infections were included and stratified according to the adequacy of antimicrobial therapy (initial inadequate antimicrobial therapy [IIAT], n = 44; initial adequate antimicrobial therapy [IAAT], n = 93). The empirical use of enterococci/methicillin-resistant Staphylococcus aureus active agents and of carbapenems was associated with a higher rate of therapeutic adequacy (p = 0.016 and p = 0.01, respectively) while empirical double gram-negative and antifungal therapy did not. IAAT showed significantly lower mortality at 28 and 90 days and increased clinical cure and microbiological eradication (p 0.01). In the logistic and Cox-regression models, IIAT and inadequate source control were the unique predictors of 28-day mortality. No costs differences were related to the adequacy of empirical therapy and source control. The empirical double gram-negative and antifungal therapy (p = 0.03, p = 0.04) as well as the isolation of multidrug-resistant (MDR) bacteria and the microbiological failure after targeted therapy were drivers of increased costs (p = 0.004, p = 0.04).IIAT and inadequate source control are confirmed predictors of mortality in ICU patients with complicated intra-abdominal infections. Empirical antimicrobial strategies and MDR may drive hospital costs.

A long-course antibiotic therapy increases the risk of antibiotic resistance. A 7- to 14-day duration of therapy has been traditionally adopted in patients with intra-abdominal infections (IAIs). Prophylactic antibiotic use is warranted in uncomplicated IAIs, in which the infection involves a single organ, and the source of the infection is completely eradicated by a surgical procedure. A large, randomized clinical trial of the treatment of complicated IAIs recently demonstrated that a fixed 4-day course of antibiotic therapy was as effective as a long-course therapy in patients who underwent adequate source control. Considering the poor prognosis and lack of clear evidence available for shortening the duration of antibiotic therapy in patients who are critically ill or those with ongoing signs of sepsis, the duration of therapy for complicated IAIs should be individually determined according to the clinical course. Limiting therapy to no more than 7 days seems to be warranted in patients who are critically ill with a good clinical response.

Background The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI. Methods The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI. Results Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI. Conclusions Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.

Background The Lebanese Society of Infectious Diseases and Clinical Microbiology (LSIDCM) is involved in antimicrobial stewardship. In an attempt at guiding clinicians across Lebanon in regards to the proper use of antimicrobial agents, members of this society are in the process of preparing national guidelines for common infectious diseases, among which are the guidelines for empiric and targeted antimicrobial therapy of complicated intra-abdominal infections (cIAI). The aims of these guidelines are optimizing patient care based on evidence-based literature and local antimicrobial susceptibility data, together with limiting the inappropriate use of antimicrobials thus decreasing the emergence of antimicrobial resistance (AMR) and curtailing on other adverse outcomes. Methods Recommendations in these guidelines are adapted from other international guidelines but modeled based on locally derived susceptibility data and on the availability of pharmaceutical and other resources. Results These guidelines propose antimicrobial therapy of cIAI in adults based on risk factors, site of acquisition of infection, and clinical severity of illness. We recommend using antibiotic therapy targeting third-generation cephalosporin (3GC)-resistant gram negative organisms, with carbapenem sparing as much as possible, for community-acquired infections when the following risk factors exist: prior (within 90 days) exposure to antibiotics, immunocompromised state, recent history of hospitalization or of surgery and invasive procedure all within the preceding 90 days. We also recommend antimicrobial de-escalation strategy after culture results. Prompt and adequate antimicrobial therapy for cIAI reduces morbidity and mortality; however, the duration of therapy should be limited to no more than 4 days when adequate source control is achieved and the patient is clinically stable. The management of acute pancreatitis is conservative, with a role for antibiotic therapy only in specific situations and after microbiological diagnosis. The use of broad-spectrum antimicrobial agents including systemic antifungals and newly approved antibiotics is preferably restricted to infectious diseases specialists. Conclusion These guidelines represent a major step towards initiating a Lebanese national antimicrobial stewardship program. The LSIDCM emphasizes on development of a national AMR surveillance network, in addition to a national antibiogram for cIAI stratified based on the setting (community, hospital, unit-based) that should be frequently updated.

Background The prognostic role of what a surgeon observes in the abdomen of patients with complicated intra-abdominal infection (cIAI) is largely unknown. The aim of this prospective study was to systemically analyze components of the intra-abdominal view (IAV) and their association to severe complicated intra-abdominal sepsis (SCIAS) or mortality. Methods The study cohort consisted of adult patients with cIAI. The operating surgeon filled a paper form describing the intra-abdominal view. Demographics, operative details, and preoperative physiological status were collected. Descriptive, univariate, and multivariate statistical analyses were performed, and a new score was developed based on regression coefficients. The primary outcome was a composite outcome of SCIAS or 30-day mortality, in which SCIAS was defined as organ dysfunctions requiring intensive care unit admission. Results A total of 283 patients were analyzed. The primary outcome was encountered in 71 (25%) patients. In the IAV, independent risk factors for the primary outcome were fecal or bile as exudate (odds ratio (OR) 1.98, 95% confidence interval 1.05–3.73), diffuse peritonitis (OR 2.15, 1.02–4.55), diffuse substantial redness of the peritoneum (OR 5.73, 2.12–15.44), and a non-appendiceal source of cIAI (OR 11.20, 4.11–30.54). Based on these factors, an IAV score was developed and its performance analyzed. The area under the receiver operating characteristic for the IAV score was 0.81. The IAV score also correlated significantly with several outcomes and organ dysfunctions. Conclusions The extent of peritonitis, diffuse substantial redness of the peritoneum, type of exudate, and source of infection associate independently with SCIAS or mortality. A high IAV score associates with mortality and organ dysfunctions, yet it needs further external validation. Combining components of IAV into comprehensive scoring systems for cIAI patients may provide additional value compared to the current scoring systems. Trial registration The study protocol was retrospectively registered on April 4, 2016, right after the first enrolled patient at Clinicaltrials.gov database (NCT02726932). Electronic supplementary material The online version of this article (10.1186/s13017-019-0232-7) contains supplementary material, which is available to authorized users.

Objective. To assess the blood serum IL-10 concentration in patients with intra-abdominal infections. Materials and methods. Clinical specimens were obtained from 56 patients, suffering intra-abdominal infections of various origin: 24 patients - with postoperative abscesses, 12 - with primary intra-abdominal abscesses, and 20 - with diffuse or local peritoneal collection at the day before surgical intervention, on 2nd-3rd day and on 5th-7th day after it. Results. There was no trustworthy difference established between the blood serum IL-10 concentrations in patients with different origin of intra-abdominal infections in perioperative period. The significant difference was established, while comparing concentrations of IL-10 in the blood serum in patients with intra-abdominal infections before and on the days 2-3 and 5-7 postoperatively, and in healthy persons. Conclusion. Concentration of the blood serum IL-10 ≥ 6.78 pg/mL in patients with different origin of intra-abdominal infections has significant prognostic significance: sensitivity (92.86%) and specificity (80.65%). Further studies, targeting a specific causative agent of nosocomial infection and the cytokine response, are needed.

Highlights • The patient was hospitalized for “intermittent fever, abdominal pain for 19 days” and then underwent laparoscopic cholecystectomy. After the operation, the patient’s condition deteriorated and eventually died. Postoperative pathological diagnosis confirmed gallbladder non-Hodgkin’s lymphoma. • Gallbladder non-Hodgkin’s lymphoma is very rare, and this case also includes hemophagocytic syndrome and bile duct disappearance syndrome, which is rare. This case is described from the onset of the patient to the hospital visit and postoperative conditions. • Bile duct disappearance syndrome (VBDS) is a syndrome characterized by reduced intrahepatic bile ducts as a pathological feature and cholestasis as the main clinical manifestation. • Hemophagocytic syndrome (HPS) is a group of heterogeneous diseases characterized by over-inflammatory responses due to hereditary or acquired immunodeficiency., Introduction Extrahepatic biliary non-Hodgkin’s lymphoma (EBNHL) is rare, with a prevalence of 0.6% of malignant biliary tumors. Primary biliary non-Hodgkin’s lymphoma accounts for 0.4% of extranodal non-Hodgkin’s lymphoma (NHL), accounting for approximately 0.016% of all NHL cases. The patient presented with typical bile duct disappearance syndrome. The late performance is a bloodthirsty syndrome. Presentation of case This patient was admitted to the hospital with “intermittent fever, abdominal pain for 19 days”. The relevant laboratory tests showed severe infection. The patients were treated according to abdominal infection, and then laparoscopic cholecystectomy was performed. After the operation, the patient's condition did not relieve and further deteriorated. Postoperative patient performance was not based on preoperative estimates, and surgery did not achieve the desired results. Postoperative pathological diagnosis confirmed gallbladder non-Hodgkin’s lymphoma. The patient eventually died. Discussion Non-calculus inflammation occurs more frequently in the gallbladder. Non-calculus infections are generally caused by bile stasis and ischemia, resulting in bacterial reproduction and reduced blood supply, and gangrene and perforation of the gallbladder are more likely to occur. This patient is also diagnosed and treated according to this idea. The development after surgery completely exceeded our expectations. Gallbladder non-Hodgkin’s lymphoma is very rare, and this case also includes hemophagocytic syndrome and bile duct disappearance syndrome, which is rare. Conclusion Malignant lymphoma of the extrahepatic biliary system is extremely rare, and its clinical manifestations are easily misdiagnosed. At the same time, non-calculous cholecystitis with fever, jaundice and hepatosplenomegaly should be considered.

Background Recent investigations noted noninferiority in short-course antimicrobial treatments following source control in abdominal infections. We set out to investigate noninferiority of a short and fixed (24 hours) antibiotic administration compared to extended treatment after source control in complicated appendicitis in a prospective single-center open-label randomized controlled trial. Methods After Institutional Review Board (IRB) approval, all consecutive adult patients (age, ≥ 18 years) with complicated appendicitis including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between May 2016 and February 2018 were randomly allocated to antibacterial therapy limited to 24 hours (short) vs. >24 hours (extended) administration after appendectomy. Primary outcomes included composite postoperative complications and Comprehensive Complication Index (CCI). Secondary outcome was hospital length of stay (HLOS). Follow-up analysis at 1 month was conducted per intention and per protocol. Results A total of 80 patients were enrolled with 39 and 41 cases allocated to the short and the extended therapy group, respectively. Demographic profile and disease severity was similar between the study groups. Overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (p = 0.23). Mean CCI did not differ between the study groups (p = 0.29). Hospital length of stay was significantly reduced in the short therapy group (61 ± 34 hours vs. 81 ± 40 hours, p = 0.005). Conclusion In the current prospective randomized investigation, the short (24 hours) antibiotic administration following appendectomy did not result in a worse primary outcome in complicated appendicitis. The short interval administration resulted in a significant reduction in HLOS with a major cost-saving and antibacterial stewardship perspective. Level of evidence Therapeutic Level IV.

Purpose: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. This study aimed to investigate the risk factors and preventive strategies for POPF after PD. Materials and Methods: We retrospectively reviewed 301 consecutive patients who underwent PD at our hospitals between January 2011 and December 2017. We analyzed the pancreatic fistula rate according to the clinical characteristics, pathologic and laboratory findings, and the anastomotic methods and summarized the prevention measures. Results: Postoperative morbidities included pancreatic leakage in 10.30% (31/301), delayed gastric emptying in 22.92% (69/301), abdominal infection in 6.98% (21/301), post-PD hemorrhage in 4.65% (14/301), and bile leakage in 4.98% (15/301), and the mortality rate was 2.33% (7/301). POPF was the most prominent factor for preoperative morbidity. Significant risk factors for pancreatic fistula were a soft pancreas, small pancreatic duct, tumor location, and interrupted anastomosis. Of these, soft texture, pancreatic duct

Song Liu, Meng Wang, Wenxian Guan Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China Abstract: The management of intra-abdominal infections (IAIs) primarily includes adequate antimicrobial therapy and appropriate source control. Vancomycin is a fundamental and most effective antimicrobial agent. The aim of this study is to search and evaluate the quality of clinical evidences regarding the exclusive use of vancomycin for the management of adult IAIs. For this purpose, we first summarized the recommendations on exclusive use of vancomycin in adult IAIs from six leading guidelines and excavated the relevant supporting references. We subsequently conducted a literature search to screen eligible clinical studies in this field for possible systematic review. Our investigation demonstrates that the exclusive use of vancomycin is recommended in restricted indications, that is, IAIs caused by Enterococcus spp. or methicillin-resistant Staphylococcus aureus. However, the supporting references in the guidelines are more subjective instead of objective, which mainly originate from experts’ personal experiences or from the therapeutic efficacy of vancomycin in other types of infections rather than in IAIs. Furthermore, our literature search fails to find high-level evidence. In conclusion, current low-level evidences are inadequate to elicit strong recommendations on the exclusive use of vancomycin in the treatment of adult IAIs. Our study would be helpful for the rational use of vancomycin and deceleration of the emerging vancomycin resistance rates. Keywords: intra-abdominal infection, vancomycin, guideline, anti-infective agents&nbsp

The results of antibiotic prophylaxis in 148 patients with destructive acute surgical sicknesses of abdominal cavity being urgently operated in the Republican hospital of Baku city from 2011 to 2016 were analyzed. Sixty-five patients were in the basic group which had got as preoperative antibiotic prophylaxis 120-hour course of amoxiclav (amoxicillin in combination with clavulanic acid). Eighty-three patients were in the control group who have performed a surgical intervention with pre-operative 120-hour antibiotic prophylaxis by Claforan (cefotaxime) combining with Metrogel (metronidazole). it was showed that applying antibiotic prophylaxis using amoxiclav positively lowered the frequency of as postoperative purulent-septic complications as recurring operations to 8.1%. How to cite this article: Jamalov FH, Agayev RM, Achundov IT, Huseynov SG, Jamalova TP. Antibacterial Prophylaxis in Emergency Surgery of Abdominal Infection. Euroasian J Hepatogastroenterol, 2018;8(2):116-120.

Background Endoscopic resection of duodenal subepithelial lesions (SELs) is a difficult procedure with a high risk of perforation. At present, dealing with perforation after endoscopic resection of duodenal SELs is still considered a great challenge. Aim To evaluate the effectiveness and safety of an over-the-scope clip (OTSC) in the treatment of perforation post-endoscopic resection of duodenal SELs. Methods From May 2015 to November 2019, 18 patients with perforation following endoscopic resection of duodenal SELs were treated with OTSCs. Data comprising the rate of complete resection, closure of intraprocedural perforation, delayed bleeding, delayed perforation, and postoperative infection were extracted. Results The rate of complete removal of duodenal SELs and successful closure of the perforation was 100%. The median perforation size was 1 cm in diameter. Seventeen patients had minor intraoperative bleeding, while the remaining 1 patient had considerable amount of bleeding during the procedure. Seven patients had postoperative abdominal infections, of which 1 patient developed an abscess in the right iliac fossa and another patient developed septic shock. All 18 patients recovered and were discharged. No delayed bleeding or perforation was reported. The mean time taken to resume normal diet after the procedure was 6.5 d. The mean postoperative hospital stay was 9.5 d. No residual or recurrent lesions were detected during the follow-up period (15-66 mo). Conclusion Closing a perforation after endoscopic resection of duodenal SELs with OTSCs seems to be an effective and reasonably safe therapeutic method.

BackgroundConsidering that current peritoneal dialysis has its own shortcomings, In this study, the Seldinger technique was modified to explore the relationship between different catheter placement methods of peritoneal dialysis and short-term postoperative complications.MethodsWe retrospectively analyzed the data of 157 patients who received peritoneal dialysis in the Department of Nephrology of our hospital from January 2017 to December 2019. According to different catheter placement methods, the patients were divided into three groups: 111 cases of open surgery technique, 23 cases of Seldinger technique, and 23 cases of modified Seldinger technique (ultrasound-guided Veress needle puncture). The general data, laboratory indexes, and abdominal infection and catheter-related complications within one month postoperatively were collected.ResultsThere were 48 (31.0 %) cases of complications in 157 patients within one month postoperatively, which were mainly catheter-related complications (45 cases, 29.0 %). The incidence of catheter tip peritoneal drift (catheter migration) in the three groups was 27.3 %, 39.1 %, and 9.1 %, respectively, with no significant difference between groups (P = 0.069). Univariate logistic regression analysis showed that the systolic blood pressure, history of abdominal and pelvic surgery, creatinine, and modified Seldinger technique were possible impact factors of catheter migration (P P = 0.045); However, the difference between the Seldinger method group and the open surgery group was not significant, with an OR of 1.061 (95 % confidence interval: 0.308–3.649,P = 0.926). Curve fitting showed that the average incidence of catheter migration in the three groups was 27.3 % (95% CI: 15.9-42.7 %), 28.5 % (95% CI: 10.7-56.9 %), and 5.7 % (95% CI: 1.0-27.0 %); the modified Seldinger method has the lowest average incidence of catheter migration.ConclusionsModified Seldinger technique can significantly reduce catheter-related short-term complications after peritoneal dialysis, and it is especially effective in reducing the incidence of catheter migration. Modified Seldinger technique is a safe and feasible method for the placement of a peritoneal dialysis catheter.

Made available in DSpace on 2022-04-28T19:47:00Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-10-01 Introduction: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. Methods: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. Results: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) Conclusion: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material. University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine the Ronald Reagan UCLA Medical Center University of California Los Angeles SSM Healthcare Semmelweis University Keck School of Medicine University of Southern California University of North Carolina School of Medicine University of Arizona the Indiana University Health Physicians Vascular Surgery Michigan Medicine University of Michigan University Heart Center Hamburg University Medical Center Hamburg-Eppendorf Penn State Heart and Vascular Institute Milton S. Hershey Medical Center Johns Hopkins Hospital The Heart Hospital Baylor Plano the Cardiovascular Surgery Clinic University of Messina National & Kapodistrian University of Athens University of Patras Keio University University of Pennsylvania Vancouver General Hospital & University of British Columbia Mayo Clinic Christiana Health System University of Chicago Harborview Medical Center University of Washington Washington University Stanford University CHU de Poitiers Baylor College of Medicine MedStar Georgetown University Hospital SSM Health St. Louis University Faculdade de Medicina de Botucatu-Unesp Beth Israel Deaconness Medical Center Brigham and Women's Hospital St. Joseph's Hospital Massachusetts General Hospital Robert Wood Johnson Medical School Rutgers University Vita-Salute University School of Medicine San Raffaele Scientific Institute Kaiser Permanente University Heart Center Freiburg-Bad Krozingen Freiburg University of Virginia Medical Center University of Siena Kyung Hee University Gustave Dron Hospital Centro Hospitalar de Lisboa Norte Wexner Medical Center Ohio State University Uppsala University University Hospital of Trieste University Hospital of Verona University Hospital of Padova University of Alabama University of California Davis University of Florida Michael E. DeBakey Department of Surgery Baylor College of Medicine University Hospital University of Missouri Faculdade de Medicina de Botucatu-Unesp